Table of Contents

Protocol 1. Universal Patient Protocol 2. Airway Adult 3. Airway Adult Failed 4. Airway Drug Assisted Intubation 5. Airway Pediatric 6. Airway Pediatric Failed 7. Back Pain 8. Behavioral 9. Fever / Infection Control 10. IV Access 11. Pain Control Adult 12. Pain Control Pediatric 13. Spinal Immobilization Clearance 14. Police Custody 15. Abdominal Pain 16. Allergic Reaction 17. Altered Mental Status 18. Asystole 19. Bradycardia 20. Cardiac Arrest 21. Chest Pain 21b. STEMI 22. Dental Problems 23. Epistaxis 24. Hypertension 25. Hypotension 26. Hypothermia – Induced 27. Overdose Toxic Ingestion 28. Post Resuscitation 29. Pulmonary Edema 30. Pulseless Electrical Activity 31. Respiratory Distress 32. Seizure 33. Supraventricular Tachycardia 34. Suspected Stroke 34b. Stroke Destination Determination 35. Syncope 36. Ventricular Fibrillation Pulseless Ventricular Tachycardia 37. Ventricular Tachycardia 38. Vomiting and Diarrhea 39. Childbirth / Labor 40. Newly Born 41. Obstetrical Emergencies 42. Pediatric Bradycardia 43. Pediatric Head Trauma 44. Pediatric Hypotension 45. Pediatric Multiple Trauma 46. Pediatric Pulseless Arrest 47. Pediatric Respiratory Distress 48. Pediatric Seizure 49. Pediatric Supraventricular Tachycardia 50. Bites and Envenomations 51. Burns – Thermal 52. Burns – Chemical and Electrical 53. Drowning 54. Extremity Trauma 55. Adult Head Trauma 56. Hyperthermia 57. Hypothermia 58. Multiple Trauma 59. WMD Nerve Agent 60. Field Triage and Bypass Protocols 2010 LEGEND

Indicates a Protocol

Indicates a Medication / L

E G

Treatment E

N D

Indicates an Intervention

Legend Indicates the Minimum Level of F First Responder F B EMT B Provider authorized to perform A Advanced EMT A this task. P Paramedic P The P/M symbol indicates that M Medical Control M the Paramedic may perform the P Paramedic with P intervention only with OnLine Online Medical M Control M Medical Direction.

LEGEND Universal Patient Care Protocol

Legend Scene Safety F First Responder F Bring all necessary equipment to patient's side B EMT B Demonstrate Professionalism and Courtesy A Advanced EMT A P Paramedic P PPE (Consider Airborne or Droplet if indicated) M Medical Control M

Initial assessment Pediatric Assessment Procedure Cardiac Arrest Cardiac Arrest Protocol G

Adult Assessment Procedure e n

Consider Spinal Immobilization e r

(< 12 years old or < 55 Kg defines the pediatric patient) a

l

P

r

o t

Airway Protocol (Adult or Pediatric) o

c

o

l Vital Signs s F F (Temperature if appropriate) If available, consider Oral Glucose, B Pulse Oximetry B < 60 F 1 to 2 tubes if awake and no risk for F Consider Glucose Measurement aspiration F Consider Supplemental Oxygen F · 50% Dextrose Adult A · 25% Dextrose Pediatric A B Consider 12 Lead ECG B Glucagon if no IV access

P Consider Cardiac Monitor P

Go to Appropriate Protocol

Patient does not fit a protocol? M M Contact Medical Control

Pearls · Recommended Exam: Minimal exam if not noted on the specific protocol is vital signs, mental status with GCS, and location of injury or complaint. · Any patient contact which does not result in an EMS transport must have a completed disposition form. · Required vital signs on every patient include blood pressure, pulse, respirations, pain / severity. · Pulse oximetry and temperature documentation is dependent on the specific complaint. · A pediatric patient is defined by <12 years old or <55 Kg. · 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. · Orthostatic vital sign procedure should be performed in situations where volume status is in question. Protocol 1 2010 Airway, Adult

Assess ABC's Legend -Respiratory Rate Supplemental F First Responder F Adequate -Effort Oxygen -Adequacy B EMT B Pulse Oximetry A Advanced EMT A P Paramedic P Inadequate M Medical Control M

Basic Maneuvers First Obstruction -open airway Unsuccessful -nasal or oral airway Airway: -Bag-valve mask (BVM) Obstruction

Procedure G Becomes Successful Direct e Unsuccessful P P n

Laryngoscopy e r

Long Transport a

l

or Need to Protect B Continue BVM B P

Airway r

o t

Blind Insertion o

B B c

Airway Device o l Oral-Tracheal s Intubation 3 Attempts Nasal-Tracheal Failed airway protocol P Intubation P Unsuccessful Post-Intubation, Consider Diazepam, Lorazepam, or Midazolam for sedation

If Available, Notify Destination Successful P Consider P M M or Contact MC Gastric Tube

Pearls · This protocol is only for use in patients with an Age >12 or >55 Kg. · Capnometry (Color) or capnography is mandatory with all methods of intubation. Document results. · Continuous capnography (EtCO2) should be utilized for the monitoring of all patients with a BIAD or endotracheal tube. · If an effective airway is being maintained by BVM with continuous pulse oximetry values of > 90, it is acceptable to continue with basic airway measures instead of using a BIAD or Intubation. · For the purposes of this protocol a secure airway is when the patient is receiving appropriate oxygenation and ventilation. · An Intubation Attempt is defined as passing the laryngoscope blade or endotracheal tube past the teeth or inserted into the nasal passage. · Ventilatory rate should be 6-10 per minute to maintain a EtCO2 of 35-45. Avoid hyperventilation. · It is strongly encouraged to complete an Airway Evaluation Form with any BIAD or Intubation procedure. · Paramedics should consider using a BIAD if oral-tracheal intubation is unsuccessful. · Maintain C-spine immobilization for patients with suspected spinal injury. · Do not assume hyperventilation is psychogenic - use oxygen, not a paper bag. · Sellick’s and or BURP maneuver should be used to assist with difficult intubations. · Hyperventilation in deteriorating head trauma should only be done to maintain a EtCO2 of 30-35. · Gastric tube placement should be considered in all intubated patients if available. · It is important to secure the endotracheal tube well and consider c-collar to better maintain ETT placement.

Protocol 2 2010 Airway, Adult - Failed

Legend F First Responder F Two (2) failed intubation attempts by most proficient B EMT B technician on scene or anatomy inconsistent with A Advanced EMT A intubation attempts. NO MORE THAN THREE (3) ATTEMPTS TOTAL P Paramedic P M Medical Control M

SPO2 > 90% with B Continue BVM B Yes BVM Ventilation ?

No

If SPO2 drops < 90% G Facial trauma or or it becomes difficult e swelling ? n

to ventilate with BVM e

r

a

l

P

No Yes r

o

t

o c

B Continue BVM B o

l s

SPO2 > 90% ? No P Surgical Airway P

Yes Ventilate at <12 BPM Continue Ventilation with Maintain ETCO2 BIAD between 35 and 45 and SPO2 above 90%

Notify Destination M M or Contact MC

Pearls · If first intubation attempt fails, make an adjustment and then consider: · Different laryngoscope blade · Gum Elastic Bougie · Different ETT size · Change cricoid pressure · Apply BURP maneuver (Push trachea Back [posterior], Up, and to patient's Right) · Change head positioning · Continuous pulse oximetry should be utilized in all patients with an inadequate respiratory function. · Continuous EtCO2 should be applied to all patients with respiratory failure or to all patients with advanced airways. · Notify Medical Control AS EARLY AS POSSIBLE about the patient's difficult / failed airway. Protocol 3 2010 Airway, Drug Assisted Intubation

B Preoxygenate 100% O2 B Legend F First Responder F Ensure adequate IV B B B EMT B Suction equipment A Advanced EMT A P Paramedic P Yes Evidence of Head Injury or Stroke? M Medical Control M P Lidocaine P No

P Etomidate P

B Cricoid Pressure B G

P Succinylcholine P e

n

e

r a

P Intubate P l

P

r o

Placement Verified with May Repeat One t P P No M M o

Capnography Time c

o

l s P Restraint Procedure P

Consider Diazepam, Lorazepam P P or Midazolam for sedation After 2nd Cycle

If Available Consider P P Gastric Tube

Consider Long Acting Paralytic P P (e.g. Norcuron) Failed airway protocol

M Notify Destination or Contact MC M

Pearls · This protocol is only for use in patients with an Age > 12 or > 55 Kg. · Once a patient has been given a paralytic drug, YOU ARE RESPONSIBLE FOR VENTILATIONS! · Items in Red Text are the key performance indicators used to evaluate protocol compliance. An Airway Evaluation Form must be completed on every patient who receives Drug Assisted Intubation. · This procedure will take away the patient’s airway away so you must be sure of your ability to intubate before giving drugs. · Continuous Waveform Capnography and Pulse Oximetry and are required for intubation verification and ongoing patient monitoring · Before administering any paralytic drug, screen for contraindications with a thorough neurologic exam. · If First intubation attempt fails, make an adjustment and try again: · Different laryngoscope blade ● Change head positioning · Different ETT size ● Continuous pulse oximetry should be utilized in all patients. · Change cricoid pressure ● Consider applying BURP maneuver (Back [posterior], Up, and to pt’s Right Pressure) · Divide the workload - ventilate, suction, cricoid pressure, drugs, intubation. · All equipment must be in place and ready for use prior to administering any RSI drugs. · Protect the patient from self extubation when the drugs wear off. Longer acting paralytics may be needed post-intubation.

Protocol 4 2010 Airway, Pediatric

Assess ABC's Legend -Respiratory Rate Supplemental F First Responder F Adequate Oxygen -Effort B EMT B -Adequacy A Advanced EMT A Pulse Oximetry P Paramedic P

Inadequate M Medical Control M

Basic Maneuvers First Obstruction -open airway Unsuccessful -nasal or oral airway Airway: Obstruction -Bag-valve mask (BVM)

Procedure G Becomes Direct Successful P P e

Unsuccessful Laryngoscopy n

e r

Long Transport Continue BVM Maintain a

l

or Need to Protect P B Pulse Ox > 90 and B

Airway r

EtCO2 > 35 and < 40 o t

Blind Insertion o c B B o

Airway Device l Oral-Tracheal s Intubation P P 3 Attempts Nasal-Tracheal Unsuccessful Failed airway protocol Post-Intubation,Intubation Consider Diazepam, P Lorazepam, or P Midazolam for sedation If Available, Notify Destination or M M Successful P Consider P Contact MC Gastric Tube

Pearls · For this protocol, pediatric is defined as < 12 years of age or any patient < 55 Kg. · Capnography is mandatory with all methods of intubation. Document results. · Continuous capnography (EtCO2) should be utilized with BIAD or endotracheal tube use. · If an effective airway is being maintained by BVM with continuous pulse oximetry values of > 94, it is acceptable to continue with basic airway measures instead of using a BIAD or Intubation. · For the purposes of this protocol a secure airway is when the patient is receiving appropriate oxygenation and ventilation. · An Intubation Attempt is defined as passing the laryngoscope blade or endotracheal tube past the teeth or inserted into the nasal passage. · Ventilatory rate should be 30 for Neonates, 25 for Toddlers, 20 for School Age, and for Adolescents the normal Adult rate of 12 per minute. Maintain a EtCO2 between 35 and 40 and avoid hyperventilation. · It is strongly encouraged to complete an Airway Evaluation Form with any BIAD or Intubation procedure. · Paramedics should consider using a BIAD if oral-tracheal intubation is unsuccessful. · Maintain C-spine immobilization for patients with suspected spinal injury. · Do not assume hyperventilation is psychogenic - use oxygen, not a paper bag. · Sellick’s and or BURP maneuver should be used to assist with difficult intubations. · Hyperventilation in deteriorating head trauma should only be done to maintain a EtCO2 (pCO2) of 30-35. · Gastric tube placement should be considered in all intubated patients. · It is important to secure the endotracheal tube well and consider c-collar to better maintain ETT placement.

Protocol 5 2010 Airway, Pediatric - Failed

Legend F First Responder F Two (2) failed intubation attempts by most proficient B EMT B technician on scene or anatomy inconsistent with A Advanced EMT A intubation attempts. NO MORE THAN THREE (3) ATTEMPTS TOTAL P Paramedic P M Medical Control M

SPO2 > 90% with B Continue BVM B Yes BVM Ventilation ?

No

If SPO2 drops < 90% Attempt Oropharyngeal or Nasopharyngeal Airway G

or it becomes difficult e

Placement. n

to ventilate with BVM e

r a

Improved? l

P

r

o t

No Yes o

c o

Blind Insertion Airway l B B s Device (Per Packaging)

SPO2 > 90% ? No B Continue BVM B

Yes

Continue Ventilation with Continue BVM Maintain Pulse Ox BIAD > 90 and EtCO2 > 35 and < 40

Notify Destination M M or Contact MC

Pearls · 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 maneuver (Push trachea Back [posterior], Up, and to patient's Right) · Change head positioning · Ventilatory rate should be 30 for Neonates, 25 for Toddlers, 20 for School Age, and for Adolescents the normal Adult rate of 12 per minute. Maintain a EtCO2 between 35 and 40 and avoid hyperventilation. · Continuous pulse oximetry should be utilized in all patients with an inadequate respiratory function. · Continuous EtCO2 should be applied to all patients with respiratory failure or to all patients with advanced airways. · Notify Medical Control AS EARLY AS POSSIBLE about the patient's difficult / failed airway. Protocol 6 2010 Back Pain

History Signs and Symptoms Differential · Age · Pain (paraspinous, spinous · Muscle spasm / strain · Past medical history · process) · Herniated disc with nerve · Past surgical history · Swelling · Compression · Medications · Pain with range of motion · Sciatica · Onset of pain / injury · Extremity weakness · Spine fracture · Previous back injury · Extremity numbness · Kidney stone · Traumatic mechanism · Shooting pain into an extremity · Pyelonephritis · Location of pain · Bowel / bladder dysfunction · Aneurysm · Fever · Pneumonia · Improvement or worsening with · Spinal Epidural Abscess activity · Metastatic Cancer

Legend

F First Responder F G

B EMT B e n

Universal Patient Care Protocol e

A Advanced EMT A r

a

l

P Paramedic P P r

M Medical Control M o t

Spinal Immobilization o Yes Injury or traumatic mechanism

Protocol c

o l No s

F Orthostatic Blood Pressure F

Positive Negative / Unable to Perform IV Protocol Signs of shock? Yes A A Normal Saline Bolus

No Pain Control Protocol

Notify Destination M M or Contact MC

Pearls · Recommended Exam: Mental Status, HEENT, Neck, Chest, Lungs, Abdomen, Back, Extremities, Neuro · Abdominal aneurysms are a concern in patients over the age of 50. · Kidney stones typically present with an acute onset of flank pain which radiates around to the groin area. · Patients with midline pain over the spinous processes should be spinally immobilized. · Any bowel or bladder incontinence is a significant finding which requires immediate medical evaluation. · In patient with history of IV drug abuse a spinal epidural abscess should be considered.

