Altered Mental Status

Universal Patient Care

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

Evaluate Mechanism of Injury (MOI) Mental Status General SectionProtocols General Consider Spinal Immobilization Exam If indicated

Unresponsive Responsive

Significant MOI No Significant MOI Primary and Chief Complaint secondary Obtain assessment SAMPLE Primary and Primary and Secondary Secondary trauma trauma assessment assessment Obtain history of Primary and Focused assessment present illness from Secondary on specific injury available sources / assessment Obtain VS scene survey Focused assessment Obtain SAMPLE on specific complaint Obtain SAMPLE Obtain VS

Repeat assessment while preparing for transport

Exit to Continue on-going assessment Exit to Appropriate Protocol Repeat initial VS Appropriate Protocol Evaluate interventions / procedures Transfer Patient hand-off includes patient information, personal property and summary of care and Patient does not Patient does not response to care fit specific fit specific protocol protocol Notify Destination or Contact Medical Control

Revised Protocol 1 10/3/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 General Section Protocols . 2012 / injury 49 kg. ≤ . weight weight , 15 ; Events leadingillness to . , Age ≤ . A palpated Systolic reading may be necessary at times. ≤ 11 years of age PMH; Last oral intake Protocol 1 's clinical condition and the transportpolicy . Diastolic reading Medications ; Universal Patient Care Patient Universal Minimal exam if not noted on the specific protocol is vital signs, mental status with the specific protocol noted on Minimal exam if not : / Symptoms; Allergies ; Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Recommended Exam Any patient contact which does not result in an EMS transport must have a completed disposition form transport resultin an EMS must have a completed disposition not does Any patient contact which and location of injury or complaint of injury or location GCS, and Luten tape the Broselow-Luten on by fitting defined A pediatric patient is Timingtransport of should be based on patient SAMPLE: Signs Pediatric AirwayProtocols are by patients defined Never hesitate to contact medical control who for patient refuses transport. Blood Pressureisdefined as a Systolic / Revised 10/3/2012 Pearls · · · · · · · · Adult General Section Protocols 2012 ? CPAP / Pediatric YES / Exit to ≥ 90% Protocol Effective BVM if indicated Adult Supplementaloxygen BVM Consider Airway CPAP Procedure Appropriate Protocol a Tracheostomy Tube Supplementaloxygen Goal oxygen saturation Respiratory Distress With I NO YES YES Reassess / Nasotracheal NO NO YES / if available if indicated Breathing Adequate? if indicated Oxygenation / Consider Sedation Protocol 2 Oral AirwayPatent ? Intubation Procedure Supportneeded ? Consider RSI Protocol Monitor Consider AMS Protocol If BIAD or ETT in place in If BIAD or ETT appropriate protocol AirwayBIAD Procedure Supplemental Oxygen Breathing / Oxygenation Notify Destination or Spinal Immobilization Procedure

open airway chin / jaw thrust lift nasal or oral airway Bag-valve mask (BVM) Contact Medical Control BasicManeuvers First - - - to Exit

, Effort Assess Respiratory Rate, Is Airway I P P B Adult Airway Adult NO NO ) as ? . should be 3 . ) /I . (1 P - Direct Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS YES 1, 2 and management Laryngoscopy

Surgical Procedure AirwayForeign Body information for airway AirwayCricothyrotomy Obstruction Procedure they contain very useful utilized (evenif together Exit to attempts. Protocol agency is not using RSI Complete Obstruction Protocols with continued Revised attempts by most 8/13/2012 Unable to Ventilate I intubation attempts Adult Failed Airway P Anatomy inconsistent or more unsuccessful during or after one experienced EMT andOxygenate ≥ 90% Three (3) unsuccessful Adult General Section Protocols . 2012 . . Luten Tape. Luten transfers. . / 35. . 30- of They may worsen view in somecases 2 . . Avoid hyperventilation 45. in absence of trauma) to better maintain ETT . 35- of 2 or patients longer than the Broselow than - or patients longer tracheal intubation is unsuccessful Protocol 2 Adult Airway Adult is strongly recommended for the monitoring of all patients with a BIAD patients with or of all themonitoring ) is strongly recommended for per minute to maintain a EtCO per minute to -10 8 . Document results . methods of intubation is mandatorywith all or capnography . . . (Color) Manual stabilization of endotracheal tube should be used duringall patient moves spine immobilization for patients with suspected spinal injury . Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Gastric tube placement shouldbe considered in allintubated patientsif available or time allows isimportantIt to secure the endotracheal tubewell andconsider c-collar ( placement . This protocol is only for use in patients with an Age ≥ 12 an Age ≥ with usein patients for only protocol is This Capnometry capnography (EtCO2 Continuous endotracheal tube Hyperventilation in deteriorating headtrauma shouldonly be doneto maintain a EtCO it is acceptable to pulse oximetryvalues ≥ 90%, it of BVM continuous effective maintained by with If an airway is being . basicairwaymeasures a BIAD or Intubation with instead of using continue appropriate oxygenation and the patient is receiving protocol a secure airway is when purposes of this For the ventilation into endotracheal tube past the teeth or inserted laryngoscope blade or Attempt as passing the is defined An Intubation the nasal passage be Ventilatory rate should It is strongly encouraged to complete an Airway Evaluation Form with any BIAD or Intubation procedure. any BIAD or Intubation with complete an Airway Evaluation Form strongly encouraged to It is Intermediates and Paramedics shouldif oral use a BIAD - Maintain C- Do not assume hyperventilation is psychogenic – use oxygen, not a paper bag Cricoid pressure and BURP maneuver may be used to assist with difficultintubations Revised 8/13/2012 · · Pearls · · · · · · · · · · · · · Adult General Section Protocols 2012 . should be 3 and 2 , 1 Calladditional for management Exit to resourcesavailable if information for airway Continue BVM they contain very useful utilized (even together if agency is not using RSI) as YES Appropriate Protocol Protocols Supplemental Oxygen / 90 % 90 % ≥ 45 ≥ / Oxygenation 2 2 Swelling / NO NO 2 35 – BVM YES 10 breaths / minute Distortion – 8 EtCO Failed Airway BIAD Successful Significant Facial Adjunctive Airway AirwayBIAD Procedure Trauma Maintain SpO Maintains SpO Notify Destination or Protocol 3 Contact Medical Control Ventilate Continue Ventilation B . . NO YES . /I P ≥ 90% during or Failed Airway , Failed Adult /

90 % ≥ 2 equipment Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Oxygenation most experienced EMT- Surgical Procedure Continue Ventilation unsuccessful attempts byThree (3) unsuccessful attempts AirwayCricothyrotomy Maintain SpO Anatomy inconsistent with continued attempts ATTEMPTS TOTAL (3) ATTEMPTS NO MORE THAN THREE Each attempt should include changein approach or Unable Ventilateand to Oxygenate P P 1) or moreunsuccessfulafter one ( intubation attempts Adult General Section Protocols . 2012 . . 's Right) failed airway / failed . 's difficult ], Up, andpatient to Protocol 3 make and then consider: an adjustment , Failed Airway , Failed Adult AS EARLY AS POSSIBLE about the patient Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Apply BURP maneuver (Push trachea Back [posterior Differentlaryngoscope blade / Video or otheroptical laryngoscopy devices Gum Elastic Bougie DifferentETT size Change cricoid pressure . Cricoid pressure no longer routinelyrecommended and may worsen view Change head positioning · If first intubation attempt fails If first intubation · · · · · Continuous pulseoximetry should be utilized inall patients with an inadequate respiratory function Continuous EtCO2 should be appliedtoall patientswith respiratory failure or to all patients with advanced airways Notify Medical Control Pearls · · · · Airway, Rapid Sequence Intubation (OPTIONAL)