Protocol 7 2010 Behavioral

History Signs and Symptoms Differential · Situational crisis · Anxiety, agitation, confusion · see Altered Mental Status · Psychiatric illness · Affect change, hallucinations differential · Medications · Delusional thoughts, bizarre behavior · Alcohol Intoxication · Injury to self or threats to others · Combative violent · Toxin / Substance abuse · Medic alert tag · Expression of suicidal / homicidal · Medication effect / overdose · Substance abuse / overdose thoughts · Withdrawal syndromes · Diabetes · Depression · Bipolar (manic-depressive) · Schizophrenia · Anxiety disorders

Scene Safety Legend

F First Responder F Universal Patient Care Protocol G

B EMT B e n

· Remove patient from stressful environment A Advanced EMT A e

r a

· Use verbal calming techniques because P Paramedic P l

F communication is very important (reassurance, F P

M Medical Control M r o

calm, establish rapport) t o

· GCS on all patients c

o l

Go to Appropriate Protocol s Altered Mental Status Overdose/Toxic Ingestion Protocol Head Trauma Protocol If available, consider Oral Glucose, 1 Check Glucose if there is any suspicion B B < 60 B to 2 tubes if awake and no risk for B of hypoglycemia aspiration If Patient Refuses Care · 50% Dextrose Adult M M A A Contact Medical Control · 25% Dextrose Pediatric

P Glucagon if no IV access P F Restraint Procedure F

Consider P P Midazolam, Lorazepam, or Diazepam

Pearls · Recommended Exam: Mental Status, Skin, Heart, Lungs, Neuro · Your safety first!! · Consider Geodon for patients with history of psychosis or a benzodiazepine for patients with presumed substance abuse ONLY with Online Medical Control permission. · Be sure to consider all possible medical/trauma causes for behavior (hypoglycemia, overdose, substance abuse, hypoxia, head injury, etc.) · Do not irritate the patient with a prolonged exam. · Do not overlook the possibility of associated domestic violence or child abuse. · If patient is suspected of agitated delirium suffers cardiac arrest, consider a fluid bolus and sodium bicarbonate early. · All patients who receive either physical or chemical restraint should be continuously observed by ALS personnel on scene or immediately upon their arrival. · Any patient who is handcuffed or restrained by Law Enforcement and transported by EMS must be accompanied by law enforcement in the ambulance. · Do not position or transport any restrained patient is such a way that could impact the patients respiratory or circulatory status. Protocol 8 2010 Fever / Infection Control

History Signs and Symptoms Differential · Age · Warm · Infections / Sepsis · Duration of fever · Flushed · Cancer / Tumors / Lymphomas · Severity of fever · Sweaty · Medication or drug reaction · Past medical history · Chills/Rigors · Connective tissue disease · Medications Associated Symptoms · Arthritis · Immunocompromised (transplant, (Helpful to localize source) · Vasculitis HIV, diabetes, cancer) · myalgias, cough, chest pain, · Hyperthyroidism · Environmental exposure headache, dysuria, abdominal pain, · Heat Stroke mental status changes, rash · Last acetaminophen or ibuprofen · Meningitis

Legend Universal Patient Care Protocol

F First Responder F G

B EMT B e Contact, Droplet, and Airborne Precautions n

A Advanced EMT A e

r a

P Paramedic P l

P

Yes M Medical Control M r

F Orthostatic Blood Pressure F o

t

o

c

o

l IV Protocol s A A No Normal Saline Bolus

Temperature Measurement Temperature greater than 100.4˚F (38˚C) B If available consider B Ibuprofen (if age ≥ 6 months) or Acetaminophen (if age ≥ 4 months Notify Destination M M Appropriate protocol by complaint or Contact MC

Pearls · Recommended Exam: Mental Status, Skin, HEENT, Neck, Heart, Lungs, Abdomen, Back, Extremities, Neuro · 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 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). · Rehydration with fluids increased the patients ability to sweat and improves heat loss. · All patients should have drug allergies documented prior to administering pain medications. · Allergies to NSAID's (non-steroidal anti-inflammatory medications) are a contraindication to Ibuprofen. · NSAID's should not be used in the setting of environmental heat emergencies. · Do not give aspirin to a child. · Pediatric Dosing: Tylenol (Acetaminophen) 15 mg/kg ; Ibuprofen 10 mg/kg Protocol 9 2010 IV Access

Legend F First Responder F B EMT B A Advanced EMT A Universal Patient Care Protocol P Paramedic P M Medical Control M

Assess need for IV Emergent or potentially emergent

medical or trauma condition G

Peripheral IV e n

External Jugular IV (≥ 12 yo) for e

r

A A a

life-threatening event l

Intraosseous IV (ped or adult P r

device) for life-threatening event o

t

o

c

o

l s

Unsuccessful x 3 Successful Attempts with any method

B Monitor med-lock B Notify Destination or M M A Monitor infusion A Contact MC

Pearls · In the setting of cardiac arrest, any preexisting dialysis shunt or external central venous catheter may be used. · Intraosseous with the appropriate adult or pediatric device. · External jugular (> 12 years of age). · Any prehospital fluids or medications approved for IV use, may be given through an intraosseous IV. · All IV rates should be at KVO (minimal rate to keep vein open) unless administering fluid bolus. · External jugular lines can be attempted initially in life-threatening events where no obvious peripheral site is noted. · In patients who are hemodynamically unstable or in extremis, ATTEMPT to contact medical control prior to accessing dialysis shunts or external central venous catheters. · Any venous catheter which has already been accessed prior to EMS arrival may be used. · Upper extremity IV sites are preferable to lower extremity sites. · Lower extremity IV sites are discouraged in patients with vascular disease or diabetes. · In post-mastectomy patients, avoid IV, blood draw, injection, or blood pressure in arm on affected side.

Protocol 10 2010 Pain Control: Adult

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

Universal Patient Care Protocol

Patient care according to Protocol

based on Specific Complaint G

e

n e

Consider if Available r

Pain Severity > 6 out of 10 a

Ibuprofen l No or B B P

or r

Indication for IV / IM Medication o

Acetaminophen t o

Yes or c P P o

Nitrous Oxide l s B Pulse Oximetry B P IV Protocol if IV medication P Legend If available consider P P Nitrous Oxide F First Responder F P P Morphine or Fentanyl B EMT B M M A Advanced EMT A Must reassess patient at least every B B 15 minutes after sedative medication P Paramedic P M Medical Control M P Paramedic WITH P Notify Destination Online Medical M M M M or Contact MC Control

Pearls · Recommended Exam: Mental Status, Area of Pain, Neuro · Pain severity (0-10) is a vital sign to be recorded pre and post IV or IM medication delivery and at disposition. · Vital signs should be obtained pre, 15 minutes post, and at disposition with all pain medications. · Contraindications to the use of a narcotic include hypotension, head injury, respiratory distress or severe COPD. · 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, or in patients who may need surgical intervention such as open fractures or fracture deformities. · All patients should have drug allergies documented prior to administering pain medications. · All patients who receive IM or IV medications must be observed 15 minutes for drug reaction. · Ibuprofen should not be given for headaches or abdominal pain, history of gastritis, stomach ulcers, fracture, or if patient will require sedation. · Do not administer any PO medications for patients who may need surgical intervention such as open fractures or fracture deformities, headaches, or abdominal pain. · Do not administer Acetaminophen to patients with a history of liver disease. · See drug list for other contraindications for Narcotics, Acetaminophen, Nitrous Oxide, and Ibuprofen. Protocol 11 2010 Pain Control: Pediatric

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, · Cardiac · If child use Wong-Baker faces scale · Respiration · Pleural / Respiratory · Past medical history · Increased with palpation of area · Neurogenic · Medications · Renal (colic) · Drug allergies

Universal Patient Care Protocol

Patient care according to Protocol based on Specific Complaint

Consider if Available G

Ibuprofen e

Pain Severity > 6 out of 10 n (Age 6 months)

≥ e

or No B B r

or a

Indication for IV / IM Medication l

Acetaminophen P r

Yes (Age ≥ 4 months) o t

or o B Pulse Oximetry B c

P Nitrous Oxide P o l A IV Protocol if IV medication A (Age > 5 years) s

Contact Medical Isolated Extremity Traumatic Pain M M Control Legend Yes F First Responder F P If no contraindication to sedation P B EMT B M Morphine or Fentanyl M A Advanced EMT A Must reassess patient at least every B B P Paramedic P 15 minutes after sedative medication M Medical Control M P Paramedic WITH P Notify Destination M M Online Medical or Contact MC M Control M

Pearls · Recommended Exam: Mental Status, Area of Pain, Neuro · Pain severity (0-10) is a vital sign to be recorded pre and post IV or IM medication delivery and at disposition. · For children use Wong-Baker faces scale or the FLACC score (see Assessment Pain Procedure) · Vital signs should be obtained pre, 15 minutes post, and at disposition with all pain medications. · Contraindications to Narcotic use include hypotension, head injury, or respiratory distress. · All patients should have drug allergies documented and avoid medications with a history of an allergy or reaction. · All patients who receive IM or IV medications must be observed 15 minutes for drug reaction. · Ibuprofen should not be given if there is abdominal pain, history of gastritis, stomach ulcers, fracture, or if patient will require sedation. · Do not administer any PO medications for patients who may need surgical intervention such as open fractures or fracture deformities. · See drug list for other contraindications for Narcotics, Nitrous Oxide, Acetaminophen, and Ibuprofen. · Pediatric Dosing: Tylenol (Acetaminophen) 15 mg/kg ; Ibuprofen 10 mg/kg Protocol 12 2010 Spinal Immobilization Clearance

Legend Neuro Exam: Any focal deficit? Yes F First Responder F No B EMT B Patient > 65 or < 5 or A Advanced EMT A Yes SIGNIFICANT traumatic mechanism? P Paramedic P No M Medical Control M

Yes Alertness: Any alteration in patient?

No G

Intoxication: Any evidence? Yes e

n

e r

No a

l

P

Distracting Injury: Any painful injury r o

that might distract the patient Yes t o

from the pain of a c-spine injury? c

o l No s

Spinal Exam: Point of tenderness P over the spinal process or P Yes pain to ROM?

No

Spinal Immobilization P P B Spinal Immobilization Required B Not Indicated

Pearls · Recommended Exam: Mental Status, Skin, Neck, Heart, Lungs, Abdomen, Back, Extremities, Neuro · Consider immobilization in any patient with arthritis, cancer, or other underlying spinal or bone disease. · Significant mechanism includes high-energy events such as ejection, high falls, and abrupt deceleration crashes and may indicate the need for spinal immobilization in the absence of symptoms. · Range of motion should NOT be assessed if patient has midline spinal tenderness. Patient's range of motion should not be assisted. The patient should touch their chin to their chest, extend their neck (look up), and turn their head from side to side (shoulder to shoulder) without spinal process pain. · The acronym "NSAIDS" should be used to remember the steps in this protocol. · "N" = Neurologic exam. Look for focal deficits such as tingling, reduced strength, on numbness in an extremity. · "S" = Significant mechanism or extremes of age. · "A" = Alertness. Is patient oriented to person, place, time, and situation? Any change to alertness with this incident? · "I" = Intoxication. Is there any indication that the person is intoxicated (impaired decision making ability)? · "D" = Distracting injury. Is there any other injury which is capable of producing significant pain in this patient? · "S" = Spinal exam. Look for point tenderness in any spinal process or spinal process tenderness with range of motion. Protocol 13 2010 Police Custody

History Signs and Symptoms Differential · Traumatic Injury · External signs of trauma · Agitated Delirium Secondary to · Drug Abuse · Palpitations Psychiatric Illness · Cardiac History · Shortness of breath · Agitated Delirium Secondary to · History of Asthma · Wheezing Substance Abuse · Psychiatric History · Altered Mental Status · Traumatic Injury · Intoxication/Substance Abuse · Closed Head Injury · Asthma Exacerbation · Cardiac Dysrhythmia

Legend Universal Patient Care Protocol F First Responder F B EMT B Appropriate Protocol Evidence of Traumatic Injury or Yes

and Transport Medical Illness? A Advanced EMT A G

P Paramedic P e

No n

M Medical Control M e

r

a l

Pepper Spray Use of Pepper Spray or Taser? Taser

P

r o

Irrigate face/eyes t o

Remove Significant Injury from Entry c Yes o

contaminated Point of Taser or from Fall l s clothing after Taser Use?

No History of No No Wheezing? Asthma? Wound Care Taser-Probe Removal Procedure Yes No Cardiac History with Pacemaker, Yes No Chest Pain, or Palpitations? Respiratory Distress A A Protocol and Consider Transport Yes Agitated Delirium? Yes Restraint Procedure and/or Yes No Behavioral Protocol

Observe 20 min. Coordinate disposition with A A Wheezing? patient, law enforcement Appropriate Protocol P P personnel, and if necessary and Transport No Medical Control Pearls · For this protocol to be used, the patient does not have to be under police custody. · Agitated delirium is characterized by marked restlessness, irritability, and/or high fever. Patients exhibiting these signs are at high risk for sudden death and should be transported to hospital by ALS personnel. · Patients restrained by law enforcement devices cannot be transported in the ambulance without a law enforcement officer in the patient compartment who is capable of removing the devices. · If there is any doubt about the cause of a patient’s alteration in mental status, transport the patient to the hospital for evaluation. · If an asthmatic patient is exposed to pepper spray and released to law enforcement, all parties should be advised to immediately recontact EMS if wheezing/difficulty breathing occurs. · All patients in police custody retain the right to request transport. This should be coordinated with law enforcement. · If extremity/chemical/law enforcement restraints are applied, complete Restraint procedure in call reporting system. Protocol 14 2010 Abdominal Pain

History Signs and Symptoms Differential · Age · Pain (location / migration) · Pneumonia or Pulmonary embolus · Past medical / surgical history · Tenderness · Liver (hepatitis, CHF) · Medications · Nausea · Peptic ulcer disease / Gastritis · Onset · Vomiting · Gallbladder · Palliation / Provocation · Diarrhea · Myocardial infarction · Quality (crampy, constant, sharp, dull, · Dysuria · Pancreatitis etc.) · Constipation · Kidney stone

· Region / Radiation / Referred · Vaginal bleeding / discharge · Abdominal aneurysm

· Severity (1-10) · Pregnancy Appendicitis

·

· Time (duration / repetition) Associated symptoms: (Helpful to · Bladder / Prostate disorder

· Fever localize source) · Pelvic (PID, Ectopic pregnancy, · Last meal eaten Fever, headache, weakness, malaise, Ovarian cyst) · Last bowel movement / emesis myalgias, cough, headache, mental status · Spleen enlargement changes, rash · Menstrual history (pregnancy) · Diverticulitis · Bowel obstruction · Gastroenteritis (infectious)

Universal Patient Care Protocol Legend

F First Responder F

B EMT B M

A IV Protocol A A Advanced EMT A e

d i

P Paramedic P c

a

l

M Medical Control M P

Yes r

F Orthostatic Blood Pressure F o

t

o c

No o

l s Normal Saline A A Nausea and/or vomiting Yes Bolus

No

Consider P If Available Consider P Chest Pain Protocol Ondansetron Pain Control Protocol Prochlorperazine

Notify Destination or Contact M M Medical Control

Pearls · Recommended Exam: Mental Status, Skin, HEENT, Neck, Heart, Lung, Abdomen, Back, Extremities, Neuro · Document the mental status and vital signs prior to administration of anti-emetics. · Abdominal pain in women of childbearing age should be treated as an ectopic pregnancy until proven otherwise. · Antacids should be avoided in patients with renal disease. · The diagnosis of abdominal aneurysm should be considered with abdominal pain in patients over 50. · Repeat vital signs after each bolus. · Appendicitis may present with vague, peri-umbilical pain which migrates to the RLQ over time. · Prochlorperazine = Compazine; Ondansetron = Zofran Protocol 15 2010 Anaphylaxis / Allergic Reaction

History Signs and Symptoms Differential · Onset and location · Itching or hives · Urticaria (rash only) · Insect sting or bite · Coughing / wheezing or · Anaphylaxis (systemic effect) · Food allergy / exposure · Respiratory distress · Shock (vascular effect) · Medication allergy / exposure · Chest or throat constriction · Angioedema (drug induced) · New clothing, soap, detergent · Difficulty swallowing · Aspiration / Airway obstruction · Past history of reactions · Hypotension or shock · Vasovagal event · Past medical history · Edema · Asthma or COPD

· Medication history · CHF

Legend

Universal Patient Care Protocol F First Responder F B EMT B Wheezing / Stridor / or A Advanced EMT A signs of Hypoperfusion P Paramedic P M Medical Control M

Hives / Rash only P Paramedic WITH P

No respiratory component B Epinephine Auto-Injector IM B Online Medical

M M

Control

M

e

d

i c

A IV Protocol A a l

A IV Protocol A

P r

B Cardiac Monitor B o

B Cardiac Monitor B t

o c

Diphenhydramine IV/IM o

P Diphenhydramine P l s If Available Consider Consider Continue to reassess airway Histamine 2 Blocking Hypotension Protocol P P Agent Dysrhythmia Protocol If Available Consider or Methylprednisolone or Respiratory Distress Solumedrol Protocol Continue to reassess airway

Notify Destination or Contact If No Improvement Contact M M M M Medical Control Medical Control

If condition worsens repeat B B Epinephrine Auto-Injector IM P P Epinephrine IV M M

Pearls · Recommended Exam: Mental Status, Skin, Heart, Lungs · Contact Medical Control prior to administering epinephrine in patients who are >50 years of age, have a history of cardiac disease, or if the patient's heart rate is >150. Epinephrine may precipitate cardiac ischemia. These patients should receive a 12 lead ECG. · Any patient with respiratory symptoms or extensive reaction should receive IV or IM diphenhydramine. · The shorter the onset from exposure to symptoms, the more severe the reaction. Protocol 16 2010 Altered Mental Status

History Signs/Symptoms Differential · Known diabetic, medic alert tag · Decreased mental status or lethargy · Head trauma · Drugs, drug paraphernalia · Change in baseline mental status · CNS (stroke, tumor, seizure, · Report of illicit drug use or toxic · Bizarre behavior infection) ingestion · Hypoglycemia (cool, diaphoretic skin) · Cardiac (MI, CHF) · Past medical history · Hyperglycemia (warm, dry skin; fruity · Hypothermia / Hyperthermia · Medications breath; Kussmaul resps; signs of · Infection (CNS and other) · History of trauma dehydration) · Thyroid (hyper / hypo)

· Change in condition · Irritability · Shock (septic, metabolic,

· Changes in feeding or sleep habits traumatic)

· Diabetes (hyper / hypoglycemia)

· Toxicologic or Ingestion · Acidosis / Alkalosis · Environmental exposure · Pulmonary (Hypoxia) · Electrolyte abnormality · Psychiatric disorder

Universal Patient Care Protocol Legend

F First Responder F

B EMT B

Consider Spinal Immobilization Protocol M

A Advanced EMT A e

d i

P Paramedic P c

A IV Protocol A a

l

M Medical Control M

P

r

o t

B Blood Glucose B o c

No o

Glucose <60 Glucose >60 l s

P Nalaxone P if Respirations Depressed If available, consider Oral Glucose, Consider other causes: B 1 to 2 tubes if awake and no risk for B Head injury, Overdose / Toxic Ingestion, Stroke, aspiration Hypoxia, Hypothermia · 50% Dextrose Adult B 12-Lead ECG B A A · 25% Dextrose Pediatric P Assess Cardiac Rhythm P P Glucagon if no IV access P IV Fluid bolus X 1 A A if sugar >250 or signs of dehydration

Notify Destination or Contact Return to baseline? Yes M M Medical Control Pearls · Recommended Exam: Mental Status, HEENT, Skin, Heart, Lungs, Abdomen, Back, Extremities, Neuro. Pay careful attention to the head exam for signs of bruising or other injury. · Be aware of AMS as presenting sign of an environmental toxin or Haz-Mat exposure and protect personal safety. · It is safer to assume hypoglycemia than hyperglycemia if doubt exists. Recheck blood glucose after Dextrose or Glucagon. · Do not let alcohol confuse the clinical picture. Alcoholics frequently develop hypoglycemia and may have unrecognized injuries. · Low glucose (< 60), normal glucose (60 - 120), high glucose ( > 250). · Consider Restraints if necessary for patient's and/or personnel's protection per the restraint procedure. Protocol 17 2010 Asystole

History Signs and Symptoms Differential · Past medical history · Pulseless · Medical or Trauma · Medications · Apneic · Hypoxia · Events leading to arrest · No electrical activity on ECG · Potassium (hypo / hyper) · End stage renal disease · No auscultated heart tones · Drug overdose · Estimated downtime · Acidosis · Suspected hypothermia · Hypothermia · Suspected overdose · Device (lead) error

· DNR form · Death

Universal Patient Care Protocol Legend

F First Responder F Cardiac Arrest Procedure B EMT B A Advanced EMT A Withhold resuscitation Yes Criteria for Death / No Resuscitation P Paramedic P No M Medical Control M 5 Cycles of CPR unless arrest

F witnessed by AED equipped F

Contact/Notify personnel M

Medical When IV/IO available e M M d

Epinephrine 1 mg IV/IO i Control or c

Supervisor** Repeat every 3 to 5 minutes a

l

or P r

Vasopressin 40 units IV/IO o t

AT ANY TIME to replace 1st or 2nd dose of o c

P Epinephrine P o l Return of Consider Atropine 1 mg IV/IO s Spontaneous and repeat every 3-5 minutes Circulation for up to 3 doses ● Consider Correctable Causes ● Consider Transcutaneous Pacing early

P Criteria for Discontinuation P Yes Stop resuscitation

No Go to Notify/Contact Continue Epinephrine and address Post Resuscitation P P M Medical Control or M correctable causes Protocol Supervisor**

Pearls · Recommended Exam: Mental Status, Heart, Lungs · Always confirm asystole in more than one lead. · Consider Calcium Gluconate in Dialysis patient. · Successful resuscitation of Asystole requires the identification and correction of a cause. Causes of Asystole include: · Acidosis ● Tension Pneumothorax · Hypovolemia ● Hypoglycemia · Hyperkalemia · Overdose (Narcotics, Tricyclic Antidepressants, Calcium Channel Blockers, Beta Blockers) **Contact Supervisor Based on Local Policy and Written Protocol to Withhold Resuscitation. Protocol 18 2010 Bradycardia

History Signs and Symptoms Differential · Past medical history · HR < 60/min with hypotension, · Acute myocardial infarction · Medications acute altered mental status, chest · Hypoxia · Beta-Blockers pain, acute CHF, seizures, · Pacemaker failure · Calcium channel blockers syncope, or shock secondary to · Hypothermia · Clonidine bradycardia · Sinus bradycardia · Digoxin · Chest pain · Athletes · Pacemaker · Respiratory distress · Head injury (elevated ICP) or · Hypotension or Shock

· Stroke

· Altered mental status · Spinal cord lesion

· Syncope · Sick sinus syndrome

· AV blocks (1˚, 2˚, or 3˚) · Overdose

Universal Patient Care Protocol Legend F First Responder F A IV Protocol A B EMT B

P Assess Rhythm P A Advanced EMT A

P Paramedic P

M Medical Control M

HR < 60/min with hypotension, acute altered M

Continue to No mental status, chest pain, acute CHF, seizures, e Monitor and d

syncope, or shock secondary to bradycardia i c

reassess a

l

Yes

P r

B 12-Lead ECG B o

t o

Atropine- if in setting of myocardial c

o l

P infarction do not give atropine if there is P s a wide complex rhythm A Fluid Bolus A

Consider External Cutaneous Pacing P early in the unstable patient (especially P in 2nd or 3rd Degree Heart Block)

· Consider Dopamine if patient still hypotensive · Consider Glucagon if patient still bradycardic and on beta blockers · Consider Calcium if patient still bradycardic and on calcium channel blockers

M Notify Destination or Contact Medical Control M

Pearls · Recommended Exam: Mental Status, Neck, Heart, Lungs, Neuro · The use of Lidocaine, Beta Blockers, and Calcium Channel Blockers in heart block can worsen Bradycardia and lead to asystole and death. · Pharmacological treatment of Bradycardia is based upon the presence or absence of symptoms. If symptomatic treat, if asymptomatic, monitor only. · In wide complex slow rhythm consider hyperkalemia. · Remember: The use of Atropine for PVCs in the presence of a MI may worsen heart damage. · Consider treatable causes for Bradycardia (Beta Blocker OD, Calcium Channel Blocker OD, etc.) · Be sure to aggressively oxygenate the patient and support respiratory effort. Protocol 19 2010 Cardiac Arrest

History: Signs and Symptoms: Differential: · Events leading to arrest · Unresponsive · Medical vs Trauma · Estimated downtime · Apneic · V. fib vs Pulseless V. tach · Past medical history · Pulseless · Asystole · Medications · Pulseless electrical activity · Existence of terminal illness (PEA) · Signs of lividity, rigor mortis

· DNR form

Legend

F First Responder F Universal Patient Care Protocol B EMT B A Advanced EMT A Withhold resuscitation Yes Criteria for Death / No Resuscitation P Paramedic P

No M Medical Control M

Contact/Notify Begin Continuous CPR Compressions AT ANY TIME

Medical

M M

Control or M ALS Available? Return of Supervisor** e

Spontaneous d i

No Yes c

Circulation a

l

P

r

o t

P Assess Rhythm P o

B AED B c

o

l s

Go to appropriate protocol: Airway Protocol Go to Ventricular Fibrillation Post Resuscitation Protocol Pulseless Ventricular Interrupt Compressions Only as per Tachycardia AED Procedure. Ventilate no more Pulseless Electrical than 12 breaths per minute (1 breath Activity every 5 seconds) Asystole Pediatric Pulseless Arrest

Pearls · Recommended Exam: Mental Status · Success is based on proper planning and execution. Procedures require space and patient access. Make room to work. · Reassess airway frequently and with every patient move. · Maternal Arrest - Treat mother per appropriate protocol with immediate notification to Medical Control and rapid transport. · Adequate compressions with timely defibrillation are the keys to success.

**Contact Supervisor Based on Local Policy and Written Protocol to Withhold Resuscitation. Protocol 20 2010 Chest Pain: Cardiac and STEMI

History Signs and Symptoms Differential · Age · CP (pain, pressure, aching, · Trauma vs. Medical · Medications vicelike tightness) · Angina vs. Myocardial infarction · Erectile Dysfunction Medication · Location (substernal, epigastric, · Pericarditis · Past medical history (MI, Angina, arm, jaw, neck, shoulder) · Pulmonary embolism Diabetes, post menopausal) · Radiation of pain · Asthma / COPD · Allergies (Aspirin, Morphine, · Pale, diaphoresis · Pneumothorax Lidocaine) · Shortness of breath · Aortic dissection or aneurysm Nausea, vomiting, dizziness

· Recent physical exertion · · GE reflux or Hiatal hernia

· Palliation / Provocation · Time of Onset · Esophageal spasm

· Quality (crampy, constant, sharp, · Chest wall injury or pain

dull, etc.) · Pleural pain · Region / Radiation / Referred · Overdose (Cocaine) or · Severity (1-10) Methamphetamine · Time (onset /duration / repetition)

Universal Patient Care Protocol Legend Positive Acute MI F First Responder F (STEMI = 1 mm ST B 12-Lead ECG B Segment Elevation in B EMT B 2 Contiguous Leads

A Advanced EMT A

P Rhythm Assessment P P Paramedic P M e

A IV Protocol A M Medical Control M d

i

c a

B Aspirin (Unless allergy) B P Paramedic WITH P l

P

Online Medical r

B Nitroglycerin SL B M M o

t Control o

P Consider Nitroglycerin Paste P c o

Transport based on l P Continued Pain P s EMS System STEMI Plan Morphine M M with Early Notification Fentanyl Keep Scene Time to < 15 Minutes Nausea and Vomiting Consider If Transporting to a Non-PCI Center Ondansetron B B P P Reperfusion Checklist Prochlorperazine Consider NS Bolus for Inferior MIs A A Diphenhydramine / Hypotension Use Protocols as Needed A Consider 2nd IV en route A Hypotension Protocol Notify Destination or Contact Dysrhythmia Protocols M M Medical Control

Pearls · Recommended Exam: Mental Status, Skin, Neck, Lung, Heart, Abdomen, Back, Extremities, Neuro · Items in Red Text are the key performance indicators for the EMS Acute Cardiac (STEMI) Care Toolkit · Avoid Nitroglycerin in any patient who has used erectile dysfunction medication (Viagra or Levitra <24 hours; or Cialis <36 hours) due to potential severe hypotension. · Patients with STEMI (ST-Elevation Myocardial Infarction) or positive Reperfusion Checklist should be transported to the appropriate destination based on the EMS System STEMI Plan · If patient has taken nitroglycerin without relief, consider potency of the medication. · Monitor for hypotension after administration of nitroglycerin and narcotics (Morphine or Fentanyl). · Nitroglycerin and Narcotics (Morphine or Fentanyl) may be repeated per dosing guidelines in Drug List. · Diabetics and geriatric patients often have atypical pain, or only generalized complaints. · Document the time of the 12-Lead ECG in the PCR as a Procedure along with the interpretation (EMT-P) Protocol 21 2010 Chest Pain: STEMI Transport

Legend F First Responder F B EMT B

Universal Patient Care Protocol A Advanced EMT A P Paramedic P

B 12-Lead ECG B M Medical Control M

P Rhythm Assessment P

A IV Protocol A

Unstable airway, cardiac arrest,

Yes No

and/or hemodynamic instability

No

M e

Transport to nearest Travel time* to PCI Travel time* to PCI d i

facility to stabilize Center ≤ 60 minutes Center > 60 minutes c

a

l

P r

Complete Pre-Fibrinolytic o Early notification/activation Yes Yes t

where feasible Survey o c

No o

l s Transport to STEMI Contraindications or Receiving Hospital other High Risk** factors

Transport to nearest Air Medical Activation? STEMI Referral Hospital

Pearls · Recommended Exam: Mental Status, Skin, Neck, Lung, Heart, Abdomen, Back, Extremities, Neuro · Items in Red Text are the key performance indicators for the EMS Acute Cardiac (STEMI) Care Toolkit · **High Risk: Cardiogenic shock – inadequate tissue perfusion due to low cardiac output. Systolic Blood Pressure ≤ 90 mm Hg in setting of acute myocardial infarction. (Killip class ≥ III) · Patients with STEMI (ST-Elevation Myocardial Infarction) or positive Reperfusion Checklist should be transported to the appropriate destination based on the EMS System STEMI Plan · Positive Acute MI (STEMI = cardiac symptoms > 15 minutes and < 12 hours AND ST segment elevation of ≥ 1 mm in 2 or more Anatomically Contiguous Leads OR Left Bundle Branch Block NOT KNOWN to be present in past) · *Travel Time defined with understanding that PCI can be completed within 90 minutes or less including transport time. · Document the time of the 12-Lead ECG in the PCR as a Procedure along with the interpretation (EMT-P) · Avoid Nitroglycerin (NTG) in patients who use erectile dysfunction medication (Viagra or Levitra < 24 hours; or Cialis < 36 hours) due to possible severe hypotension. · If patient has taken NTG without relief, consider potency of medication. · Monitor for hypotension after administration of NTG and/or Fentanyl. · Perform a patient interview, examination and treatment as simultaneously and expediently as possible, do not excessively delay treatment or transportation of this patient. · Additional Information is appended in POLICY: STEMI.

Protocol 21b 2010 Dental Problems

History Signs and Symptoms Differential · Age · Bleeding · Decay · Past medical history · Pain · Infection · Medications · Fever · Fracture · Onset of pain / injury · Swelling · Avulsion · Trauma with "knocked out" tooth · Tooth missing or fractured · Abscess · Location of tooth · Facial cellulitis · Whole vs. partial tooth injury · Impacted tooth (wisdom)

· TMJ syndrome

· Myocardial infarction

Legend Universal Patient Care Protocol F First Responder F B EMT B

Control bleeding with pressure A Advanced EMT A P Paramedic P

M Medical Control M

Tooth avulsion Yes

M e

Place tooth back in socket if d i

feasible. Secure to surrounding No c

a l

teeth with tape. P

No r

o

t o

Place tooth in milk or normal c o

saline l s

Pain Control Protocol

Reassess and Monitor

Notify Destination or Contact M M Medical Control

Pearls · Recommended Exam: Mental Status, HEENT, Neck, Chest, Lungs, Neuro · Significant soft tissue swelling to the face or oral cavity can represent a cellulitis or abscess. · Scene and transport times should be minimized in complete tooth avulsions. Reimplantation is possible within 4 hours if the tooth is properly cared for. · All tooth disorders typically need antibiotic coverage in addition to pain control. · Occasionally cardiac chest pain can radiate to the jaw. · All pain associated with teeth should be associated with a tooth which is tender to tapping or touch (or sensitivity to cold or hot). · DO NOT replace tooth if: - Obtunded patient - Spinal Immobilization - AMS - Multiple Teeth missing Protocol 22 2010 Epistaxis

History Signs and Symptoms Differential · Age · Bleeding from nasal passage · Trauma · Past medical history · Pain · Infection (viral URI or Sinusitis) · Medications (HTN, anticoagulants, · Nausea · Allergic rhinitis Aspirin, NSAIDS) · Vomiting · Lesions (polyps, ulcers) · Previous episodes of epistaxis · Hypertension · Trauma · Duration of bleeding

· Quantity of bleeding

Universal Patient Care Protocol

Compress Nostrils F Ice Packs (if available) F

Tilt head forward

Orthostatic Blood Pressure Positive or Hypotension

M

P Consider Afrin Nasal Spray P e d

IV Protocol i

Use Protocols as Needed A A c

a l

Hypotension Protocol Normal Saline Bolus

P r

Dysrhythmia Protocols o

t

o

c

o

l s

Notify Destination or Contact M M Medical Control

Legend F First Responder F B EMT B A Advanced EMT A P Paramedic P M Medical Control M

Pearls · Recommended Exam: Mental Status, HEENT, Heart, Lungs, Neuro · It is very difficult to quantify the amount of blood loss with epistaxis. · Bleeding may also be occurring posteriorly. Evaluate for posterior blood loss by examining the posterior pharnyx. · Anticoagulants include Aspirin, Coumadin, non-steroidal anti-inflammatory medications (Ibuprofen), and many over the counter headache relief powders. Protocol 23 2010 Hypertensive Emergency / Urgency

History Signs and Symptoms Differential · Documented hypertension One of these · Hypertensive encephalopathy · Related diseases: diabetes, CVA · Systolic BP 220 or greater · Primary CNS Injury · renal failure, cardiac · Diastolic BP 120 or greater (Cushing's response = · Medications (compliance ?) bradycardia with · Erectile dysfunction medication AND at least one of these hypertension) (Levitra/Cialis/Viagra) · Headache · Myocardial infarction · Pregnancy · Nosebleed · Aortic dissection (aneurysm)

· Blurred vision

· Pre-eclampsia / Eclampsia

· Dizziness

Legend F First Responder F Universal Patient Care Protocol B EMT B A Advanced EMT A P Paramedic P F Check BP in both arms F

M Medical Control M

If Respiratory Distress Consider M e

Pulmonary Edema Protocol d

i c

Consider a

l

Chest Pain Protocol P

r

o t

B Cardiac Monitor B o

c o

B 12-Lead ECG B l s

No Headache or mental status changes?

Yes

A IV Protocol A P Consider P M IV Labetalol M

M Notify Destination or Contact Medical Control M

Pearls · Recommended Exam: Mental Status, Skin, Neck, Lung, Heart, Abdomen, Back, Extremities, Neuro · Never treat elevated blood pressure based on one set of vital signs or on vital signs alone. · Symptomatic hypertension is typically revealed through end organ damage to the cardiac, CNS or renal systems. · All symptomatic patients with hypertension should be transported with their head elevated.