Indications for RSI Preoxygenate 100% O2 IV Procedure Failure to protect the airway IO Procedure I (preferably 2 sites) P Protocols 1, 2 and 3 should be Unable to oxygenate Assemble Airway Equipment utilized together (even if P Suction equipment agency is not using RSI) as Unable to ventilate Alternative Airway Device they contain very useful information for airway Impending airway management. compromise Evidence of Head Injury / CVA or NO Reactive Airway Disease? Age ≥ 12 / Length > Broselow- Luten Tape YES

P

Etomidate 0.3 mg/kg IV / IO Or

Procedure will remove Ketamine 1.5 - 2 mg/kg IV / IO Protocols Section Adult General patient’s protective Succinylcholine 1.5 mg / kg IV/ IO airway reflexes and Or ability to ventilate. P Rocuronium 1 mg / kg IV / IO If indicated (if Succinylcholine contraindicated) You must be sure of your ability to intubate Intubate trachea before beginning this procedure. Placement Verified Continuous Capnography NO May Repeat Must have two (2) Sequence x1 EMT-P on scene Consider Restraints Physical Procedure Confirm appropriate drug doses P Consider Gastric Tube Insertion Procedure P Change positioning / approach / equipment Red Text Awakening or Moving are the key NO performance indicators after intubation used to evaluate protocol compliance. YES After 2nd RSI Attempt An Airway Evaluation Form must be completed on every patient who receives Rapid Sequence Exit to Intubation. Adult Failed Airway P Protocol

Notify Destination or Contact Medical Control Protocol 4 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 Adult General Section Protocols . 2012 . intubation . , . . . drugs . . %. cricoid pressure cricoid , Luten Tape -Luten , and to patient’s Right) , Up, , suction posterior ], – ventilate : ; Nolonger routinely recommended andmayworsen your view . Longer. acting paralyticsbeneeded-intubation may post or patients longer than the Broselow longer than or patients Protocol 4 12 Divide the workload Divide the ARE RESPONSIBLE FOR VENTILATIONS if desaturation occurs if desaturation VENTILATIONS ARE RESPONSIBLE FOR

whenable to maintain oxygensaturation 90 ≥ ) (OPTIONAL . screen for contraindications with a thorough neurologic exam neurologic a thorough with screenfor contraindications -Paramedics EMT ● Change● cricoid pressure ● Continuous● pulseoximetryshould be utilized in all patients. Consider● applying BURP maneuver (Back [ make an adjustmentand again try , -extubation when the drugs wear off

Rapid Sequence Intubation Sequence , Rapid Airway Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS YOU a paralytic drug, has been given Once a patient This protocol is only for use in patients with an Age ≥ with use in patients for is only protocol This fails First intubationIf attempt Different laryngoscope blade self Protect the patient from program in your is used the drug how systemsto State Medical Director detailing Ketaminesubmit a local plan must Agencies utilizing size Different ETT Change head positioning Consider Naso or orogastric tube placementaspiration in all intubatedlimit patients to anddecompress stomach if needed RSI not recommended inurban setting (short transport) Before administering any paralytic drug, Before administering g monitorin patient ongoing verification and Oximetryand are required for intubation and Pulse Waveform Capnography Continuous This procedure requires at least 2procedure This . a separateRapid Sequence Intubation Agencies must maintain Performance Improvement Program specific to · · · · · · · · · · · · · Pearls · Adult General Section Protocols 2012 NO Appropriate Procedure as indicated Shock If indicated Cardiac Protocol Instability? if indicated Hemodynamic Spinal Immobilization Monitorand Reassess YES Pain Control Protocol Muscle / strain spasm Herniated disc withnerve compression Sciatica Spine fracture Kidney stone Pyelonephritis Aneurysm Pneumonia Spinal Epidural Abscess Metastatic Cancer AAA Differential · · · · · · · · · · · YES spinous , if indicated if indicated Cardiac Monitor Mechanism Protocol 5 Injury or Traumatic IO ProcedureIO 12 Lead Procedure ECG Consider Cardiac Etiology Notify Destination or bladder dysfunction P 10 minutes / Contact Medical Control - YES Shock Protocol P Back Pain Back B Reassess VS if indicated if indicated if indicated if indicated process) Swelling Pain with range of motion Extremity weakness Extremity numbness Shooting painintoan extremity Bowel Pain (paraspinous every 5 AirwayProtocol (s) Pain Control Protocol · · · · · · Signs and Symptoms Signs · Multiple Trauma Protocol

IV Procedure Hypotension / NO I Shock Instability? Hemodynamic injury / Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS NO Reassess Monitorand Protocol if indicated Pain Control Past medical history Past surgical history Medications Onset of pain Previous back injury Traumatic mechanism Location of pain Fever Improvementorworsening with activity Age · · · · · · · · · History · Back Pain Adult General Section Protocols Section Adult General

Pearls · Patients with underlying spinal deformity should be immobilized in their functional position. · Abdominal aneurysms are a concern especially in patients over the age of 50 and / or with vascular or hypertensive disease. · Kidney stones typically present with an acute onset of flank pain which radiates around to the groin area. · Patients with midline pain over the spinous processes should be spinally immobilized. · Any bowel or bladder incontinence is a significant finding which requires immediate medical evaluation · In patient with history of IV drug abuse a spinal epidural abscess should be considered.

Protocol 5 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Adult General Section Protocols 2012 Procedure if indicated IV Procedure overdose Cardiac Monitor Diabetic Protocol Monitorand Reassess Preferably 2 large bore ExternalCooling Measures YES Consider RestraintPhysical I P manic-depressive ) NO Altered Mental Status differentialAlteredMental Status Alcohol Intoxication abuseToxin / Substance Medication effect / Withdrawal syndromes Depression Bipolar ( Schizophrenia Anxiety disorders Differential · · · · · · · · · hyper- , homicidal Violent, / NO increased strength, if indicated Agitation , disorientation hallucinations If indicated hyperthermia , , Protocol 6 behavioral change Aggressive, Setting of Psychosis Threat to Self or others Head Trauma Protocol agitationconfusion , Notify Destination or aggression, hallucination, Contact Medical Control Excited Delirium Syndrome Exit to Appropriate Protocol Exit to Blood Glucose Analysis Procedure Paranoia tachycardia Altered Mental Status Protocol Altered Mental Status Behavioral Toxic Ingestion Protocol Protocol Overdose/Toxic Ingestion Assume patient has Medical cause of Assume has Medical cause of patient Affect changeAffect Anxiety, Delusional bizarre thoughts, behavior Combative violent Expression of suicidal thoughts · Signs and Symptoms Signs · · · · YES YES if indicated IV Procedure Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Monitor and Reassess Safe Scene Monitorper restraint procedure resources Consider RestraintPhysical Procedure Situational crisis illnessPsychiatric /medications or threats to others Injury to self Medic alert tag Substanceoverdose abuse / Diabetes Revised 8/13/2012 NO Stage until scene safe I History · · · · · · Callhelp for / additional P Adult General Section Protocols in , head tatus. PO 2012 , -threatening IM / May present / . IO / Most commonly seen in male . speech disturbances , substance abuse, hypoxia , particularly stimulantdrugs such as neck and upper extremities , overdose , . anxiety, hallucinations , hypoglycemia ( hyperthermia and increasedPotentially lifestrength. consider a fluid bolus and sodium bicarbonate early , , Neuro includingphysical restraints and Tasers mg IV When recognizedgive 50 mg IV Diphenhydramine . Protocol 6 , , Lungs psychomotor agitation , amphetamines or similar Alcohol agents. withdrawal or head trauma may also . . , Heart, insensitivity to pain Behavioral , in pediatrics. PO / IM / : methamphetamine bizarre behavior , : IO / / Combinationdelirium of Mental Status, Skin, : . kg IV mg/kg IV 1 crack cocaine Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS adultsor Condition causing involuntary muscle movements or spasms typically the face of Medical emergency with contorted neck and trunk with difficultmotormovements . Typically an adverse reactionantipsychotic drugslike to Haloperidol and may occur withyour administration disorientation, violent andassociated withuse physical measures of control , subjectswithserious a history of mentalillness and/or acute or chronic drug abuse, cocaine, contribute the condition to . : Recommended: Exam Crew / responders safetyis the main priority law Enforcement be accompanied by transported by EMS must or restrained by Law and is handcuffed Any patient who enforcementthe ambulance. in with presumed for patients psychosis or a benzodiazepine history of for patients with or Ziprasidone Consider Haldol substance abuse All patients who receive either physical or chemical restraint must be continuously observed by ALS personnel on observed by ALS personnel who receive either physical or chemical restraintmustbe continuously All patients their arrivalsceneor immediatelyupon . Be sure to consider all possible medical/trauma causesfor behavior injury.) , etc Do not irritate the patient with a prolonged exam Do not overlook the possibility domestic of associated violence or child abuse patientIf is suspected of agitated delirium cardiac suffers arrest Do not position or transport any restrained patientis suchawaycould that impact the patients respiratory or circulatory s Excited Delirium Syndrome Extrapyramidal reactions Revised 8/13/2012 Pearls · · · · · · · · · · · · Pain Control: Adult

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

Enter from Protocol based on Specific Complaint

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

Mild Moderate to Severe Adult General Section Protocols Section Adult General

IV Procedure P IO Procedure I

B P

I Consider IV Procedure Cardiac Monitor Monitor and Reassess

P

Monitor and Reassess Every 10 minutes following sedative Monitor and Reassess

Notify Destination or Contact Medical Control

Protocol 7 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 Pain Control: Adult Adult General Section Protocols Section Adult General

Pearls · Recommended Exam: Mental Status, Area of Pain, Neuro · Pain severity (0-10) is a vital sign to be recorded before and after PO, IV, IO or IM medication delivery and at patient hand off. Monitor BP closely as sedative and pain control agents may cause hypotension. · Both arms of the treatment may be used in concert. For patients in Moderate pain for instance, you may use the combination of an oral medication and parenteral if no contraindications are present. · Vital signs should be obtained before, 10 minutes after, and at patient hand off with all pain medications. · All patients who receive IM or IV medications must be observed 15 minutes for drug reaction in the event no transport occurs. · Do not administer any PO medications for patients who may need surgical intervention such as open fractures or fracture deformities, headaches, or abdominal pain. · Ketorolac (Toradol) and Ibuprofen should not be used in patients with known renal disease or renal transplant, in patients who have known drug allergies to NSAID's (non-steroidal anti-inflammatory medications), with active bleeding, headaches, abdominal pain, stomach ulcers or in patients who may need surgical intervention such as open fractures or fracture deformities. · Do not administer Acetaminophen to patients with a history of liver disease. · Burn patients may required higher than usual opioid doses to effect adequate pain control Protocol 7 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Adult General Section Protocols 2012 out ounces minutes Extend Extend Improve Improve 20 Responder Exit to Cannot Wear Rehabilitation Rehabilitation Time Until VS Time UntilVS Protocol Protective Gear Responder SceneRehabilitation place in warm area YES YES COLD STRESS YES Active WarmingMeasures Rehydration Techniques Active Warming Measures 32 oz Oral Fluid over , .6 ) or groinHot packs to axillaand / or of fluid between change SCBA - Dry responder, 110 HR NO NO 12 – Firefightersshouldconsume 8 Oral Rehydration occur along may with Temp ≥ ≥ 100 Symptoms YES YES ≤ 80 YES Symptoms 110 then obtain Temp or > 40 / > -Mat Suits, Turnout Gear 8 symptoms / .6 Haz Signs Reports Reassignment for If HRIf Discharge Responder from ( 110 or Serious Signs / HR General Rehabilitation Section NO NO NO NO Heat : Temp ≥ ≥ 100 Reassess VS Protocol 8 Initial Process Initial Cold stress ) (Optional Significant Injury Recorded Body Armor, / , General Rehabilitation Section Respiratory Rate < Diastolic BloodPressure Reassessafter 20 Minutesin responder YES Cardiac Complaint: Other equipment as indicated Respiratory Complaint Personnel assessed signs for Personnel logged into General Rehabilitation Section VS Assessed VS Assessed Remove PPE out - . . . . ounces 3 1 2 4 : General Rehabilitation Scene minutes . Must . ≥ 160 or . However this . 20 Minutes : Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 10 – : Complaint HEAT STRESS Active Cooling Measures Rehydration Techniques Active Cooling MeasuresActive Cooling VITAL SIGN CAVEATS VITAL of fluid between change SCBA 12 – 32 ozOral Fluid20 over Firefightersconsume should 8 Oral Rehydrationoccuralong may with Forearm immersion, coolshirts , cool mist fans etc. oralIV hydration or . Firefightersmayhave increased temperature duringrehabilitation . Blood PressureBlood Proneto inaccuracy on scenes Firefighterswith Systolic BP be interpreted in context Firefightershave elevatedblood pressure due to physical exertion andisnottypically pathologic. Diastolic BP ≥ 100 may need extended rehabilitation Temperature doesnot necessarily prevent them from returningduty to . appropriate treatment should treated using be protocol beyondneed for / Injury / Illness Scene Rehabilitation: General (Optional) Adult General Section Protocols Section Adult General

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

Protocol 8 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Adult General Section Protocols . 2012 Protocol . of additional rehabilitation Important after 30 minutes No improvement General Rehabilitation Use inconjunctionwith . -evaluate in 10 minutes Rehydration is Most Mandatory Rest Period Re I YES YES YES YES YES ) diuretics or stimulants areand diuretics or stimulants at increased risk for cold EMS and training scenes rescue EMS and , , % symptoms .6 Orthostatic Vital Signs Orthostatic / NFPA 100 160 or > 40 % (if available < 90 Agencies may and are encouraged to develop their own Agencies may areencouragedto develop their and 8 ≥ 100 ≥ < > 10 Or NO NO NO NO NO Protocol 9 Reportsfor SPCO Initial Process Initial from General Reassignment law enforcement, Systolic BP Diastolic BP ≥ Temperature privacyand freedom from smoke or otherhazards Discharge Responder Rehabilitation Section 20 MinuteRestPeriod Pulse oximetry , Respirations Age Predicted Maximum Notify Destination or Pulse Rate > 85 % Contact Medical Control blood pressure medication blood , Section Personnel logged into Responder Rehabilitation VS Assessed andRecordedVS Assessed / Pulse oximetry and SPCO Personnel assessedsigns for . . . . 1 2 3 4