Protocol 24 2010 Hypotension (Symptomatic)

History Signs and Symptoms Differential · Blood loss - vaginal or · Restlessness, confusion · Shock gastrointestinal bleeding, AAA, · Weakness, dizziness Hypovolemic ectopic · Weak, rapid pulse Cardiogenic · Fluid loss - vomiting, diarrhea, · Pale, cool, clammy skin Septic fever · Delayed capillary refill Neurogenic · Infection · Coffee-ground emesis Anaphylactic · Cardiac ischemia (MI, CHF) · Tarry stools · Ectopic pregnancy

· Dysrhythmias

· Medications

· Allergic reaction · Pulmonary embolus

· Pregnancy · Tension pneumothorax

· History of poor oral intake · Medication effect / overdose · Vasovagal · Physiologic (pregnancy) Legend Universal Patient Care Protocol F First Responder F B EMT B A Advanced EMT A

A IV Protocol A

P Paramedic P

M Medical Control M M

e

d

i

c

a l

Non-cardiac

Trauma Cardiac P

Non-trauma r

o

t o

Normal Saline fluid c A A o

bolus May Repeat X 1 l Treatment per appropriate Treatment per appropriate s Trauma Protocol Cardiac Protocol

P Consider Dopamine P No rales present A Consider Normal A Saline fluid bolus

Notify Destination or M M Contact Medical Control

Notify Destination or M M Contact Medical Control

Pearls · Recommended Exam: Mental Status, Skin, Heart, Lungs, Abdomen, Back, Extremities, Neuro · Consider all possible causes of shock and treat per appropriate protocol. · For non-cardiac, non-trauma hypotension, Dopamine should only be started after 2 liters of NS have been given.

Protocol 25 2010 Hypothermia-Induced

History: Signs and Symptoms: Differential: · Non-traumatic cardiac arrest · Return of pulse · Continue to address specific (drowning and hanging are differentials associated with the permissible in this protocol) original dysrhythmia Legend ROSC F First Responder F

B EMT B

Post-Resuscitation Criteria for Induced Hypothermia and

NO A Advanced EMT A initial temperature > 34 C/93.2˚F

Protocol ˚

P Paramedic P Unsuccessful M Medical Control M Airway Management Advanced airway in place with NO Protocols ETCO2 > 20 mmHg?

Successful Perform Neuro Exam

Expose Patient and Apply Ice

Packs to Axilla and Groin

M e

Cold Saline Bolus 30 d

A A i mL/kg to max 2 L c

Continue to a

l

Monitor P

Dopamine 10-20 mcg/kg/min r P P Temperature o target systolic BP 100 t

and Go to o c

Discontinue Cooling > 33˚C/91.4˚F Post o l

< 33˚C/91.4˚F Reassess Temperature s Measures No Shivering Resuscitation Protocol > 33˚C/91.4˚F and Patient Shivering

Shivering Stops Post-Resuscitation P Etomidate 20 mg IV/IO P Protocol Still Shivering

Consider Vecuronium 0.15 P P mg/kg to max 10 mg

Pearls Inclusion Criteria for Induced Hypothermia · If BIAD is already in place – DO NOT REMOVE to intubate ü ROSC not related to blunt/penetrating trauma or hemorrhage · If no advanced airway can be obtained, cooling may only be ü Age 12 or older OR > 55 Kg with adult body habitus initiated on order from online medical control ü Temperature after ROSC greater than 34˚C/93.2˚F degrees · Take care to protect patient modesty. Undergarments may ü Advanced airway in place with no purposeful response to pain remain in place during cooling ü Comatose after ROSC; GCS < 8 AND No purposeful movement · Do not delay transport to cool · Frequently monitor airway, especially after each patient move EXCLUSION Criteria for Induced Hypothermia · Patients may develop metabolic alkalosis with cooling. Do X Uncontrolled GI Bleeding not hyperventilate. X Conflict with Do Not Resuscitate (DNR) order. · Induction of hypothermia REQUIRES transport of patient to a X Major intracranial, intra-thoracic, or intra-abdominal surgery facility capable of continuing/maintaining hypothermia within last 14 days. protocol. X Sepsis as suspected cause of cardiac arrest. X Cardiovascular instability as evidenced by: uncontrollable arrythmias, refractory hypotension. Protocol 26 2010 Overdose / Toxic Ingestion

History Signs and Symptoms Differential · Ingestion or suspected ingestion of a · Mental status changes · Tricyclic antidepressants (TCAs) potentially toxic substance · Hypotension / hypertension · Acetaminophen (Tylenol) · Substance ingested, route, quantity · Decreased respiratory rate · Aspirin · Time of ingestion · Tachycardia, dysrhythmias · Depressants · Reason (suicidal, accidental, criminal) · Seizures · Stimulants · Available medications in home · Anticholinergic · Past medical history, medications · Cardiac medications

· Solvents, Alcohols, Cleaning agents

· Insecticides (organophosphates)

Legend Universal Patient Care Protocol F First Responder F

B Cardiac Monitor B B EMT B B 12-Lead ECG B A Advanced EMT A A IV Protocol A P Paramedic P B Consider Charcoal if patient alert B M Medical Control M Tricyclic Ingestion?

P P

Sodium Bicarbonate if Tachycardia or QRS widening

Consider Chest Pain Protocol M

e

d

i

c

a l

Respiratory Depression Organophosphates Other P

Carbamates

r

o t P Naloxone P If Available o Hypotension, Seizures, c

B Nerve Agent Antidote Kits B o

Ventricular dysrhythmias, l

No Max Dose s or Mental status changes Atropine P P Notify Destination Pralidoxime (2PAM) M or Contact M Notify Destination or Medical Control M M Contact Medical Control Appropriate Protocol

Pearls · Recommended Exam: Mental Status, Skin, HEENT, Heart, Lungs, Abdomen, Extremities, Neuro · 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. · Bring bottles, contents, emesis to ED. · Tricyclic: 4 major areas of toxicity: seizures, dysrhythmias, hypotension, decreased mental status or coma; rapid progression from alert mental status to death. · Acetaminophen: initially normal or nausea/vomiting. If not detected and treated, causes irreversible liver failure · Aspirin: Early signs consist of abdominal pain and vomiting. Tachypnea and altered mental status may occur later. Renal dysfunction, liver failure, and or cerebral edema among other things can take place later. · Depressants: decreased HR, decreased BP, decreased temperature, decreased respirations, non-specific pupils · Stimulants: increased HR, increased BP, increased temperature, dilated pupils, seizures · Anticholinergic: increased HR, increased temperature, dilated pupils, mental status changes · Cardiac Medications: dysrhythmias and mental status changes · Solvents: nausea, coughing, vomiting, and mental status changes · Insecticides: increased or decreased HR, increased secretions, nausea, vomiting, diarrhea, pinpoint pupils · Consider restraints if necessary for patient's and/or personnel's protection per the Restraint Procedure. · Nerve Agent Antidote kits contain 2 mg of Atropine and 600 mg of pralidoxime in an autoinjector for self administration or patient care. These kits may be available as part of the domestic preparedness for Weapons of Mass Destruction.

Protocol 27 2010 Post Resuscitation

History Signs/Symptoms Differential · Respiratory arrest · Return of pulse · Continue to address specific · Cardiac arrest differentials associated with the original dysrhythmia

Repeat Primary Assessment Legend F First Responder F

Consider Induced Hypothermia Protocol

B EMT B

A Advanced EMT A Continue ventilatory support P Paramedic P • 100% oxygen M Medical Control M B • ETCO2 ideally >20 B • Resp Rate <12 DO NOT HYPERVENTILATE A IV Protocol A B Cardiac Monitor B

F Vital Signs F

Pulse Oximetry

B B M

12 Lead ECG e d

Continue anti-arrythmic if return of i c

P P a

spontaneous circulation was l

P

associated with its use r

o

t o

Significant Ectopy c

Hypotension Bradycardia o

l s

Consider A A Treat per Ventricular Treat per Normal Saline bolus Tachycardia Protocol Bradycardia Protocol Consider Dopamine if P still hypotensive after P fluid bolus If arrest reoccurs, revert to appropriate protocol and/or initial successful treatment Notify Destination M or Contact M Medical Control Pearls · Recommended Exam: Mental Status, Neck, Skin, Lungs, Heart, Abdomen, Extremities, Neuro · Hyperventilation is a significant cause of hypotension and recurrence of cardiac arrest in the post resuscitation phase and must be avoided at all costs. · Most patients immediately post resuscitation will require ventilatory assistance. · The condition of post-resuscitation patients fluctuates rapidly and continuously, and they require close monitoring. Appropriate post-resuscitation management may best be planned in consultation with medical control. · Common causes of post-resuscitation hypotension include hyperventilation, hypovolemia, pneumothorax, and medication reaction to ALS drugs. · Titrate Dopamine to maintain a systolic blood pressure >100. Ensure adequate fluid resuscitation is ongoing. · Induction of hypothermia REQUIRES transport of patient to a facility capable of continuing/maintaining hypothermia protocol. Protocol 28 2010 Pulmonary Edema

History Signs/Symptoms Differential · Congestive heart failure · Respiratory distress, bilateral rales · Myocardial infarction · Past medical history · Apprehension, orthopnea · Congestive heart failure · Medications (Digoxin, Lasix) · Jugular vein distention · Asthma · Erectile Dysfunction Medication · Pink, frothy sputum · Anaphylaxis · Cardiac history –past myocardial · Peripheral edema, diaphoresis · Aspiration infarction · Hypotension, shock · COPD · Chest pain · Pleural effusion

· Pneumonia

· Pulmonary embolus

· Pericardial tamponade

· Toxic Exposure

Universal Patient Care Protocol Legend F First Responder F Add non-rebreather mask at 15 L/min O2 if patient will B EMT B tolerate A Advanced EMT A Obtain and Record P Paramedic P

Pulse Oximetry M Medical Control M

and EtCO2 if available

P Paramedic WITH P M e

Nitroglycerin If BP >110 systolic Online Medical d

P P i M M c

May use Nitroglycerin Paste if available Control a

l

A IV Procedure A P

r o

B 12-Lead ECG Procedure B t

o c

B CPAP if Available B o

l s

Consider P P Furosemide

M Notify Destination or Contact Medical Control M

P Consider P Diazepam, Ativan, or Midazolam if M M needed to better tolerate CPAP

Pearls · Recommended Exam: Mental Status, Skin, Neck, Lung, Heart, Abdomen, Back, Extremities, Neuro · Items in Red Text are key performance measures used to evaluate protocol compliance and care · Avoid Nitroglycerin in any patient who has used erectile dysfunction medication (Viagra or Levitra <24 hours; or Cialis <36 hours) due to potential severe hypotension. · Furosemide and Narcotics have NOT been shown to improve the outcomes of EMS patients with pulmonary edema. This historically has been a mainstay of EMS treatment. · If patient has taken nitroglycerin without relief, consider potency of the medication. · Consider myocardial infarction in all these patients. Diabetics and geriatric patients often have atypical pain, or only generalized complaints. · Carefully monitor the level of consciousness, BP, and respiratory status with the above interventions. · If Nitropaste is used, do not continue to use Nitroglycerin SL · Allow the patient to be in their position of comfort to maximize their breathing effort. · Document CPAP application using the CPAP procedure in the PCR. Document 12 Lead ECG using the 12 Lead ECG procedure. Protocol 29 2010 Pulseless Electrical Activity (PEA)

History Signs and Symptoms Differential · Past medical history · Pulseless · Hypovolemia (Trauma, AAA, · Medications · Apneic other) · Events leading to arrest · Electrical activity on ECG · Cardiac tamponade · End stage renal disease · No heart tones on auscultation · Hypothermia · Estimated downtime · Drug overdose (Tricyclics, · Suspected hypothermia Digitalis, Beta blockers, · Suspected overdose Calcium channel blockers)

· Tricyclics · Massive myocardial infarction

· Digitalis · Hypoxia

· Beta blockers · Tension pneumothorax

· Calcium channel blockers · Pulmonary embolus · DNR form · Acidosis · Hyperkalemia

Cardiac Arrest Protocol Legend F First Responder F B Cardiac Monitor B B EMT B F CPR F AT ANY TIME A Advanced EMT A

Airway Protocol

P Paramedic P

A IV Protocol A

Return of M Medical Control M M e

Spontaneous d

Epinephrine i

Circulation c

or a

P P l

Vasopressin

P r

Atropine if rate <60 o

t

o c

Normal Saline Bolus o

A A l Dextrose 50% s Naloxone Go to P Glucagon (suspected P Post Resuscitation Beta Blocker Overdose Protocol Atropine if rate <60 Bicarbonate (tricyclic overdose, hyperkalemia, P renal failure P Dopamine Chest decompression

Consider P P Epinephrine Drip

Criteria for Discontinuation Yes No Stop resuscitation Notify Destination or M M Contact Medical Control Pearls · Recommended Exam: Mental Status · Consider each possible cause listed in the differential: Survival is based on identifying and correcting the cause! · Discussion with Medical Control can be a valuable tool in developing a differential diagnosis and identifying possible treatment options. Protocol 30 2010 Respiratory Distress

History Signs and Symptoms Differential · Asthma; COPD – chronic · Shortness of breath · Asthma bronchitis, emphysema, · Pursed lip breathing · Anaphylaxis congestive heart failure · Decreased ability to speak · Aspiration · Home treatment (oxygen, · Increased respiratory rate and · COPD (Emphysema, Bronchitis) nebulizer) effort · Pleural effusion · Medications (theophylline, · Wheezing, rhonchi · Pneumonia steroids, inhalers) · Use of accessory muscles · Pulmonary embolus Toxic exposure, smoke inhalation

· · Fever, cough · Pneumothorax

· Tachycardia · Cardiac (MI or CHF)

· Pericardial tamponade

· Hyperventilation · Inhaled toxin (Carbon monoxide, etc.)

Universal Patient Care Protocol Legend Respiratory/Ventilatory Insufficiency? Yes F First Responder F Airway Protocol If Available Measure EtCO2

B EMT B

No

Pulmonary A Advanced EMT A M Yes

Rales or signs of CHF? e

Edema Protocol P Paramedic P d

No i c

M Medical Control M a l

Position Patient for Comfort

P

r

o t

A IV Protocol A o

c

o l

Wheezing Stridor s

Beta-Agonist B B B Normal Saline Nebulized B Albuterol or other Beta-Agonist If No Improvement Repeat Beta-Agonist P P Albuterol or other Beta-Agonist Racemic Epinephrine Nebulized A A If Available with P P Methylprednisolone Ipratropium if Available If No improvement Consider SubCu Terbutaline M M Contact Medical Control P Epinephrine IV 1:10000 P Consider Epinephrine Epinephrine IM 1:1000 B B Auto-Injector IM, If Available or P P P P Methylprednisolone Epinephrine IV/IM

Pearls · Recommended Exam: Mental Status, HEENT, Skin, Neck, Heart, Lungs, Abdomen, Extremities, Neuro · Items in Red Text are key performance measures used to evaluate protocol compliance and care · EMT administration of Beta-Agonists (e.g., Albuterol) is restricted to patients who are under doctor's orders with a prescription for the drug. · Pulse oximetry should be monitored continuously if initial saturation is < or = 96%, or there is a decline in patients status despite normal pulse oximetry readings. · Contact Medical Control prior to administering epinephrine in patients who are >50 years of age, have a history of cardiac disease, or if the patient's heart rate is >150. Epinephrine may precipitate cardiac ischemia. A 12-lead ECG should be performed on these patients. · A silent chest in respiratory distress is a pre-respiratory arrest sign. · ETCO2 should be used when Respiratory Distress is significant and does not respond to initial Beta-Agonist dose.

Protocol 31 2010 Seizure

History Signs and Symptoms Differential · Reported / witnessed seizure activity · Decreased mental status · CNS (Head) trauma · Previous seizure history · Sleepiness · Tumor · Medical alert tag information · Incontinence · Metabolic, Hepatic, or Renal failure · Seizure medications · Observed seizure activity · Hypoxia · History of trauma · Evidence of trauma · Electrolyte abnormality (Na, Ca, Mg) · History of diabetes · Unconscious · Drugs, Medications, · History of pregnancy · Non-compliance

· Infection / Fever

· Alcohol withdrawal

· Eclampsia

· Stroke · Hyperthermia · Hypoglycemia

Universal Patient Care Protocol Legend F First Responder F Spinal Immobilization Protocol B EMT B A Advanced EMT A Status epilepticus Post-ictal

P Paramedic P

Assess Patient M

Airway Protocol M Medical Control M e

B Cardiac Monitor B d i

A IV Protocol A c

a

l

Midazolam (IM/IV) B Blood Glucose B Glucose <60 P r

or o t

Lorazepam (Rectal/IM/IV) A 50% Dextrose A o P P c

or Glucose >60 Glucagon if o l

P P s Diazepam (Rectal/IV) no IV

May Repeat X 1 in 5 min. Seizure Recurs Blood Glucose Midazolam (IM/IV) A If < 60 A or 50% Dextrose Lorazepam (Rectal/IM/IV) P Glucagon if no IV P P or P No Diazepam (Rectal/IV) Still Seizing? May Repeat X 1 in 5 min.