% 132 160 155 152 148 140 136 170 165 ) (Optional : Responder Rehabilitation Scene : Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Complaint Section : Continue Responders taking anti-histamines heat stress. Rehabilitation Section is an integral functionwithin the Incident ManagementSystem. Establish section such that it providesshelter Rehabilitation officer has full authority in deciding when responders. when may return to duty deciding authority in officer has full Rehabilitation Protocol. GeneralRehabilitation not appropriate for when responder is Utilized responders fire, adult on with May be utilized . only as an example. and given optional protocol is This Maximum HeartRate oralIV hydration. or from GeneralRehab 51 -55 55 - 60 61 - 65 41 - 45 46 - 50 26 - 30 31 - 35 36 - 40 20 - 25 treatment techniques Heat and Cold Stress appropriate treatment NFPA Age Predicted 85 · · · · · · Pearls · should be treated using protocol beyondneed for Remove PPE Body Armor Chemical Suits SCBA Turnout Gear Other equipment as indicated Injury / Illness / Adult Cardiac Section Protocols ) ) 2012 ) other) Digitalis, Beta , AAA, , cardiac coronary (MI pulmonary Follow Go to Go Protocol Return of Discontinue Circulation Resuscitation Hyperkalemia Trauma Spontaneous Spontaneous ( / AT ANY TIME Reversible Causes ) Post Resuscitation Deceased Subjects Policy PE Thrombosis; Hypovolemia Hypoxia Hydrogen ion (acidosis Hypothermia Hypo Hypoglycemia Tension pneumothorax Tamponade; Toxins Thrombosis; ( Cardiac tamponade Hypothermia Drugoverdose (Tricyclic Hypovolemia , blockersCalcium, channel blockers Massive myocardial infarction Hypoxia Tension pneumothorax Pulmonary embolus Acidosis Hyperkalemia NO YES · · · Differential · · · · · · · ) min) / → ≥ 100 ( minutes 10 seconds 2 ≤ mg IV / IO IO ProcedureIO No minutes 5 000) 1 / IO IV / 40 units P Or 10, : 1 NO NO Protocol 11 pulses checks Cardiac Monitor / Resuscitation ≥ 2 inches) Push Fast Shockable Rhythm Criteriafor Death/ Cardiac Arrest Protocol Pulseless Apneic No electrical activity on ECG No hearttones on auscultation Repeat every 3 to Notify Destination or Vasopressin Review DNR Form / MOST Contact Medical Control Criteriafor Discontinuation Searchfor Reversible Causes Epinephrine ( Epinephrine Signs and Symptoms Signs · · · · Change Compressors every Begin Continuous CPR Compressions Begin Continuous IV Procedure Consider Chest Decompression Procedure May replaceor second first doseof epinephrine Limit changes ( Push Hard Push ( I P P YES YES Pulseless Electrical Activity Electrical Pulseless / Asystole Adult Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS MOST, or Living Will life , Tricyclic Digitalis Beta blockers Calcium channel blockers Policy Follow Follow Protocol asystole Protocol Dialysis / if indicated Rigor mortis resuscitation Do not begin Renal Failure Past medical history Medications Events leading to arrest End stagerenal disease Estimated downtime Suspected hypothermia Suspected overdose · · · · DNR Decomposition Dependent lividity Blunt force trauma Deceased Subjects Rhythm Appropriate Injury incompatible with History · · · · · · · · Extendedwith downtime Adult Asystole / Pulseless Electrical Activity Adult Cardiac Section Protocols Adult Cardiac Section

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

Protocol 11 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 Adult Cardiac Section Protocols 2012 °) 3 or °, 2 or °, 1 ( and / Protocol Appropriate Airway Respiratory Distress Overdose Acute myocardial infarction Hypoxia Pacemaker failure Hypothermia Sinus bradycardia Athletes Head injury (elevated ICP) or Stroke Spinal cord lesion Sick sinussyndrome AV blocks · Differential · · · · · · · · · · YES , acute , , ) AVB

or Shock rd chest pain , syncope, or 3 , IO ProcedureIO , or nd minute and 2 / Syncope P , seizures , NO YES Protocol 12 Acute AMS, Chest Pain Cardiac Monitor Symptomatic Seizures Work of Breathing , Dyspnea Increased / Transcutaneous Pacing 12 LeadProcedure ECG especially withhypoxia HR < 60/min withhypotension acute CHF altered status mental shock secondary to bradycardia Chest pain Respiratory distress Hypotension or Shock Alteredmental status Syncope Notify Destination or secondary to bradycardia

If not responsiveIf to Atropine

Contact Medical Control Heart Rate < 60 Consider earlier in Signs and Symptoms Signs · · · · · ·

Hypotension, IV Procedure Acute CHF I I P P P B P NO Pulse Present Pulse ; Bradycardia / -Blocker Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Follow Blocker Beta-Blockers Calcium channel blockers Clonidine Digoxin Protocol Overdose Exit to Toxic Ingestion Toxic Ingestion Past medical history Medications · · · · Pacemaker Protocol Appropriate or Calcium Channel History · · · P Suspected Beta Bradycardia; Pulse Present Adult Cardiac Section Protocols Adult Cardiac Section

Pearls · Recommended Exam: Mental Status, Neck, Heart, Lungs, Neuro · Bradycardia causing symptoms is typically < 50/minute. Rhythm should be interpreted in the context of symptoms and pharmacological treatment given only when symptomatic, otherwise monitor and reassess. · Identifying signs and symptoms of poor perfusion caused by bradycardia are paramount. · Atropine: Caution in setting of acute MI. The use of Atropine for PVCs in the presence of a MI may worsen heart damage. Should not delay Transcutaneous Pacing with poor perfusion. Ineffective in cardiac transplantation. · Utilize transcutaneous pacing early if no response to atropine. If time allows transport to specialty center as transcutaneous pacing is a temporizing measure and patient will likely require transvenous pacemaker. · Wide complex, bizarre appearance of complex with slow rhythm consider hyperkalemia. · Consider treatable causes for bradycardia (Beta Blocker OD, Calcium Channel Blocker OD, etc.) · Hypoxemia is a common cause of bradycardia be sure to oxygenate the patient and support respiratory effort. Protocol 12 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Adult Cardiac Section Protocols 2012 VT / YES Follow Airway VF Go to Go Protocol(s) Protocol Tachycardia as indicated Return of Circulation Spontaneous Spontaneous Trauma AT ANY TIME . Post Resuscitation Pulseless VT . Medical vs VF vs Asystole PEA Primary Cardiac eventvs. Respiratory arrest or DrugOverdose Cardiac Monitor YES Shockable Rhythm Differential · · · · · s) PEA ( / P ) NO Follow min) Airway / Protocol as indicated Asystole ≥ 100 ( minutes 10 seconds 2 ≤ No Resuscitation / Protocol 13 NO pulses checks / ALS Available ≥ 2 inches) Push Fast Unresponsive Apneic Pulseless YES Signs and Symptoms Signs · · · MOST Form Review DNR / MOST AED Procedure AED if available AirwayProtocol (s) Shock Delivery Minutes Change Compressors every Begin Continuous CPR Compressions Begin Continuous Criteriafor Death Continue CPR 2 Repeat and reassess Limit changes ( Push Hard Push (

; Adult Arrest Cardiac YES Notify Destination or Contact Medical Control NO NO Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS life AirwayProtocol (s) Shockable Rhythm Policy Follow asystole Rigor mortis Continue CPR 2 Minutes Repeat and reassess resuscitation Do not begin Events leading to arrest downtimeEstimated Past medical history Medications Existenceof terminal illness Decomposition Dependent lividity Blunt force trauma Deceased Subjects Injury incompatible with History · · · · · Extendedwith downtime Adult Cardiac Section Protocols . May 2012 30:2. If Makeroom to . 2 minutes each or difficult IV access IV or difficult / , after every move, and at transfer of renal failure patient experiencing cardiac compressions to ventilations are ) compressions ventilations are to cardioversion energy whenspecified . 2 frequently . interruptions Consider BIAD firstto limit ETT . rounds of compressionsor 2 rounds of ( IO accessIV/IO preferably above diaphragm . . IN. EMT-B may administerNaloxone via IN route only . Procedures require space and patient access IO / IV / Refer to optionalprotocol or development of localagency protocol. Protocol 13 uninterrupted compressions , uninterrupted continuous breathsperminute with . 8 – 10 Consider early IO placement if available and Consider early placement if available IO If no advanced airway If no (BIAD,