Yes M Contact Medical Control M

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 · Status epilepticus is defined as two or more successive seizures without a period of consciousness or recovery. · This is a true emergency requiring rapid airway control, treatment, and transport. · Grand mal seizures (generalized) are associated with loss of consciousness, incontinence, and tongue trauma. · Focal seizures (petit mal) effect only a part of the body and are not usually associated with a loss of consciousness · Jacksonian seizures are seizures which start as a focal seizure and become generalized. · Be prepared for airway problems and continued seizures. · Assess possibility of occult trauma and substance abuse. · Be prepared to assist ventilations especially if diazepam or midazolam is used. · For any seizure in a pregnant patient, follow the OB Emergencies Protocol. · Diazepam (Valium) is not effective when administered IM. It should be given IV or Rectally. Midazolam is well absorbed when administered IM. Protocol 32 2010 Supraventricular Tachycardia

History Signs and Symptoms Differential · Medications · HR > 150/Min · Heart disease (WPW, Valvular) (Aminophylline, Diet pills, · QRS < .12 Sec (if QRS >.12 sec, · Sick sinus syndrome Thyroid supplements, go to V-Tach Protocol · Myocardial infarction Decongestants, Digoxin, · If history of WPW, go to V-tach · Electrolyte imbalance Ritalin, Adderall) Protocol · Exertion, Pain, Emotional stress · Diet (caffeine, chocolate) · Dizziness, CP, SOB · Fever · Drugs (nicotine, cocaine) · Potential presenting rhythm · Hypoxia Past medical history Atrial/Sinus tachycardia

· · Hypovolemia or Anemia

· History of palpitations / heart Atrial fibrillation / flutter · Drug effect / Overdose (see HX )

racing Multifocal atrial tachycardia · Hyperthyroidism

· Syncope / near syncope · Pulmonary embolus Legend Universal Patient Care Protocol F First Responder F B EMT B A Advanced EMT A A IV Protocol A P Paramedic P Unstable/Altered mental Stable

M Medical Control M status

M

Adenosine e d

B 12-Lead ECG B i

Consider Sedation c

a

l

Midazolam P

r o

May attempt or t o

Valsalva or other c

P Lorazepam P o

vagal maneuver l s P initially and after each P or drug administration if Diazepam indicated Synchronized Adenosine Cardioversion May Repeat as Needed If rhythm changes Go to Appropriate Protocol

Consider Diltiazem P P or Beta-Blocker Notify Destination or Contact B 12-Lead ECG B M M Medical Control Notify Destination or Contact M M Medical Control Pearls · Recommended Exam: Mental Status, Skin, Neck, Lung, Heart, Abdomen, Back, Extremities, Neuro · 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. · Adenosine may not be effective in identifiable atrial flutter/fibrillation, yet is not harmful. · Monitor for hypotension after administration of Calcium Channel Blocker or Beta Blockers. · Monitor for respiratory depression and hypotension associated with Midazolam. · Continuous pulse oximetry is required for all SVT Patients. · Document all rhythm changes with monitor strips and obtain monitor strips with each therapeutic intervention. Protocol 33 2010 Suspected Stroke

History Signs and Symptoms Differential · Previous CVA, TIA's · Altered mental status · See Altered Mental Status · Previous cardiac / vascular · Weakness / Paralysis · TIA (Transient ischemic attack) surgery · Blindness or other sensory loss · Seizure · Associated diseases: diabetes, · Aphasia / Dysarthria · Hypoglycemia hypertension, CAD · Syncope · Tumor · Atrial fibrillation · Vertigo / Dizziness · Trauma · Medications (blood thinners) · Vomiting

· History of trauma · Headache

· Seizures

· Respiratory pattern change

· Hypertension / hypotension

Universal Patient Care Protocol

Screen If Positive and Symptoms < 8 hours, F Prehospital Stroke Screen F Positive transport to the destination as per the EMS System Stroke Plan. Negative

Limit Scene Time to 10 Minutes

Provide Early Notification M e

A IV Protocol A d

i

c a

Glucose <60 l

Blood Glucose P

B B r o

12-Lead ECG t o

A 50% Dextrose A c

o l Consider other protocols as indicated P Glucagon if no IV P s Altered Mental Status

Hypertension Legend

Seizure F First Responder F B EMT B Overdose/Toxic Ingestion A Advanced EMT A P Paramedic P Notify Destination or Contact M M Medical Control M Medical Control M 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 · The Reperfusion Checklist should be completed for any suspected stroke patient. With a duration of symptoms of less than 8 hours, scene times should be limited to 10 minutes, early destination notification/activation should be provided and transport times should be minimized based on the EMS System Stroke Plan. · 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 of the previous night when patient was symptom free) · The differential listed on the Altered Mental Status Protocol should also be considered. · Elevated blood pressure is commonly present with stroke. Consider treatment if diastolic is > 120 mmHg. · 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. · Document the 12 Lead ECG as a procedure in the PCR. Protocol 34 2010 Adult Stroke Patient Destination Determination by Stroke Center Capability

PRIORITY 1 PRIORITY 1 PRIORITY 1 PRIORITY 2 Stroke Patient Stroke Patient Stroke Patient Stroke Patient No Hospital Preference Hospital Preference Hospital Preference (Onset of Symptoms of (Onset of Symptoms of (Onset of Symptoms of (Onset of Symptoms of Stroke within 3 - 8 hours) Stroke within 3 hours) Stroke >8 hours or time Stroke within 3 hours) indeterminate)

Transport to Closest A

Time and Distance to Transport to Closest d Level I, II, III Stroke patient’s hospital of Level 1 Comprehensive u

YES Hospital of Patient’s l choice detrimental to Stroke Hospital. t

Choice or closest Stroke clinical condition? *within 1 hour drive time S

Hospital t

r

o

k

e

D

NO e s

DEFINITION OF ADULT STROKE PATIENT t

i

n

a t

Ø Priority I Adult Stroke Patient i Transport to Level I, II, III Transport to Closest o

Stroke Hospital of Level I or II Stroke Patient with acute stroke symptoms (within eight (8) n

Patient’s Choice Hospital hours of onset) using SCENE Tool D

e

t e

Ø Priority II Adult Stroke Patient r

Patient with acute stroke symptoms > 8 hours of onset or m i

time indeterminate using SCENE Tool n

a

t

i

o n Level I Stroke Hospital Level II Stroke Hospital Level III Stroke Hospital COMPREHENSIVE STROKE CENTER PRIMARY STROKE CENTER STROKE ENABLED CENTER Ø Physician / Nursing Staff trained Ø Physician / Nursing Staff trained Ø Emergency Department 24 hours in neurologic care on-site 24 in neurologic care on-site 24 a day with Physician or physician hours a day hours a day extender and nursing staff trained Ø Organized Emergency Ø Organized Emergency in neurological care on-site 24 Department with written pathway Department with written pathway hours a day. for rapid identification and for rapid identification and Ø CT of the head with technician on- management of acute stroke management of acute stroke site 24 hours a day patient patient Ø Clinical Laboratory Services Ø CT of the head with technician Ø CT of the head with technician Ø Telestroke Video – Conferencing on-site 24 hours a day on-site 24 hours a day Capabilities Ø Clinical Laboratory Services Ø Clinical Laboratory Services Ø 24 / 7 Stroke Call with Capabilities Ø 24 / 7 Stroke Call and capabilities Ø 24 / 7 Stroke Call and capabilities for IV tPA therapy for eligible for IV tPA therapy for eligible for IV tPA therapy for eligible patients patients patients Ø Transfer agreement established in Ø 24 / 7 Endovascular Call and Ø Stroke Registry and Quality advance to ensure orderly capabilities for endovascular Improvement Process transition from Level II Stroke therapy for eligible patients Hospital to specialized stroke Ø 24 / 7 Neurosurgery Call care facility Ø Neuro-Intensive Care Unit and neurointensivists Level IV Non-Stroke Hospitals No organized treatment for acute stroke Ø Stroke Registry and Quality Improvement Process

Protocol 34b 2010 Syncope

History Signs and Symptoms Differential · Cardiac history, stroke, seizure · Loss of consciousness with · Vasovagal · Occult blood loss (GI, ectopic) recovery · Orthostatic hypotension · Females: LMP, vaginal bleeding · Lightheadedness, dizziness · Cardiac syncope · Fluid loss: nausea, vomiting, · Palpitations, slow or rapid pulse · Micturation / Defecation diarrhea · Pulse irregularity syncope · Past medical history · Decreased blood pressure · Psychiatric · Medications · Stroke

· Hypoglycemia

· Seizure

· Shock (see Shock Protocol)

· Toxicologic (Alcohol) · Medication effect (hypotension)

Universal Patient Care Protocol

Spinal Immobilization Protocol

M

A IV Protocol A e

d

i c

B Check Blood Glucose B Glucose <60 A 50% Dextrose A a

l

P r

F Orthostatic Vital Signs F P Glucagon if no IV P o

t

o c

B Cardiac Monitor B o

l s B 12-Lead ECG B

AT ANY TIME If relevant signs / symptoms found go to appropriate protocol: Legend Dysrhythmia F First Responder F Altered Mental Status B EMT B Hypotension A Advanced EMT A P Paramedic P M Medical Control M Notify Destination or Contact M M Medical Control

Pearls · Recommended Exam: Mental Status, Skin, HEENT, Heart, Lungs, Abdomen, Back, Extremities, Neuro · Assess for signs and symptoms of trauma if associated or questionable fall with syncope. · Consider dysrhythmias, GI bleed, ectopic pregnancy, and seizure as possible causes of syncope. · These patients should be transported. · More than 25% of geriatric syncope is cardiac dysrhythmia based. Protocol 35 2010 Ventricular Fibrillation Pulseless Ventricular Tachycardia

History Signs and Symptoms Differential · Estimated down time · Unresponsive, apneic, pulseless · Asystole · Past medical history · Ventricular fibrillation or ventricular · Artifact / Device failure · Medications tachycardia on ECG · Cardiac · Events leading to arrest · Endocrine / Metabolic · Renal failure / dialysis · Drugs · DNR or living will · Pulmonary

Cardiac Arrest Protocol

AT ANY TIME

Defibrillate X 1 (AED ONLY if < Paramedic)

Rhythm Changes to

• if monophasic shock at 360J P P Nonshockable Rhythm • Manual Biphasic typically 120 to 200J After defibrillation resume CPR without pulse check

Legend Airway Protocol F First Responder F Ventilations should be < 12/min

B EMT B F 5 Cycles of CPR F A Advanced EMT A A IV Protocol A

P Paramedic P Go to appropriate

Check Rhythm and Pulse

M Medical Control M

protocol M

Defibrillate X 1 (AED ONLY if < Paramedic) e

d i

• if monophasic shock at 360J c

a

• Manual Biphasic typically 120 to 200J l

P After defibrillation resume CPR w ithout pulse check P P

AT ANY TIME r Epinephrine 1 mg IV/IO repeat every 3-5 minutes o

Return of t o

May give Vasopressin 40 U IV/IO to replace 1st or 2nd Spontaneous c o

dose of Epinephrine Circulation l s

After 5 Cycles of CPR check rhythm and pulse

B Repeat Defibrillation B Consider Amiodarone or Lidocaine P • Amiodarone 1st dose is 300 mg and may be repeated once at 150 mg P • First dose of Lidocaine is 1.5 mg/kg and may be repeated tw ice at 0.75mg Go to Post F Continue CPR F Resuscitation After 5 Cycles of CPR check rhythm and pulse Protocol

Notify Destination No pulse M or Contact M Yes Discontinue Resuscitation Medical Control No Criteria for Discontinuation?

Pearls · Recommended Exam: Mental Status · If no IV, drugs that can be given down ET tube should have dose doubled and then flushed with 5 ml of Normal Saline. IV/IO is the preferred route when available. · Reassess and document endotracheal tube placement and EtCO2 frequently, after every move, and at transfer of care. · Calcium and sodium bicarbonate if hyperkalemia is suspected (renal failure, dialysis). · Treatment priorities are: uninterrupted chest compressions, defibrillation, then IV access and airway control. · Polymorphic V-Tach (Torsades de Pointes) may benefit from administration of magnesium sulfate if available. · Do not stop CPR to check for placement of ET tube or to give medicines. · If arrest not witnessed by EMS then 5 cycles of CPR prior to 1st defibrillation. · Effective CPR and prompt defibrillation are the keys to successful resuscitation. · If BVM is ventilating the patient successfully, intubation should be deferred until rhythm has changed or 4 or 5 defibrillation sequences have been completed. Protocol 36 2009 Ventricular Tachycardia

History Signs and Symptoms Differential · Past medical history / · Ventricular tachycardia on ECG · Artifact / Device failure · medications, diet, drugs. (Runs or sustained) · Cardiac · Syncope / near syncope · Conscious, rapid pulse · Endocrine / Metabolic · CHF · Chest pain, shortness of breath · Drugs · Palpitations · Dizziness · Pulmonary · Pacemaker · Rate usually 150 - 180 bpm for · Allergies: lidocaine / novacaine sustained V-Tach

QRS > .12 Sec ·

Universal Patient Care Protocol Legend

F First Responder F • Palpable pulse? No B EMT B Appropriate Protocol • Wide, regular rhythm with QRS >0.12 s A Advanced EMT A

Yes P Paramedic P M Medical Control M

A IV Protocol A

Stable Unstable M

e d

Consider Sedation i

c a

B 12-Lead ECG B Midazolam l

or P Amiodarone, r

Lorazepam o t

Lidocaine, or o

P Procainamide P P or P c o

Diazepam l (consider in this order s if available) Yes Synchronized Cardioversion If Unsuccessful - Rapid Transport May Repeat as Needed with Early Destination Notification

Becomes Unstable? Amiodarone, Lidocaine, or No P Procainamide P Notify Destination or Contact (consider in this order M M Medical Control if available) 12-Lead ECG B B Repeat Dose or After Conversion Choose Another Drug P Amiodarone, P Notify Destination or Contact Lidocaine, or M M Medical Control Procainamide

Pearls · Recommended Exam: Mental Status, Skin, Neck, Lung, Heart, Abdomen, Back, Extremities, Neuro · For witnessed / monitored ventricular tachycardia, try having patient cough. · Polymorphic V-Tach (Torsades de Pointes) may benefit from the administration of magnesium sulfate if available. · If presumed hyperkalemia (end-state renal disease, dialysis, etc.), administer Sodium Bicarbonate. · Procainamide (if available) is no longer second line agent although it should not be given if there is history of CHF. Protocol 37 2010 Vomiting and Diarrhea

History Signs and Symptoms Differential · Age · Pain · CNS (increased pressure, · Time of last meal · Character of pain (constant, headache, stroke, CNS lesions, · Last bowel movement/ emesis intermittent, sharp, dull, etc.) trauma or hemorrhage, · Improvement or worsening with · Distention vestibular) food or activity · Constipation · Myocardial infarction · Duration of problem · Diarrhea · Drugs (NSAID's, antibiotics, · Other sick contacts · Anorexia narcotics, chemotherapy)

· Past medical history · Radiation · GI or Renal disorders

· Past surgical history Associated symptoms: · Diabetic ketoacidosis

· (Helpful to localize source) ·

Medications Gynecologic disease (ovarian

· Menstrual history (pregnancy) Fever, headache, blurred vision, cyst, PID) · Travel history weakness, malaise, myalgias, · Infections (pneumonia, · Bloody emesis / diarrhea cough, headache, dysuria, mental influenza) status changes, rash · Electrolyte abnormalities · Food or toxin induced · Medication or Substance abuse · Pregnancy · Psychological

Universal Patient Care Protocol

M

e d

Negative F Signs of Hypoperfusion F Positive i c

a

l

P

r

o t D50 in Adults o

B Blood Glucose B <60 A IV Protocol A c

A A o

D25 in Pediatrics l <60 B Blood Glucose B s Glucagon if no P P Normal Saline IV A A Bolus

>60

Vomiting

Legend If Available F First Responder F Ondansetron (Zofran) (age > 1 yr) B EMT B P Prochlorperazine (age > 2 yrs) P A Advanced EMT A Diphenhydramine

P Paramedic P Notify Destination or Contact M M M Medical Control M Medical Control

Pearls · Recommended Exam: Mental Status, Skin, HEENT, Neck, Heart, Lungs, Abdomen, Back, Extremities, Neuro · Document the mental status and vital signs prior to administration of antiemetic medications. · Beware of vomiting only in children. Pyloric stenosis, bowel obstruction, and CNS processes (bleeding, tumors, or increased CSF pressures) all often present with vomiting.