Naloxone mg IM / 2 ; Adult Arrest Cardiac . Renal Failure protocolcaveats when faced with dialysis / / Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS .) Efforts should be directed at high quality and continuous compressions with limited interruptions and early interruptions compressionswith limited continuous quality and be directed at high Efforts should . indicated when defibrillation anticipated. HYPERVENTILATE DO NOT : givefromsupply EMS Follow manufacture's recommendations concerning defibrillation / advancedairway place ventilate in to place endotracheal tube interrupt compressionsDo not Breathing / Airway management after / second shock and round Success is based on proper planning and execution. work. ConsiderTeamFocused Approach assigning responders to predetermined tasks. Team Focused Approach / Pit-Crew Approach . Reassess anddocument endotracheal tubeplacement and EtCO care. MaternalArrest - Treat mother per appropriate protocol with immediate notification to Medical Control and rapid transportpreferably to obstetrical center available if andproximate . Place mother supine and perform Manual Left Uterine Displacementmoving uteruspatient’s to the left side . Defibrillation is safe at all energylevels Consider mechanical CPR (compression) deviceavailable if Refer to Dialysis arrest. Consider Opioid Overdose : Pearls · · · · · · · · · · · · Adult Cardiac Section Protocols 2012 Exit to Protocol Appropriate Myocardial infarction Cocaine) or P Pericarditis Pulmonary embolism Asthma / COPD Pneumothorax Aortic dissection or aneurysm GE reflux or Hiatalhernia Esophagealspasm Chest wall injuryorpain Pleural pain Overdose ( Methamphetamine . MedicalTrauma vs Angina. vs NO I · · · · · · · · · · Differential · · NO Notify Destination or Contact Medical Control vice-like : epigastric, arm, Pulmonary , / aching, STEMI STEMI dizziness YES YES if capable Exit to , Edema Edema Protocol symptoms Lung Exam Reperfusion Checklist : Transport based on CHF / Pulmonary / DyspneaAtypical / Adult CHF ) vomiting If transportingIf to NonPCI Center Suspect cardiac etiology Protocol 14 diaphoresis Immediate Transmission of ECG EMS Triage and Destination Plan EMS Triage and Immediate Notification of Facility Immediate Notification Keep SceneTime to ≤ 10 Minutes B Time of Onset Time of tightness Shortnessof breath Nausea, Locationsubsternal ( jaw, neck, shoulder) Radiation of pain Pale, CP (painpressure, , NO YES · · · · · · Signs and Symptoms Signs · NO ) , tadalafil) sharp, chewed) / , ) Angina ( , IO ProcedureIO Cardiac and STEMI and : Cardiac Pain Chest PO Referred .3 / 0.4 mg SL 4 / 0 STEMI mg PO P / BP ≥ 100 .3 / 0.4 mg Sublingual NO YES 0 mg x Contiguous Leads) Contiguous mm ST Segment duration / repetition YES rovocation 2 Or 325 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS and ( Cardiac Monitor New LBBB

post menopausal) Chest Pain Systolic BP ≥ 100 Acute MI if prescribed to patient if prescribed to 12 Lead ECG Procedure with cardiac etiology Repeat3 every 5 minutesx etc.) Nitroglycerin Repeat every 5 minutes as needed Aspirin 81 (STEMI = 1 Signs / Symptoms consistent Quality (crampy, constant Recentphysical exertion PalliationP / Allergies Age Medications (Viagra / sildenafil, Levitra / vardenafil, Cialis Diabetes, Past medical history (MI dull, Region / Radiation Severity (1-10) Time (onset / IV Procedure Nitroglycerin Elevation ≥ Revised 8/13/2012 I I · · · · History · · · · · · P P B Adult Cardiac Section Protocols . . 2012 24 ). -P.) Neuro , . or Dilaudid . in the past ) in . (STEMI) Care Toolkit Maygive from EMS supply , Extremities , Fentanyl, . (Morphine ) or Levitra (vardenafil V3 or V4). If ST Sided ECG ( Consider Right Abdomen, Back , or only generalized complaints or positive Reperfusion Checklist should be ) or positive Reperfusion Checklist should , aVF) MI. , Heart, Lung , Protocol 14 hours due to potential severehypotension to potential hours due 36 -Lead ECG in the PCR as aProcedure along with the interpretation (EMT 12 Mental Status, Skin, Neck : Cardiac and STEMI and : Cardiac Pain Chest Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Cardiogenic shock resulting from inferior (II, III Cardiogenic shock resulting Nitroglycerin and opioids may be repeated per dosing guidelines. Diabetics, geriatricand female patients often have atypical pain Document the time of the EMT-B may administerNitroglycerinto patients alreadyprescribed medication. or opioids may cause hypotension requiring normal saline boluses requiring maycause and / or opioids hypotension Nitroglycerin elevation noted patientIf has taken nitroglycerin without relief consider, of the medication potency Monitor for hypotension after administration nitroglycerin of andnarcotics Recommended Exam Items in Red Text arethe key performanceindicators for the EMS Acute Cardiac has used Viagra (sildenafil who any patient Avoid Nitroglycerin in the past (tadalafil) in hours or Cialis STEMI (ST-Elevation Myocardial Infarction Patients with EMSTriage and Destination Plan based STEMI transported to the appropriate facility on If CHF / Agency medical director may requireContact of Medical Control prior to administration. Revised

8/13/2012 · · · · · · · Pearls · · · · · Adult Cardiac Section Protocols 2012 s) ( Protocol if in place if in if indicated Protocol bradycardia hypotension Adult Airway if indicated Remove CPAP AirwayProtocol (s) Chest Pain and STEMI Tachycardia followed by CARDIOGENIC SHOCK Hypertension followed by Myocardial infarction Congestive heart failure Asthma Anaphylaxis Aspiration COPD Pleural effusion Pneumonia Pulmonary embolus Pericardial tamponade Toxic Exposure I P Differential · · · · · · · · · · · NO 3 mg IV minutes ) minutes IO ProcedureIO .3 / 0.4 mg 30 SEVERE 0 .3 / 0.4 mg SL > 0 diaphoresis >100 P YES BP Afebrile ( ONLY IF Sublingual Elevated BP Cardiac Monitor AirwayPatent if indicated Protocol 15 Elevated Heart Rate AirwayProtocol (s) Repeat every 5 Ventilations adequate 12 LeadProcedure ECG Oxygenation adequate Airway CPAP Procedure MODERATE / Nitroglycerin Known CHF / Daily Lasix Repeat every 5 minutes x frothy sputum Assess Symptom Severity if prescribed to patient and if prescribed to Notify Destination or Nitroglycerin Transport time , Contact Medical Control Consider Furosemide 40 IV Procedure Respiratory distress, bilateral rales Apprehension, orthopnea Jugular vein distention Pink Peripheral edema , Hypotension, shock Chest pain I I P P B Signs and Symptoms Signs · · · · · · · YES NO / Pulmonary Edema / Pulmonary CHF minutes Levitra / tadalafil) , / past myocardial .3 / 0.4 mg SL 0 YES MILD Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Improving Signs / Symptoms Pulmonary Edema Normal Heart Rate consistentwith CHF Repeat every 5 Elevated BP or Normal Nitroglycerin Congestive heart failure Past medical history Medications (digoxin, Lasix , Viagrasildenafil / infarction , vardenafilCialis, Cardiac history -- I History · · · · Adult Cardiac Section Protocols . . . 2012 Lead 24 12 Neuro , in the past ) in . Maygive from EMS supply , Extremities Lead ECG usingthe it is no longer routinely no longer it is , . 12 Monitor the patientclosely . ) or Levitra (vardenafil V3 or V4). If ST Sided ECG ( Consider Right . Document Abdomen, Back geriatric and female patients often have atypical pain, , aVF) MI. , and respiratory the above interventions status with , Heart, Lung , Protocol 15 hours due to potential severehypotension to potential hours due 36 . Mental Status, Skin, Neck : do notcontinue to useNitroglycerin SL. , Pulmonary Edema / Pulmonary CHF . . Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Even though this historically hasbeen amainstayEMS treatment of this historically Even though Cardiogenic shock resulting from inferior (II, III Cardiogenic shock resulting . Agency medical director may requireContact of Medical Control. EMT-B may administerNitroglycerinto patients alreadyprescribed medication. Recommended Exam Items in Red Text arekey performance measuresevaluate compliance and care used to protocol EMSpatients with pulmonary to improve the outcomes of have been shown NOT Furosemide and Opioids edema Contraindications to opioidsinclude severe COPD and respiratory . distress Consider myocardial infarctionin allthese patients. Diabetics, or onlygeneralized complaints Allow the patientto be in their position maximize of comfort to their breathing effort. Document CPAP application using the CPAP procedure in the PCR If patientIf has taken nitroglycerin without relief consider, of the medication potency recommended has used Viagra (sildenafil who any patient Avoid Nitroglycerin in normal saline boluses requiring maycause and / or opioids hypotension Nitroglycerin elevation noted NitroIf -paste is used in the past (tadalafil) in hours or Cialis consciousness, BP Carefullymonitor the level of If CHF / ECG procedure · · Pearls · · · · · · · · · · · · Adult Tachycardia Narrow Complex (≤ 0.11 sec) History Signs and Symptoms Differential · Medications · Heart Rate > 150 · Heart disease (WPW, Valvular) (Aminophylline, Diet pills, Thyroid · Systolic BP < 90 · Sick sinus syndrome supplements, Decongestants, · Dizziness, CP, SOB, AMS, · Myocardial infarction Digoxin) Diaphoresis · Electrolyte imbalance · Diet (caffeine, chocolate) · CHF · Exertion, Pain, Emotional stress · Drugs (nicotine, cocaine) · Potential presenting rhythm · Fever · Past medical history Atrial/Sinus tachycardia · Hypoxia · History of palpitations / heart racing Atrial fibrillation / flutter · Hypovolemia or Anemia · Syncope / near syncope Multifocal atrial tachycardia · Drug effect / Overdose (see HX) Ventricular Tachycardia · Hyperthyroidism · Pulmonary embolus Unstable / Serious Signs and Symptoms Cardioversion Procedure NO HR Typically > 150 YES

B 12 Lead ECG Procedure I IV Procedure IO Procedure P P P Cardiac Monitor

Regular Rhythm Irregular Rhythm (SVT) (Atrial Fibrillation / Flutter) Adult Cardiac Section Protocols Adult Cardiac Section P Attempt Vagal Maneuvers Exit to Appropriate Protocol P Rhythm Converts YES

NO

YES Rhythm Converts P Single lead ECG able to diagnose and treat arrhythmia NO 12 Lead ECG not necessary to diagnose and treat, but preferred Rhythm Converts YES when patient is stable.

NO

P

P

Rhythm Converts / 12 Lead ECG Procedure Rate Controlled YES B

NO Notify Destination or Contact Medical Control Protocol 16 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 Adult Tachycardia Narrow Complex (≤ 0.11 sec) Adult Cardiac Section Protocols Adult Cardiac Section

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

Protocol 16 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Adult Cardiac Section Protocols . 2012 but see HX)

Emotional stress Overdose ( Exit to Protocol Pain, Appropriate , Cardioversion Procedure diagnose and treat, Single lead ECG able to lead ECG able Single 12 Lead not necessary ECG to ) preferred when patient is stable Fever Hypoxia HypovolemiaAnemia or Drugeffect / Hyperthyroidism Pulmonary embolus , ValvularHeart disease) (WPW, syndromeSick sinus Myocardial infarction Electrolyteimbalance Exertion diagnose and treatarrhythmiadiagnose P YES · · · · · · Differential · · · · · P , Procedure sec ≥0.12 flutter Cardioversion YES Irregular Rhythm Follow Unstable Arm Rhythm Converts Torsade de) pointes ( Polymorphic Complex SOB, AMS P 150 <90 Sinus tachycardia NO Protocol 17 Exit to Atrial/ Atrial fibrillation / Multifocal atrial tachycardia Ventricular Tachycardia Protocol ) Adult VF / after rhythm conversion Pulseless VT Notify Destination or Systolic BP Systolic BP Dizziness, CP, > Heart Rate > Diaphoresis CHF Potential presenting rhythm Contact Medical Control IO ProcedureIO · · Signs and Symptoms Signs · · · excitation - Control B P 12 LeadECG Procedure Pre Adult Tachycardia Adult ( Contact Medical Atrial Fibrillation Irregular Rhythm , Monomorphic Complex Cardiac Monitor Thyroid Wide Complex ( Wide , YES YES HR Typically > 150 ) ) heart racing IV Procedure ) 12 LeadECG Procedure NO / UnstableSerious / Signs andSymptoms I chocolate B P Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS nearsyncope NO nicotine, cocaine (VT or Digoxin) (Aminophylline, Diet pills supplements, Decongestants NO Rhythm Converts Regular Rhythm Rhythm Converts SVT with aberrancy Drugs ( Past medical history History of palpitations / Syncope / Diet (caffeine, Medications Monomophic Complex Revised 8/13/2012 P P · · · · · History · Adult Tachycardia Wide Complex (≥0.12 sec) Adult Cardiac Section Protocols Adult Cardiac Section

Pearls · Recommended Exam: Mental Status, Skin, Neck, Lung, Heart, Abdomen, Back, Extremities, Neuro · Most important goal is to differentiate the type of tachycardia and if STABLE or UNSTABLE. · If at any point patient becomes unstable move to unstable arm in algorithm. · Symptomatic tachycardia usually occurs at rates of 120 – 150 and typically ≥ 150 beats per minute. Patients symptomatic with heart rates < 150 likely have impaired cardiac function such as CHF. · Serious Signs / Symptoms: Hypotension. Acutely altered mental status. Signs of shock / poor perfusion. Chest pain with evidence of ischemia (STEMI, T wave inversions or depressions.) Acute congestive heart failure. · Search for underlying cause of tachycardia such as fever, sepsis, dyspnea, etc. · If patient has history or 12 Lead ECG reveals Wolfe Parkinson White (WPW), DO NOT administer a Calcium Channel Blocker (e.g., Diltiazem) or Beta Blockers. Use caution with Adenosine and give only with defibrillator available. · Search for underlying cause of tachycardia such as fever, sepsis, dyspnea, etc. · Typical sinus tachycardia is in the range of 100 to (220 – patients age) beats per minute. · Regular Wide-Complex Tachycardias: Unstable condition: Immediate cardioversion or pre-cordial thump if defibrillator not available. Stable condition: Typically VT or SVT with aberrancy. Adenosine may be given if regular and monomorphic and if defibrillator available. Verapamil contraindicated in wide-complex tachycardias. Agencies using Amiodarone, Procainamide and Lidocaine need choose one agent primarily. Giving multiple anti-arrhythmics requires contact of medical control. Atrial arrhythmias with WPW should be treated with Amiodarone or Procainamide · Irregular Tachycardias: Wide-complex, irregular tachycardia: Do not administer calcium channel or beta blockers, adenosine as this may cause paradoxical increase in ventricular rate. This will usually require cardioversion. Contact medical control. · Polymorphic / Irregular Tachycardia: This situation is usually unstable and immediate defibrillation is warranted . When associated with prolonged QT this is likely Torsades de pointes : Give 2 gm of Magnesium Sulfate slow IV / IO . Without prolonged QT likely related to ischemia and Magnesium may not be helpful. · 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. · Follow manufacture 's recommendations concerning defibrillation / cardioversion energy when specified.