Protocol 38 2010 Childbirth / Labor

History Signs and Symptoms Differential · Due date · Spasmodic pain · Abnormal presentation · Time contractions started / how often · Vaginal discharge or bleeding Buttock · Rupture of membranes · Crowning or urge to push Foot · Time / amount of any vaginal · Meconium Hand bleeding · Prolapsed cord · Sensation of fetal activity · Placenta previa · Past medical and delivery history · Abruptio placenta · Medications · Gravida/Para Status

· High Risk pregnancy

Illicit Drug Use

·

Legend

Universal Patient Care Protocol

F First Responder F

B EMT B

Left Lateral Position

A Advanced EMT A

P Paramedic P

Obstetrical Yes Hypertension? P e

Emergencies Protocol No M Medical Control M d

i

a t

Hypotension? Yes Hypotension Protocol r i

c

No a n

Inspect perineum d

O

(No digital vaginal exam) B

P r

Consider Cardiac Monitoring o

t

o

c

o l

Crowning s >36 weeks gestation Priority symptoms: Crowning Monitor and reassess A IV Protocol A <36 weeks gestation Document frequency and Abnormal Presentation duration of contractions Childbirth Procedure Severe/abnormal vaginal bleeding Multiple gestation If prolapsed cord, push up on head Rapid transport and Newly Born Protocol Early Notification of Destination/Receiving Notify Destination or Contact Facility M M Medical Control Pearls · Recommended Exam (of Mother): Mental Status, Heart, Lungs, Abdomen, Neuro · Document all times (delivery, contraction frequency, and length). · If maternal seizures occur, refer to the Obstetrical Emergencies Protocol. · After delivery, massaging the uterus (lower abdomen) will promote uterine contraction and help to control postpartum bleeding. · Some perineal bleeding is normal with any childbirth. Large quantities of blood or free bleeding are abnormal. · Record APGAR at 1 minute and 5 minutes after birth. (APGAR = Appendix C) Protocol 39 2010 Newly Born

History Signs and Symptoms Differential · Due date and gestational age · Respiratory distress · Airway failure · Multiple gestation (twins etc.) · Peripheral cyanosis or mottling Secretions · Meconium (normal) Respiratory drive · Delivery difficulties · Central cyanosis (abnormal) · Infection · Congenital disease · Altered level of responsiveness · Maternal medication effect · Medications (maternal) · Bradycardia · Hypovolemia · Maternal risk factors · Hypoglycemia substance abuse · Congenital heart disease

smoking · Hypothermia

Universal Patient Care Protocol

Legend

(for mother)

F First Responder F

Dry infant and keep warm.

No

Meconium in amniotic fluid? B EMT B

Bulb syringe suction mouth / nose

A Advanced EMT A

YES with signs of respiratory distress

Stimulate infant and

and/or poor muscle tone P Paramedic P

note APGAR Score

M Medical Control M

B Airway Suction B P e

Respirations present? d

Visualize i

a t

hypopharynx and Yes r i

No c

Perform Deep Suction

P P a

Repeat until free of Heart Rate HR n

BVM 30 seconds d

meconium < 100 at 40-60 O

Oral Intubation HR >100 B

Breaths/minute P

Reassess and r

with 100% o t

Give report to receiving hospital Oxygen o

c o

HR < 60 HR > 100 l HR 60-100 s

Peds Airway Protocol / CPR Pediatric Airway Protocol Monitor Reassess Continue Oxygen Continue Oxygen 5 Minute APGAR HR > 100 A IV Protocol A HR < 60 Reassess heart rate

Appropriate Protocol HR 60-100 Continue Oxygen Pediatric Bradycardia Pediatric Pulseless Arrest A IV Protocol A

Notify Destination or Contact A D10, NS Bolus A M M Medical Control Pearls · Recommended Exam: Mental Status, Skin, HEENT, Neck, Chest, Heart, Abdomen, Extremities, Neuro · CPR in infants is 120 compressions/minute with a 3:1 compression to ventilation ratio · It is extremely important to keep infant warm. · Maternal sedation or narcotics will sedate infant. · Consider hypoglycemia in infant. · Document 1 and 5 minute APGAR in PCR (APGAR = Appendix C) · D10 = D50 diluted (1 ml of D50 with 4 ml of Normal Saline) Protocol 40 2010 Obstetrical Emergency

History Signs and Symptoms Differential · Past medical history · Vaginal bleeding · Pre-eclampsia / Eclampsia · Hypertension meds · Abdominal pain · Placenta previa · Prenatal care · Seizures · Placenta abruptio · Prior pregnancies / births · Hypertension · Spontaneous abortion · Gravida / Para · Severe headache · Ectopic Pregnancy · Visual changes · Edema of hands and face

Universal Patient Care Protocol Legend

F First Responder F

B EMT B

A IV Protocol A

A Advanced EMT A

Vaginal bleeding / Abdominal pain? P Paramedic P

M Medical Control M

No Yes

P

Known pregnancy / Missed period? No e

d i

Yes a t

Yes No r

i c

Left lateral recumbant position

a n

Abdominal d

F Orthostatic BP F Hypertension? No A Pain A O

Protocol B

Yes Yes P

r o

Normal Saline t

History of Seizure or seizure-like activity? No A A o

Bolus c o

Blood Glucose l F F s Measurement Complaint of Labor? Yes A D50 A No P Glucagon if Glucose <60 P Childbirth Protocol Magnesium Sulfate (if Left lateral recumbant P P available) position Active Seizure Activity? Midazolam (IM/IV) P P Lorazepam (IM/IV) Diazepam (IV) Transport to Hospital Notify Destination or Contact M M Medical Control Pearls · Recommended Exam: Mental Status, Abdomen, Heart, Lungs, Neuro · Severe headache, vision changes, or RUQ pain may indicate preeclampsia. · In the setting of pregnancy, hypertension is defined as a BP greater than 140 systolic or greater than 90 diastolic, or a relative increase of 30 systolic and 20 diastolic from the patient's normal (pre-pregnancy) blood pressure. · Maintain patient in a left lateral position to minimize risk of supine hypotensive syndrome. · Ask patient to quantify bleeding - number of pads used per hour. · Any pregnant patient involved in a MVC should be seen immediately by a physician for evaluation and fetal monitoring. · Magnesium may cause hypotension and decreased respiratory drive. Use with caution. Protocol 41 2010 Pediatric Bradycardia

History Signs and Symptoms Differential · Past medical history · Decreased heart rate · Respiratory failure · Foreign body exposure/swallowed · Delayed capillary refill or cyanosis Foreign body · Respiratory distress or arrest · Mottled, cool skin Secretions · Apnea · Hypotension or arrest Infection (croup, epiglotitis) · Possible toxic or poison exposure · Altered level of consciousness · Hypovolemia (dehydration) · Congenital disease · Congenital heart disease · Medication (maternal or infant) · Trauma · Tension pneumothorax

· Hypothermia

· Toxin or medication

· Hypoglycemia

· Acidosis

Legend

Universal Patient Care Protocol

F First Responder F

B EMT B

Pediatric Airway Protocol

A Advanced EMT A

P

IV Protocol P Paramedic P e

Poor perfusion d i Normal Saline M Medical Control M a

Decreased blood pressure Yes A A t

r i

Respiratory insufficiency Bolus c

May Repeat a

No n

d

Monitor and Heart rate in infant <60? O

F F B CPR

reassess

P

r o

Epinephrine 1:10,000 t

P P o

(if on Cardiac Monitor) c

o l Consider s A D10* or D25* or A P Atropine P NS Bolus Glucagon (if no IV) P P Pulse Reassess Naloxone Pulseless Notify Destination or Contact No pulse M M Arrest Protocol Medical Control

Consider External Cardiac Pacing P Consider Glucagon for suspected Beta-Blocker Toxicity P Consider Calcium for Calcium Blocker Toxicity

Pearls · Recommended Exam: Mental Status, HEENT, Skin, Heart, Lungs, Abdomen, Back, Extremities, Neuro · Use Broselow-Luten Tape for Drug Dosages. · Infant = < 1 year of age · The majority of pediatric arrests are due to airway problems. · Most maternal medications pass through breast milk to the infant. · Hypoglycemia, severe dehydration and narcotic effects may produce bradycardia. · Pediatric patients requiring external transcutaneous pacing require the use of pads appropriate for pediatric patients per the manufacturers guidelines. · Minimum Atropine dose is 0.1 mg IV. · * D10 used in Newborn/Infant and D25 used in Pediatric Protocol 42 2010 Pediatric Head Trauma

History Signs and Symptoms Differential · Time of injury · Pain, swelling, bleeding · Skull fracture · Mechanism (blunt vs. penetrating) · Altered mental status · Brain injury (Concussion, · Loss of consciousness · Unconscious Contusion, Hemorrhage or · Bleeding · Respiratory distress / failure Laceration) · Past medical history · Vomiting · Epidural hematoma · Medications · Major traumatic mechanism of · Subdural hematoma · Evidence for multi-trauma injury · Subarachnoid hemorrhage · Evidence of abuse · Seizure · Spinal injury

· Gait Disturbance · Abuse

Legend

Universal Patient Care Protocol

F First Responder F

Pediatric Multiple

No Isolated head trauma? B EMT B

Trauma Protocol

Yes A Advanced EMT A

P Paramedic P

F Spinal Immobilization Protocol F

M Medical Control M

A IV Protocol A P

e

d

i a

Obtain and Record GCS t

r

i c

GCS < 8 a

Pediatric Airway n

No Can patient cough or speak? d

Protocol O

Yes B

P

Basic Airway Maneuvers with BVM r

o

t o

Maintain Pulse Ox Repeat every c

GCS > 8 o

F F 5 minutes

l >90% s

Pediatric Seizure Yes Seizure? Protocol No

A D10* or D25* A < 60 F Blood Glucose F Glucagon (if no IV) P P > 60 Consider Naloxone Monitor and reassess

M Notify Destination or Contact Medical Control M

Pearls · Recommended Exam: Mental Status, HEENT, Heart, Lungs, Abdomen, Extremities, Back, Neuro · If GCS < 12 consider air / rapid transport and if GCS < 8 intubation should be anticipated. · Increased intracranial pressure (ICP) may cause hypertension and bradycardia (Cushing's Response). · Hypotension usually indicates injury or shock unrelated to the head injury. · The most important item to monitor and document is a change in the level of consciousness. · Concussions are periods of confusion or LOC associated with trauma which may have resolved by the time EMS arrives. 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. · * D10 used in Newborn/Infant and D25 used in Pediatric Protocol 43 2010 Pediatric Hypotension

History Signs and Symptoms Differential · Blood loss · Restlessness, confusion, · Trauma · Fluid loss weakness · Infection Vomiting · Dizziness · Dehydration Diarrhea · Increased HR, rapid pulse Vomiting Fever · Decreased BP Diarrhea · Infection · Pale, cool, clammy skin Fever · Congenital Defects · Delayed capillary refill · Congenital heart disease · Birth Complications · Medication or Toxin

· Allergic reaction

Legend

F First Responder F

Universal Patient Care Protocol

B EMT B

Use Age appropriate BP levels

A Advanced EMT A

P Paramedic P

A IV Protocol A

M Medical Control M

P e

Pediatric Multiple d

Yes Evidence or history of trauma? i

Trauma Protocol a

t

r i

No c

a n

Blood Glucose < 60 d F F

Measurement O

D10* or B

A A P

> 60 D25* or

r o

Glucagon t

P P o

(if no IV) c

Normal Saline Bolus (#1) 20cc/Kg o l

A A s may repeat but consider medical history

Consider Repeating A A Normal Saline Bolus (#2) 20cc/Kg

Consider Repeating A A Maximum Total Normal Saline Bolus (#3) 20cc/Kg Boluses 60cc/Kg

P Consider Dopamine P

Notify Destination or Contact M M Medical Control Pearls · Recommended Exam: Mental Status, Skin, HEENT, Heart, Lung, Abdomen, Extremities, Back, Neuro · Consider all possible causes of shock and treat per appropriate protocol. · Decreasing heart rate and hypotension occur late in children and are signs of imminent cardiac arrest. · Most maternal medications pass through breast milk to the infant. Examples: Narcotics, Benzodiazepines. · Consider possible allergic reaction or early anaphylaxis. · If patient has a history of cardiac disease, (prematurity) chronic lung disease, or renal disease limit Normal Saline bolus to 10 ml/kg. · * D10 used in Newborn/Infant and D25 used in Pediatric Protocol 44 2010 Pediatric Multiple Trauma

History Signs and Symptoms Differential (Life Threatening) · Time and mechanism of injury · Pain, swelling · Chest · Height of any fall · Deformity, lesions, bleeding Tension pneumothorax · Damage to structure or vehicle · Altered mental status Flail chest · Location in structure or vehicle · Unconscious Pericardial tamponade · Others injured or dead · Hypotension or shock Open chest wound · Speed and details of MVC · Cardiac/Respiratory Arrest Hemothorax · Restraints / Protective equipment · Intra-abdominal bleeding Car Seat · Pelvis / Femur fracture

Helmet · Spine fracture / Cord injury

Pads · Head injury (see Head Trauma )

· Ejection · Extremity fracture / dislocation

· Past medical history · HEENT (Airway obstruction)

· Medications · Hypothermia

Universal Patient Care Protocol Legend

F First Responder F

Pediatric Assessment Procedure focusing on

B EMT B

initial ABC and level of responsiveness P

A Advanced EMT A e

Spinal Immobilization Protocol d i

P Paramedic P a

t r

Pediatric Airway Protocol if appropriate M Medical Control M i

c

a

n d

F Vital Signs including GCS F

O B

Abnormal Normal

P

r o

Rapid Transport to appropriate destination t Complete Pediatric Assessment o

using c o

EMS System Trauma Plan Splint Suspected Fractures l F F s Limit Scene Time to 10 minutes Provide Control External Hemorrhage Early Notification Transport to appropriate destination using Splint Suspected Fractures EMS System Trauma Plan F F Control External Hemorrhage F Continually Reassess F IV Protocol A A Normal Saline Bolus May repeat for hypotension Tension Pneumothorax? P P Chest Decompression Notify Destination or Contact Consider M M Pediatric Head Injury Protocol Medical Control

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. · Mechanism is the most reliable indicator of serious injury. Examine all restraints / protective equipment for damage. · In prolonged extrications or serious trauma consider air transportation for transport times. · Do not overlook the possibility for child abuse. · Scene times should not be delayed for procedures. These should be performed en route when possible. · Bag valve mask is an acceptable method of managing the airway if pulse oximetry can be maintained above 90%. Protocol 45 2010 Pediatric Pulseless Arrest

History Signs and Symptoms Differential · Time of arrest · Unresponsive · Respiratory failure · Medical history · Cardiac arrest Foreign body, Secretions, · Medications Infection (croup, epiglotitis) · Possibility of foreign body · Hypovolemia (dehydration) · Hypothermia · Congenital heart disease · Trauma · Tension pneumothorax, cardiac tamponade, pulmonary embolism · Hypothermia · Toxin or medication · Electrolyte abnormalities (Glucose, K)

· Acidosis

Universal Patient Care Protocol

F CPR F

P Cardiac Monitor P

Asystole / PEA

Ventricular Fibrillation / Tachycardia

Airw ay Protocol

Give 1 shock P

A A e

Manual: 2J/Kg IV Protocol d i May use AED if >1 year of age (use Epinephrine every 3-5 minutes a AT ANY TIME t

pediatric AED if available for ages 1- r i Return of Consider D10* or D25* c

8 years) a

Immediately start CPR, do not check Spontaneous Continue CPR 5 cycles at a time n Circulation d

for pulse

Check rhythm betw een cycles of CPR O

Airw ay Protocol B

A A Only check for pulse betw een groups of IV Protocol P

5 cycles of CPR and if there is a r o

Give 5 cycles of CPR perfusing rhythm t o

Check rhythm, Check pulse If at any time rhythm becomes c shockable then go to left column of o Shockable rhythm? l this protocol s Yes Go to Post Give 1 shock 4J/Kg or use AED as described above Resuscitation Try to identify and treat the cause: Resume CPR immediately after shock Protocol Hypoxemia Epinephrine IV/IO/ET Acidosis P P and repeat every 3-5 minutes Volume Depletion Tension pneumothorax Continue w ith 5 cycles of CPR after shock Legend Hypothermia Check rhythm, Check pulse F First Responder F Hypoglycemia Shockable rhythm? Hypokalemia Yes B EMT B Hyperkalemia Give 1 shock 4J/Kg or use AED as described above A Advanced EMT A Resume CPR immediately P Paramedic P Consider Amiodarone, P P M Medical Control M Procainamide, or Lidocaine Continue w ith 5 cycles of CPR after shock Notify Destination or Contact M M Check rhythm, Check pulse Medical Control Pearls · Recommended Exam: Mental Status, Heart, Lungs · Monophasic and Biphasic waveform defibrillators should use the same energy levels noted above. · In order to be successful in pediatric arrests, a cause must be identified and corrected. · Airway is the most important intervention. This should be accomplished immediately. Patient survival is often dependent on airway management success. · * D10 used in Newborn/Infant and D25 used in Pediatric Protocol 46 2010 Pediatric Respiratory Distress

History Signs and Symptoms Differential · Time of onset · Wheezing or stridor · Allergic Reaction · Possibility of foreign body · Respiratory retractions · Asthma · Medical history · Increased heart rate · Aspiration · Medications · Altered level of consciousness · Foreign body · Fever or respiratory infection · Nasal flaring / tripoding · Infection · Other sick siblings / contacts · Anxious appearance Pneumonia · History of trauma Croup Epiglotitis

· Congenital heart disease

· Medication or Toxin

· Trauma

Universal Patient Care Protocol

Legend

F First Responder F

Airway

Yes B EMT B

Respiratory/Ventilatory Insufficiency?

Protocol

A Advanced EMT A

No

P Paramedic P P Position Patient for Comfort e

M Medical Control M d

i a

F Pulse Oximetry F t

r

i

c

a

Wheezing Stridor n

d

Patient Assisted Beta-Agonist O

Normal Saline Nebulized B B B B B Albuterol or other Beta Agonist

Consider EPINEPHRINE Auto-Injector P r

If No Improvement o IV Protocol P P A A t Racemic Epinephrine Nebulized o

if SAO2 < 92 after first treatment c IV Protocol o

No Improvement? Repeat Beta-Agonist X 3 l

A A s Albuterol or other Beta Agonist P P if SAO2 < 92 after first treatment with If Available P P Ipratropium (if available) Methylprednisolone or Prednisone If Available P P Methylprednisolone or Prednisone Notify Destination or Contact M M Medical Control

Consider Epinephrine IM or IV P P Repeat Albuterol or Levalbuterol

Pearls · Recommended Exam: Mental Status, HEENT, Skin, Neck, Heart, Lungs, Abdomen, Extremities, Neuro · Items in Red Text are key performance measures used to evaluate protocol compliance and care. · Pulse oximetry should be monitored continuously if initial saturation is < 96%, or there is a decline in patient status despite normal pulse oximetry readings. · Do not force a child into a position. They will protect their airway by their body position. · The most important component of respiratory distress is airway control. · Bronchiolitis is a viral infection typically affecting infants which results in wheezing which may not respond to beta-agonists. Consider Epinephrine if patient < 18 months and not responding to initial beta-agonist treatment. · Croup typically affects children < 2 years of age. It is viral, possible fever, gradual onset, no drooling is noted. · Epiglottitis typically affects children > 2 years of age. It is bacterial, with fever, rapid onset, possible stridor, patient wants to sit up to keep airway open, drooling is common. Airway manipulation may worsen the condition. · Avoid direct laryngoscopy unless intubation is imminent. Protocol 47 2010 Pediatric Seizure

History Signs and Symptoms Differential · Fever · Observed seizure activity · Fever · Prior history of seizures · Altered mental status · Infection · Seizure medications · Hot, dry skin or elevated body · Head trauma · Reported seizure activity temperature · Medication or Toxin · History of recent head trauma · Hypoxia or Respiratory failure · Congenital abnormality · Hypoglycemia · Consider pregnancy in teenage · Metabolic abnormality / acidosis female · Tumor

Legend

Universal Patient Care Protocol

F First Responder F

B EMT B

Post-ictal

Pediatric Airway Protocol

A Advanced EMT A

P Paramedic P

Actively-Seizing

M Medical Control M

Assess Patient

Blood Glucose

F Blood Glucose F Glucose <60

A If < 60 A P e

D10* or D25* d

Glucose >60 A D10* or D25* A i

P Glucagon if no IV P a t

Glucagon (if r i

P P c Evidence of Trauma?

no IV) a

Pediatric Head Injury n

Airway Protocol d

Protocol O

A IV Protocol A F Obtain Temperature F Febrile B

Seizure Recurs P

Midazolam (IM/IV/PR) Cooling Measures r o

Midazolam (IM/IV/PR) If Available t or o

or Tylenol c P Lorazepam (IM/IV/PR) P o

P P l

or Lorazepam (IM/IV/PR) (if ≥ 4 months of s Diazepam (IV/PR) or P age) P May Repeat X 1 after 5 min Diazepam (IV/PR) or Ibuprofen May Repeat X 1 after 5 min (if ≥ 6 months of age)

Still seizing? No Notify Destination or Contact Yes M M Medical Control

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 · Addressing the ABCs and verifying blood glucose is more important than stopping the seizure · Avoiding hypoxemia is extremely important · Status Epilepticus is defined as two or more successive seizures without a period of consciousness or recovery. This is a true emergency requiring rapid airway control, treatment, and transport. · Grand mal seizures (generalized) are associated with loss of consciousness, incontinence, and tongue trauma. · Focal seizures (petit mal) effect only a part of the body and do not usually result in a loss of consciousness. · Jacksonian seizures are seizures which start as a focal seizure and become generalized. · Be prepared to assist ventilations especially if a benzodiazepine is used. · If evidence or suspicion of trauma, spine should be immobilized. · In an infant, a seizure may be the only evidence of a closed head injury. · Rectal Diazepam/Lorazepam: Draw drug dose up in a 3 ml syringe. Remove needle from syringe and attached syringe to an IV extension tube. Cut off the distal end of the extension tube leaving about 3 or 4 inches of length. Insert tube in rectum and inject drug. Flush extension tube with 3 ml of air and remove. · * D10 used in Newborn/Infant and D25 used in Pediatric Protocol 48 2010 Pediatric Supraventricular Tachycardia History Signs and Symptoms Differential · Past medical history · Heart Rate: Child > 180/bpm · Heart disease (Congenital) · Medications or Toxic Ingestion Infant > 220/bpm · Hypo / Hyperthermia (Aminophylline, Diet pills, · Pale or Cyanosis · Hypovolemia or Anemia Thyroid supplements, · Diaphoresis · Electrolyte imbalance Decongestants, Digoxin) · Tachypnea · Anxiety / Pain / Emotional · Drugs (nicotine, cocaine) · Vomiting stress · Congenital Heart Disease · Hypotension · Fever / Infection / Sepsis · Respiratory Distress · Altered Level of Consciousness · Hypoxia

· Syncope or Near Syncope · Pulmonary Congestion · Hypoglycemia

· Prior Hx of SVT? · Syncope · Medication / Toxin / Drugs (see

Hx)

· Pulmonary embolus

· Trauma

· Tension Pneumothorax

Legend

Universal Patient Care Protocol

F First Responder F

B EMT B P e

Continuous Cardiac Monitor A Advanced EMT A d i

P Attempt to Identify Cause P a

P Paramedic P t r

Narrow QRS duration < 0.08 s i c

M Medical Control M

a n

Stable Unstable d

O B

Synchronized Cardioversion A IV Protocol A P P P

(0.5 joules/kg) r

o t

A Consider IV Protocol A o

May attempt c For sedation consider o

Valsalva's maneuver l s Diazepam or P and / or Carotid P P P Massage initially and Midazolam or after each drug Lorazepam If unsuccessful P Repeat Cardioversion P Adenosine P P (1.0 - 2.0 joules/kg) May Repeat X 1 If rhythm changes Go to Appropriate Protocol

Notify Destination or Contact M M Medical Control Pearls · Recommended Exam: Mental Status, Skin, Neck, Lung, Heart, Abdomen, Back, Extremities, Neuro · Carefully evaluate the rhythm to distinguish Sinus Tachycardia, Supraventricular Tachycardia, and Ventricular Tachycardia · Separating the child from the caregiver may worsen the child's clinical condition. · Pediatric paddles should be used in children < 10 kg or Broselow-Luten color Purple · Monitor for respiratory depression and hypotension associated if Diazepam or Midazolam is used. · Continuous pulse oximetry is required for all SVT Patients if available. · Document all rhythm changes with monitor strips and obtain monitor strips with each therapeutic intervention. · As a rule of thumb, the maximum sinus tachycardia rate is 220 – the patient’s age in years. Protocol 49 2010 Bites and Envenomations

History Signs and Symptoms Differential · Type of bite / sting · Rash, skin break, wound · Animal bite · Description or bring creature / · Pain, soft tissue swelling, redness · Human bite photo with patient for identification · Blood oozing from the bite wound · Snake bite (poisonous) · Time, location, size of bite / sting · Evidence of infection · Spider bite (poisonous) · Previous reaction to bite / sting · Shortness of breath, wheezing · Insect sting / bite (bee, wasp, · Domestic vs. Wild · Allergic reaction, hives, itching ant, tick) · Tetanus and Rabies risk · Hypotension or shock · Infection risk · Immunocompromised patient

Universal Patient Care Protocol

Animal Bites: Document contact with Animal No EMS transport? Control Officer if not transported

Yes T

r

a u

Position patient supine m

F F a

P

Immobilize area or limb r

o t

Legend o

Refer to Pain Control Protocol if there c F First Responder F o

is significant pain l B EMT B s A Advanced EMT A If there is allergic reaction refer to Allergic Reaction Protocol P Paramedic P M Medical Control M

Notify Destination or Contact M M South Carolina Poison Control Medical Control Center (803) 765-7359 (800) 222-1222

Pearls · Recommended Exam: Mental Status, Skin, Extremities (Location of injury), and a complete Neck, Lung, Heart, Abdomen, Back, and Neuro exam if systemic effects are noted · Human bites have higher infection rates than animal bites due to normal mouth bacteria. · Carnivore bites are much more likely to become infected and all have risk of Rabies exposure. · Cat bites may progress to infection rapidly due to a specific bacteria (Pasteurella multicoda). · Poisonous snakes in this area are generally of the pit viper family: rattlesnake, copperhead, and water moccasin. · Coral snake bites are rare: Very little pain but very toxic. "Red on yellow - kill a fellow, red on black - venom lack." · Amount of envenomation is variable, generally worse with larger snakes and early in spring. · If no pain or swelling, envenomation is unlikely (except for Coral snakes). · Black Widow spider bites tend to be minimally painful, but over a few hours, muscular pain and severe abdominal pain may develop (spider is black with red hourglass on belly). · Brown Recluse spider bites are minimally painful to painless. Little reaction is noted initially but tissue necrosis at the site of the bite develops over the next few days (brown spider with fiddle shape on back). · Evidence of infection: swelling, redness, drainage, fever, red streaks proximal to wound. · Immunocompromised patients are at an increased risk for infection: diabetes, chemotherapy, transplant patients. · Consider contacting the South Carolina Poison Control Center for guidance (1-800-222-1222). Protocol 50 2010 Burns: Thermal

History Signs and Symptoms Differential · Type of exposure (heat, gas, chemical) · Burns, pain, swelling · Superficial (1st Degree) red and painful · Inhalation injury · Dizziness · Partial Thickness (2nd Degree) blistering · Time of Injury · Loss of consciousness · Full Thickness (3rd Degree) painless/ · Past medical history and Medications · Hypotension/shock charred or leathery skin · Other trauma · Airway compromise/distress · Thermal · Loss of Consciousness · singed facial or nasal hair · Chemical · Tetanus/Immunization status · Hoarseness / wheezing · Electrical · Radiation

Legend Universal Patient Care Protocol F First Responder F B EMT B A Advanced EMT A Critical Serious Minor P Paramedic P (Red) (Yellow) (Green) M Medical Control M

5-15% TBSA 2nd/3rd Degree Burn >15% TBSA 2nd/3rd Degree Burn Suspected Inhalation injury or Burns with Multiple Trauma < 5% TBSA 2nd/3rd Degree Burn T

requiring intubation for airway r

Burns with definite airway No inhalation injury, Not a stabilization compromise Intubated, u

Hypotension or GCS < 14 m (When reasonable or reasonably Normotensive

(When reasonable or reasonably a

accessible, GCS>14

accessible, P transport to a Burn Center or (Transport to the Local Hospital)

transport to a Burn Center or r

Level I Trauma Center) o

Level I Trauma Center) t

o

c

o l Remove Rings, Bracelets, and Cool Dow n the Wound w ith s other Constricting items Normal Saline Airway Protocol Cover Burn w ith Dry sterile sheet or dressings Cover Burn w ith Dry sterile sheet or dressings

IV NS / RL, 2 large bore IVs, infuse total of 0.25 x kg body A w t. x % TBSA per hour for A up to the first 8 hrs. (More info below) IV NS / RL, infuse total of 0.25 x kg body w t. x A % TBSA per hour for up A Pain Control Protocol to the first 8 hrs. (More info below) Notify Destination or M M Contact Medical Control

1. The IV solution should be changed to Lactated Ringers if it is available. It is preferred over Normal Saline. Pearls 2. Formula example and a rule of thumb is; an 80 kg patient with 50% · Burn patients are Trauma Patients, evaluate for multisystem trauma. TBSA will need 1000 cc of fluid per hour. · Assure whatever has caused the burn, is no longer contacting the injury. · Critical or Serious Burns (Stop the burning process!) · > 5-15% total body surface area (TBSA); 2nd or 3rd degree burns, or · Recommended Exam: Mental Status, HEENT, Neck, Heart, Lungs, Abdomen, Extremities, Back, and Neuro · 3rd degree burns > 5% TBSA for any age group, or · Early intubation is required when the patient experiences significant · circumferential burns of extremities, or inhalation injuries. · electrical or lightning injuries, or · Potential CO exposure should be treated with 100% oxygen. (For · suspicion of abuse or neglect, or patients suffering from CO inhalation, transport to a hospital equipped inhalation injury, or · with a hyperbaric chamber is indicated [when reasonably accessible].) · chemical burns, or · Circumferential burns to extremities are dangerous due to potential · burns of face, hands, perineum, or feet, or vascular compromise secondary to soft tissue swelling. · any burn requiring hospitalization. · Burn patients are prone to hypothermia - never apply ice or cool burns, (These burns will require direct transport to a burn center, or transfer once must maintain normal body temperature. seen at a local facility where the patient can be stabilized with interventions · Evaluate the possibility of child abuse with children and burn injuries. such as airway management or pain relief if this is not available in the field or the distance to a Burn Center is significant.) Protocol 51 2010 Burns: Chemical and Electrical

History Signs and Symptoms Differential · Type of exposure (heat, gas, chemical) · Burns, pain, swelling · Superficial (1st Degree) red and painful · Inhalation injury · Dizziness · Partial Thickness (2nd Degree) blistering · Time of Injury · Loss of consciousness · Full Thickness (3rd Degree) painless/ · Past medical history and Medications · Hypotension/shock charred or leathery skin · Other trauma · Airway compromise/distress · Thermal · Loss of Consciousness · singed facial or nasal hair · Chemical · Tetanus/Immunization status · Hoarseness / wheezing · Electrical · Radiation

Universal Patient Care Protocol Legend

P Cardiac Monitor P F First Responder F B EMT B Eye Involvement? Continuous saline flush A Advanced EMT A in affected eye. Flush with water or Normal Saline for 10- P Paramedic P 15 minutes. M Medical Control M

F Remove Rings, Bracelets, and other F T r

Constricting items. Remove clothing or a u

expose area. m

Identify entry and exit sites, apply sterile a

P

dressings. r

o t

Pain Control Protocol o

c

o l

(IV only for serious/critical burn patients) s A A IV Protocol NS / RL Bolus

Chemical and Electrical Burn Patients Must be Triaged using the Guidelines below and their care must conclude in the Thermal Burn Protocol

Critical Serious Minor (Red) (Yellow) (Green)

5-15% TBSA 2nd/3rd Degree Burn >15% TBSA 2nd/3rd Degree Burn Suspected Inhalation injury or requiring Burns with Multiple Trauma < 5% TBSA 2nd/3rd Degree Burn intubation for airway stabilization Burns with definite airway compromise No inhalation injury, Not Intubated, Hypotension or GCS < 14 (When reasonable or reasonably Normotensive (When reasonable or reasonably accessible, GCS>14 accessible, transport to a Burn Center or Level I (Transport to the Local Hospital) transport to a Burn Center or Level I Trauma Center) Trauma Center) Pearls Chemical Pearls Electrical · Refer to Decontamination Standard Procedure (Skill) WMD Page · Do not contact the patient until you are certain the source of the · Certainly 0.9% NaCl Soln or Sterile Water is preferred, however if it electric shock has been disconnected. is not readily available, do not delay, use tap water for flushing the · Attempt to locate contact points, (entry wound where the AC source affected area or other immediate water sources. Flush the area as contacted the patient, an exit at the ground point) both sites will soon as possible with the cleanest readily available water or saline generally be full thickness. solution using copious amounts of fluids. · Cardiac monitor, anticipate ventricular or atrial irregularity, to include Vtach, V-fib, heart blocks, etc. · If able, identify the nature of the electrical source (AC vs. DC), the amount of voltage and the amperage the patient may have been exposed to during the electrical shock. Protocol 52 2010 Drowning

History Signs and Symptoms Differential · Submersion in water regardless of · Unresponsive · Trauma depth · Mental status changes · Pre-existing medical problem · Possible trauma to C-spine · Decreased or absent vital signs · Pressure injury (diving) · Possible history of trauma ie: · Vomiting · Barotrauma diving board · Coughing · Decompression sickness · Duration of immersion · Apnea · Post-immersion syndrome · Temperature of water or · Stridor · Hypothermia · possibility of hypothermia · Wheezing · Rhales