Revised Protocol 17 8/13/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 Adult Cardiac Section Protocols 2012 alcoholic) Renal / / Exit to Protocol if indicated Dialysis Failure Protocol Tosadesde points Post Resuscitation Device Failure LowMagnesium States Malnourished ( P Suspected Digitalis Toxicity Asystole Artifact / Cardiac Endocrine / Medicine Drugs Pulmonary ) YES ) Differential · · · · · · min) min) / . / ≥ 100 ( minutes 10 seconds ≥ 100 ( minutes 10 seconds 2 ≤ 2 Vasopressin mg IV / IO ≤ IO Procedure IO minutes 5 000) 1 pulseless OR / IO IV / 40 units Or P 10, : 1 Epinephrine / Epinephrine Continuous Compressions apneic, pulses checks AND / pulses checks , / / / If Rhythm Refractory AirwayProtocol (s) Protocol 18 ≥ 2 inches) Push Fast during compressions. during ≥ 2 inches) Push Fast Repeat every 3 to Notify Destination or Vasopressin Contact Medical Control Epinephrine ( Epinephrine to defibrillate with device charged with . to defibrillate Repeat pattern during resuscitationRepeatpatternduring Return of Spontaneous Circulation High Quality, Change Compressors every Begin Continuous CPR Compressions Begin Continuous IV Procedure Change Compressors every Begin Continuous CPR Compressions Begin Continuous arrhythmics Unresponsive Ventricular fibrillation or ventricular tachycardia on EKG May replaceor second doseof epinephrine first Limit changes Continue CPRand give Agency specific Anti- Continue ( Continue CPR up to point where you are ready whereyou are point CPRup to Continue Push Hard Push ( Limit changes ( Push Hard Push ( Ventricular Fibrillation Ventricular Signs and Symptoms Signs · · I P P P NO Pulseless Ventricular Tachycardia Ventricular Pulseless Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Consider Go to Go Protocol Discontinuation Return of Circulation Spontaneous Spontaneous Cardiac Arrest Protocol Estimated downEstimated time Past Medical History Medications Events leading to arrest Renal failure Dialysis / DNRor form MOST of Resuscitation Policy AT ANY TIME Post Resuscitation History · · · · · · P P P Ventricular Fibrillation Pulseless Ventricular Tachycardia Adult Cardiac Section Protocols Adult Cardiac Section

Pearls · Recommended Exam: Mental Status · Efforts should be directed at high quality and continuous compressions with limited interruptions and early defibrillation when indicated. Consider early IO placement if available and difficult IV anticipated. · DO NOT HYPERVENTILATE: If no advanced airway (BIAD, ETT) compressions to ventilations are 30:2. If advanced airway in place ventilate 8 – 10 breaths per minute with continuous, uninterrupted compressions. · Do not interrupt compressions to place endotracheal tube. Consider BIAD first to limit interruptions. · Breathing / Airway management after second shock and / or 2 rounds of compressions (2 minutes each round.) · Avoid Procainamide in CHF or prolonged QT. · Effective CPR and prompt defibrillation are the keys to successful resuscitation. · If no IV / IO, drugs that can be given down ET tube should have dose doubled and then flushed with 5 ml of Normal Saline followed by 5 quick ventilations. IV / IO is the preferred route when available. · Reassess and document endotracheal tube placement and EtCO2 frequently, after every move, and at transfer of care. · Do not stop CPR to check for placement of ET tube or to give medications. · If BVM is ventilating the patient successfully, intubation should be deferred until rhythm has changed or 4 or 5 defibrillation sequences have been completed. · Return of spontaneous circulation: Heart rate should be > 60 when initiating anti-arrhythmic infusions. · Sodium bicarbonate no longer recommended. Consider in the dialysis / renal patient, known hyperkalemia or tricyclic overdose at 50 mEq total IV / IO. · Follow manufacture's recommendations concerning defibrillation / cardioversion energy when specified. Protocol 18 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 Adult Cardiac Section Protocols 2012 s) Utilized Protocol if available to address specific to address Refer to Appropriate Chest Pain and ArrhythmiaProtocol ( STEMI ProtocolSTEMI Destination Plan Continue Antiarrhythmic InducedHypothermia STEMI EMS TriageSTEMI and P Continue differentials associatedthe original with dysrhythmia P Differential · NO YES YES IO Procedure IO Paralysis / 12 / minute < 90 94 % / if indicated ≥ P NO NO NO NO YES STEMI ROSC with Cardiac Monitor Hypotension Suspicion of MI Systolic BP Protocol 19 Follows Commands 12 LeadProcedure ECG Antiarrhythmic given Notify Destination or Consider Sedation Symptomatic Bradycardia / MonitorVitalReassess/ Signs Return of pulseReturn of Contact Medical Control Remove ImpedanceThreshold Device HYPERVENTILATE DO NOT Maintain SpO2 Advanced airway ETCO2 ideally 35 – 45 mm Hg Respiratory Rate 8 – RepeatPrimary Assessment Use only with definitiveairway inplace Signs/Symptoms · · · Optimize Ventilation and Oxygenation Ventilation Optimize · · · · YES P IV Procedure NO YES I P B B Post Resuscitation Post after ROSC follow Rhythm Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Protocol Bradycardia; Appropriate Protocol Pulse Present If ArrhythmiaIf Persists andusually self limiting Arrhythmiasare common Respiratory arrest Cardiac arrest Revised 8/13/2012 I History · · P Adult Cardiac Section Protocols , 2012 and Neuro . , , pneumothorax , hypovolemia -resuscitation care Abdomen, Extremities Ensure adequate fluid resuscitationis ongoing. While goal is goal normalize. While will usually resuscitation but Protocol 19 , HeartSkin, Lungs , , . Post Resuscitation Post Mental Status, Neck : Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Hyperventilation is a significant cause of hypotension and recurrence causehypotension of cardiacarrest in the post Hyperventilation is a significant of atall costs. resuscitation phase and must be avoided tidal CO2 may be elevatedimmediately post- End Initial 35 – 45avoid hyperventilation mm Hg therapy hypothermia -arrestcapable managing the post patient including Consider transport to facility of cardiac catherterization and intensive care service. Most patients immediately post resuscitation will require ventilatory assistance. The conditionof post -resuscitation patients fluctuates rapidly and continuously, and theyrequire close monitoring . Appropriate post-resuscitation management maybest be planned inconsultation with medical control . Common causespost of -resuscitation hypotension include hyperventilation , Recommended Exam Continue to search for potential cause of cardiacarrestpost to searchpotential Continue for during medicationreaction to ALS drugs . Titrate Dopamineorother vasopressors to maintain SAP ≥ 90. Revised 8/13/2012 · · · · · · Pearls · · · Adult Cardiac Section Protocols 2012 Post Exit to Cooling Protocol Continue Resuscitation P ≥ 92 F (33.3 C) Continueto address specific differentials associated with the arrhythmia NO NO Differential · ) mmHg ) ) > 20 33C 93.3 F 34C) F ( 34C (includes BIAD) in 32 – YES YES 93.2 F ( andgroin areas Temperature with EtCO2 ≥ Shivering noted Range Protocol 20 Reassess Rectal Circulation ROSC ( Continued Shivering Target: 91.4 Return of Spontaneous Range 89.6 F to Initialrectal temperature Notify Destination or ( place Contact Medical Control Perform Neurological Assessment Exposeandpacks apply ice to axilla CriteriaInduced for Hypothermia Advanced Airway Cardiac arrest SpontaneousReturn of Circulation post-cardiac arrest ) I B P P YES Signs and Symptoms Signs · · P (33 C NO NO .4 F 91 ≤