Legend Universal Patient Care Protocol F First Responder F

B EMT B

T r

A Advanced EMT A Spinal Immobilization Protocol a u

P Paramedic P m

Cardiac Monitor a

M Medical Control M B B P

Pulse Oximetry r o

Capnography if Available t

o c

Apply 12-Lead ECG o

l s Consider CPAP if available for respiratory distress

A IV Protocol A

Consider Albuterol or other Beta- Agonist for respiratory distress

Monitor and reassess

Appropriate Protocol based on symptoms

Notify Destination or Contact M M Medical Control

Pearls · Recommended Exam: Trauma Survey, Head, Neck, Chest, Abdomen, Pelvis, Back, Extremities, Skin, Neuro · Have a high index of suspicion for possible spinal injuries. · With cold water no time limit -- resuscitate all. These patients have an increased chance of survival. · Some patients may develop delayed respiratory distress. · All victims should be transported for evaluation due to potential for worsening over the next several hours. · Drowning is a leading cause of death among would-be rescuers. · Allow appropriately trained and certified rescuers to remove victims from areas of danger. · With pressure injuries (decompression / barotrauma), consider transport to or availability of a hyperbaric chamber. Protocol 53 2010 Extremity Trauma

History Signs and Symptoms Differential · Type of injury · Pain, swelling · Abrasion · Mechanism: crush / penetrating / · Deformity · Contusion amputation · Altered sensation / motor function · Laceration · Time of injury · Diminished pulse / capillary refill · Sprain · Open vs. closed wound / fracture · Decreased extremity temperature · Dislocation · Wound contamination · Fracture · Medical history · Amputation · Medications · Tetanus Hx

Legend

F First Responder F Universal Patient Care Protocol B EMT B A Advanced EMT A

P Paramedic P T r

Wound Care a

M Medical Control M u

F Control Hemorrhage with Pressure F m

Splinting as required a

If hemorrhage can not be controlled P r

by direct pressure and is life o t

B B o

threatening then consider c

Touniquet procedure o l IV Protocol if life or limb s A threatening event or if pain A medication needed

Pain Control Protocol

If amputation Clean amputated part Wrap part in sterile dressing soaked F F in normal saline and place in air tight container. Place container on ice if available

Notify Destination or Contact M M Medical Control

Pearls · Recommended Exam: Mental Status, Extremity, Neuro · Peripheral neurovascular status is important. · In amputations, time is critical. Transport and notify medical control immediately, so that the appropriate destination can be determined. · Hip dislocations and knee and elbow fracture / dislocations have a high incidence of vascular compromise. · Urgently transport any injury with vascular compromise. · Blood loss may be concealed or not apparent with extremity injuries. · Lacerations must be evaluated for repair within 6 hours from the time of injury. Protocol 54 2010 Head Trauma

History Signs and Symptoms Differential · Time of injury · Pain, swelling, bleeding · Skull fracture · Mechanism (blunt vs. penetrating) · Altered mental status · Brain injury (Concussion, · Loss of consciousness · Unconscious · Contusion, Hemorrhage or · Bleeding · Respiratory distress / failure Laceration) · Past medical history · Vomiting · Epidural hematoma · Medications · Major traumatic mechanism of injury · Subdural hematoma · Evidence for multi-trauma · Seizure · Subarachnoid hemorrhage · Spinal injury · Abuse

Universal Patient Care Protocol Legend F First Responder F Adult Multiple No Isolated head trauma? Trauma Protocol B EMT B Yes A Advanced EMT A P Paramedic P Spi Spinal Immobilization Protocol

nal M Medical Control M T

r a

A IV Protocol A u

m

a

Obtain and Record GCS P

r o

GCS < 8 t

If intubation required, o c

P consider Lidocaine if P No Can patient cough or speak? o

l s available Yes

Airway Protocol Basic Airway Maneuvers with BVM

Maintain Pulse Ox > 90% Repeat every F F 5 minutes Maintian EtCO2 between 35 and 45 GCS > 8 Seizure Protocol Yes Seizure? No

A D50 A < 60 F Blood Glucose F Glucagon (if no IV) P P > 60 Consider Naloxone Monitor and reassess

M Notify Destination or Contact Medical Control M Pearls · Recommended Exam: Mental Status, HEENT, Heart, Lungs, Abdomen, Extremities, Back, Neuro · If GCS < 12 consider air / rapid transport · In the absence of Capnography, hyperventilate the patient (adult: 20 breaths/min, child: 30, infant: 35) only if ongoing evidence of brain herniation (blown pupil, decorticate or decerebrate posturing, or bradycardia) · Increased intracranial pressure (ICP) may cause hypertension and bradycardia (Cushing's Response). · Hypotension usually indicates injury or shock unrelated to the head injury and should be aggressively treated. · The most important item to monitor and document is a change in the level of consciousness. · Consider Restraints if necessary for patient’s and/or personnel’s protection per the Restraint Procedure. · Limit IV fluids unless patient is hypotensive. · Concussions are periods of confusion or LOC associated with trauma which may have resolved by the time EMS arrives. 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. · In areas with short transport times, RSI/Drug-Assisted Intubation is not recommended for patients who are spontaneously breathing and who have oxygen saturations of greater than 90% with supplemental oxygen. Protocol 55 2010 Hyperthermia

History Signs and Symptoms Differential · Age · Altered mental status or · Fever (Infection) · Exposure to increased unconsciousness · Dehydration temperatures and / or humidity · Hot, dry or sweaty skin · Medications/Drugs · Past medical history / medications · Hypotension or shock · Hyperthyroidism (Storm) · Extreme exertion · Seizures · Delirium tremems (DT's) · Time and length of exposure · Nausea · Heat cramps · Poor PO intake · Heat exhaustion · Fatigue and / or muscle cramping · Heat stroke · EtOH / Illicit Drug Use · CNS lesions or tumors

Legend Universal Patient Care Protocol F First Responder F B EMT B A Advanced EMT A

Cardiac Monitor T r

P Paramedic P B B a

Apply 12-Lead ECG u

M Medical Control M m

a

Document Patient Temperature P

Remove from heat source r o

Remove clothing t o

Apply room temperature water to c

F F o

skin and increase air flow around l s patient Consider ice packs to groin and axillae A IV Protocol A

Monitor and reassess

Appropriate Protocol based on symptoms

Notify Destination or Contact M M Medical Control

Pearls · Recommended Exam: Mental Status, Skin, HEENT, Heart, Lungs, Neuro · Extremes of age are more prone to heat emergencies (i.e. young and old). · Predisposed by use of: tricyclic antidepressants, phenothiazines, anticholinergic medications, and alcohol. · Cocaine, Amphetamines, and Salicylates may elevate body temperatures. · Sweating generally disappears as body temperature rises above 104˚ F (40˚ C). · Intense shivering may occur as patient is cooled. · Heat Cramps consists of benign muscle cramping 2˚ to dehydration and is not associated with an elevated temperature. · Heat Exhaustion consists of dehydration, salt depletion, dizzyness, 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. Protocol 56 2010 Hypothermia

History Signs and Symptoms Differential · Past medical history · Cold, clammy · Sepsis · Medications · Shivering · Environmental exposure · Exposure to environment even in · Mental status changes · Hypoglycemia normal temperatures · Extremity pain or sensory · CNS dysfunction · Exposure to extreme cold abnormality Stroke · Extremes of age · Bradycardia Head injury · Drug use: Alcohol, barbituates · Hypotension or shock Spinal cord injury · Infections / Sepsis · Length of exposure / Wetness

Legend Universal Patient Care Protocol F First Responder F B EMT B B Cardiac Monitor B A Advanced EMT A Temperature < 95˚F (35˚C) Yes

P Paramedic P T r Handle very gently a M Medical Control M u

F Remove wet clothing F m

a

Hot Packs and Blankets

P r

F Blood Glucose F o

t

o c

No A IV Protocol A o

l s If Glucose < 60 A D50 if Adult A D10 if Pediatric Glucagon (if no IV) P P Consider Naloxone

Appropriate Protocol based on symptoms

Notify Destination or Contact M M Medical Control Pearls · Recommended Exam: Mental Status, Heart, Lungs, Abdomen, Extremities, Neuro · NO PATIENT IS DEAD UNTIL WARM AND DEAD. · Defined as core temperature < 35˚C (95˚F). · Extremes of age are more susceptable (i.e. young and old). · With temperature less than 30˚C (86˚F) ventricular fibrillation is common cause of death. Handling patients gently may prevent this. · If the temperature is unable to be measured, treat the patient based on the suspected temperature. · Hypothermia may produce severe bradycardia so take at least 45 second to palpate a pulse. · Hot packs can be activated and placed in the armpit and groin area if available. Care should be taken not to place the packs directly against the patient's skin. · Consider withholding CPR if patient has organized rhythm or has other signs of life. Discuss with Medical Control. · Intubation can cause ventricular fibrillation so it should be done gently by most experienced person. · Do not hyperventilate the patient as this can cause ventricular fibrillation. · If the patient is below 30˚C or 86˚F then only defibrillate 1 time if defibrillation is required. Normal defibrillation procedure may resume once patient reaches 30˚C or 86˚F. · Below 30˚C (86˚F) antiarrythmics may not work and if given should be given at reduced intervals. Contact medical control before they are administered. · Below 30˚C or (86˚F) pacing should not be done Protocol 57 2010 Multiple Trauma

History Signs and Symptoms Differential (Life threatening) · Time and mechanism of injury · Pain, swelling · Chest · Damage to structure or vehicle · Deformity, lesions, bleeding Tension pneumothorax · Location in structure or vehicle · Altered mental status or Flail chest · Others injured or dead · unconscious Pericardial tamponade · Speed and details of MVC · Hypotension or shock Open chest wound · Restraints / protective equipment · Arrest Hemothorax · Past medical history · Intra-abdominal bleeding · Medications · Pelvis / Femur fracture · Spine fracture / Cord injury · Head injury (see Head Trauma) · Extremity fracture / Dislocation · HEENT (Airway obstruction) · Hypothermia

Universal Patient Care Protocol Legend F First Responder F Adult Assessment Procedure focusing on initial ABC and level of responsiveness B EMT B

A Advanced EMT A T

Spinal Immobilization Protocol r a

P Paramedic P u m Airway Protocol if appropriate

M Medical Control M a

P

P Consider insertion of Oro-Gastric Tube P r

o

t

o c

F Vital Signs including GCS F o

l s Abnormal Normal

Rapid Transport to appropriate destination Complete Assessment using EMS System Trauma Plan Splint Suspected Fractures Limit Scene Time to 10 minutes Provide F Consider Pelvic Binding F Early Notification Control External Hemorrhage Transport to appropriate destination using IV Protocol EMS System Trauma Plan A A Normal Saline Bolus F Continually Reassess F May repeat for hypotension Splint Suspected Fractures F Consider Pelvic Binding F Control External Hemorrhage Tension Pneumothorax? P P Chest Decompression Consider Notify Destination or Contact M M Head Injury Protocol Medical Control 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. · Geriatric patients should be evaluated with a high index of suspicion. Often occult injuries are more difficult to recognize and patients can decompensate unexpectedly with little warning. · Mechanism is the most reliable indicator of serious injury. · In prolonged extrications or serious trauma, consider air transportation for transport times and the ability to give blood. · Do not overlook the possibility of associated domestic violence or abuse. · Scene times should not be delayed for procedures. These should be performed en route when possible. Rapid transport of the unstable trauma patient is the goal. · Bag valve mask is an acceptable method of managing the airway if pulse oximetry can be maintained above 90% Protocol 58 2010 WMD-Nerve Agent Protocol

History Signs and Symptoms Differential · Exposure to chemical, biologic, · Visual Disturbances · Nerve agent exposure (e.g., VX, radiologic, or nuclear hazard · Headache Sarin, Soman, etc.) · Potential exposure to unknown · Nausea/Vomiting · Organophosphate exposure substance/hazard · Salivation (pesticide) · Lacrimation · Vesicant exposure (e.g., · Respiratory Distress Mustard Gas, etc.) · Diaphoresis · Respiratory Irritant Exposure · Seizure Activity (e.g., Hydrogen Sulfide, · Respiratory Arrest Ammonia, Chlorine, etc.)

Ensure Scene Safety and Proper PPE Legend F First Responder F Universal Patient Care Protocol B EMT B A Advanced EMT A

Obtain history of exposure P Paramedic P T r Observe for specific toxidromes a M Medical Control M u

Initiate triage and/or decontamination as m a

indicated

P

r

o t

Assess for presence of major or minor Major Symptoms: o c

symptoms. There must be symptoms Altered Mental Status, Seizures, o l

before treatment. Respiratory Distress s

Minor Symptoms: Nerve Agent Kit IM Salivation, Lacrimation, Visual B X 3 rapidly B Disturbances (See Pediatric Doses Below)

A IV Protocol A A IV Protocol A Atropine If Seizures: 2 mg IV/IM q 5 min Notify P Midazolam (IV/IM) P P P (0.02-0.05 mg/kg) Destination or Lorazepam (IV/IM) until symptoms resolve M Contact M Atropine Medical 2 mg IV/IM q 5 min Pralidoxime 1 gram (15- Control P P P 25 mg/kg for Peds) IV P (0.02-0.05 mg/kg) over 30 minutes until symptoms resolve Pralidoxime 2 grams Monitor for appearance of major symptoms P (15-25 mg/kg for Peds) P IV over 30 minutes Pearls · In the face of a bona fide attack, begin with 1 Nerve Agent Kit for patients less than 7 years of age, 2 Nerve Agent Kits from 8 to 14 years of age, and 3 Nerve Agent Kits for patients 15 years of age and over. · If Triage/MCI issues exhaust supply of Nerve Agent Kits, use pediatric atropens (if available). Use the 0.5 mg dose if patient is less than 40 pounds (18 kg), 1 mg dose if patient weighs between 40 to 90 pounds (18 to 40 kg), and 2 mg dose for patients greater than 90 pounds (>40 kg). · Follow local HAZMAT protocols for decontamination and use of personal protective equipment · For patients with major symptoms, there is no limit for atropine dosing. · Carefully evaluate patients to ensure they are not reacting from exposure to another agent (e.g., narcotics, vesicants, etc.) · Each Nerve Agent Kit contains 600 mg of Pralidoxime (2-PAM) and 2 mg of Atropine · The main symptom that the atropine addresses is excessive secretions so atropine should be given until salivation improves. Protocol 59 2010 Field Triage and Bypass

Universal Patient Care Protocol

Adult Assessment Procedure focusing on initial ABC and level of responsiveness Spinal Immobilization Protocol Airway Protocol if appropriate

Glasgow Coma Scale < 14 or Yes Systolic blood pressure, mm Hg < 90 or Age Appropriate hypotension; or No Respiratory rate < 10 or > 29 per minute (< 20 in infant less than 1 year)

Transport to closest designated trauma Assess anatomy of injury: center available. Air transport or • Penetrating injuries to head, neck, torso or • Amputation proximal to w rist or ankle bypass of level 3 trauma center to level extremity to elbow and knee 1 or level 2 trauma center should be • Flail chest • Clinically apparent pelvic fracture considered if distance and • Tw o or more proximal long bone fractures • Paralysis circumstances are appropriate and/or • Crush, de-gloved, or mangled extremity • Severe burns w ith other traumatic injuries

no level 3 trauma center is available. • Isolated severe burns T

r a

Yes No u

m a

Transport to closest designated trauma Assess mechanism of injusry and evidence of high energy impact: P

center available. Air transport or • Fall >20 ft. in adult (one story = 10 feet) • Death in same passenger compartment r o

bypass of level 3 trauma center to level • Fall > 10 ft. or tw o to three times the height • Pedestrian struck by vehicle, throw n, run t o

1 or level 2 trauma center should be of a child over, or w ith impact > 20 MPH c considered if distance and • Bicyclist throw n, run over, or w ith impact o • Intrusion > 12 inches occupant side l circumstances are appropriate and/or > 20 MPH s no level 3 trauma center is available. • Intrusion > 18 inches on any side • Motorcycle crash > 20 MPH • Ejection (partial or complete) from automobile

No Transport to closest available trauma Yes center. A lower level trauma center Assess special patient or system considerations: should not be bypassed to • Older adults • End stage renal disease requiring dialysis transport to a higher level trauma • Children • Pregnancy > 20 w eeks center. If no trauma center is available, • Patients w ith bleeding disorders or on anti- transport to closest appropriate hospital coagulation medication emergency department for evaluation and transfer as necessary. Air Yes No transport from incident scene is rarely appropriate.

Transport to closest available trauma center. A lower Transport according to usual level trauma center should not be bypassed to transport protocol. transport to a higher level trauma center. If no trauma center is available, transport to closest appropriate hospital emergency department for evaluation and transfer as necessary.

Pearls · Decision to call for on-scene Air Transport should come from South Carolina certified personnel associated with a South Carolina Licensed EMS or First Responder Agency. · EMS Service must identify - in their local protocols - appropriate hospitals when no trauma center is available. · Transport Destination is chosen based on the EMS System Trauma Plan with EMS pre-arrival notification. · Geriatric patients should be evaluated with a high index of suspicion. Often occult injuries are more difficult to recognize and patients can decompensate unexpectedly with little warning. · Mechanism is the most reliable indicator of serious injury. · In prolonged extrications or serious trauma, consider air transportation for transport times and the ability to give blood. · Scene times should not be delayed for procedures. These should be performed en route when possible. Rapid transport of the unstable trauma patient is the goal. Protocol 60 2010