) (Optional Hypothermia Induced Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Exit to Protocol as indicated traumatic cardiacarrests-traumatic Document initial AirwayProtocol (s) transport. Post Resuscitation minutes temperature increases Reassess measures (drownings and hanging / asphyxiation arepermissible in this protocol.) All presenting rhythms are permissible inthisprotocol Age 18 or greater Non assessmentnot Stop cooling change in rectal Agencies utilizing Continue Post temperature during are unlikely to see a Untiltemperature warranted with these Resuscitation Care Continued temperature · · History · cerebral cooling devices temperature10 every devices. Adult Cardiac Section Protocols 2012 -arrest patient and While goal is goal normalize. While will usually resuscitation but Protocol 20 (34 C). cooling may only be initiatedon order from medical control. . , : 93 degrees in place with no purposeful responseto verbal purposeful commands. BIAD placewith no ) in (including ) (Optional Hypothermia Induced Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS penetrating trauma. / penetrating or hemorrhage relatedto blunt not circulation Return of spontaneous Temperature greater than Advancedairway CriteriaInduced Hypothermia for Maintain patient modesty. Undergarmentsmay remainin placeduring cooling . Monitor advance airwayfrequently , especially any movement after of patient. Do not delay transport to initiate induced hypothermia. delay transportto initiate Do not and recurrence causehypotension of cardiacarrest in the post Hyperventilation is a significant of atall costs. resuscitation phase and must be avoided tidal CO2 may be elevatedimmediately post- End Initial 35 – 45avoid hyperventilation mm Hg managing the post protocol mandates transport to facility capable of of this Utilization hypothermiatherapy induced . of continuation noIf advanced airway in place obtained Pearls · · · · · · · · Adult Cardiac Section Protocols 2012 with with Go to Go Protocol Return of Circulation IO IO Spontaneous Spontaneous ) AT ANY TIME Utilize this Protocol Utilize this Post Resuscitation B Cardiac Arrest Protocol ALS EMT- Hierarchy ( Establish / IV Establish / IV EMS ALS Personnel First Arriving Responder ) Establish Team Leader Continuous Cardiac Monitoring min) Fire DepartmentSquad Officer or / AdministerMedications Appropriate Administer Appropriate Medications Initiate Defibrillation Manual Procedure Continue CardiacContinue ArrestProtocol Establish Airway with BIAD if not in place Establish Airway with BIAD if not in place Initiate Defibrillation Automated Procedure Manual ≥ 100 / ( minutes 10 seconds I P 2 ≤ ALS Responder ALS Responder / breathsper minute No Resuscitation / to 8 NO Procedure if available PlaceBIAD pulses checks / Protocol 21 BLS or ALS ) (Optional ≥ 2 inches) Push Fast Assume Compressionsor Calladditional for resources DO NOT InterruptCompressionsDO NOT Third Arriving Responder Third MOST Form Review DNR / MOST Initiate Compressions CPR Only Initiate Ventilateat 6 First Arriving BLS Initiate Defibrillation Automated / BLS / Second Arriving Team Focused CPR Focused Team Initiate Defibrillation Automated Procedure Change Compressors every Begin Continuous CPR Compressions Begin Continuous Criteria for DeathCriteriafor Limit changes ( Push Hard Push ( ) B BLS EMT- Hierarchy YES ( compressions Team Leader ALS Personnel Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Incident CommanderIncident Rotate with CompressorRotate with First Arriving Responder Subsequent Arriving Responders Subsequent Establish Team Leader Responsiblepatient for care Manages Bystanders Scene / Team Leader until ALS arrival life Take direction from Team Leader Take direction Team Leader from Policy Fire DepartmentSquad Officer or Follow Ensureshigh -quality compressions asystole Ensures frequent compressorchange Continue CardiacContinue ArrestProtocol Rigor mortis To prevent Fatigueand high effect quality resuscitation Do not begin Fire Department First Responder / Officer Decomposition Fourth / Fourth Responsible briefing counseling for / family Dependent lividity Blunt force trauma Deceased Subjects Responsible briefingALSarrival for family prior to Injury incompatible with Extended downtimewith Adult Cardiac Section Protocols . 2012 If advanced . 2 30: . Make room to work. . . compressions to ventilations are) compressionsto ventilations ETT Agencies may and are encouraged to develop their own Agencies may areencouragedto develop their and . Procedures require space and patient access Protocol 21 ) (Optional Team Focused CPR Focused Team If no advanced airway (BIAD, : If no 10 breaths per minute – Consider early IO placement if available and difficult IV anticipated IV available and difficult Consider early IO placement if Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Do not interrupt compressionsplace endotracheal to tube. Consider to limit interruptions BIAD first Success is based on properplanning and execution. airway in place ventilateairway in place 8 Efforts should be directed at high quality and continuous compressions with limited interruptions and early defibrillation and early defibrillation interruptions compressions limited with and continuous quality be directed at high Efforts should indicated. when HYPERVENTILATE DO NOT . only as an example. and given optional protocol is This · · · · Pearls · Adult Medical Section Protocols Ovarian NO 2012 IO ProcedureIO Gastritis ) Shock P CHF Symptoms , NO Exit to Etiology Ectopic pregnancy, Protocol Improving , or Vomiting Cardiac Monitor if indicated Nausea and / PID Signs / Suggesting Cardiac hepatitis Hypotension / Adult Pain Control Protocol IV Procedure Peptic ulcer disease / Pneumonia or Pulmonary embolus Liver ( Gallbladder Myocardial infarction Pancreatitis Kidney stone Abdominal aneurysm Appendicitis BladderProstate disorder / Pelvic ( cyst) Spleen enlargement Diverticulitis Bowel obstruction Gastroenteritis (infectious) Ovarian and Torsion Testicular I YES P · Differential · · · · · · · · · · · · · · · YES YES , malaise, ) mental , ) , discharge / migration Symptoms weakness headache , rash poorperfusion , shock Protocol 23 Appropriate as indicated Cardiac Protocol headache , Pain (location/ Tenderness Nausea Vomiting Diarrhea Dysuria Constipation Vaginal bleeding Pregnancy Notify Destination or Serious Signs / Contact Medical Control Hypotension Helpful to localize source Helpful Signs and Symptoms Signs · · · · · · · · · Associatedsymptoms : ( Fever status changes, , myalgiascough, , P Abdominal Pain Abdominal NO YES sharp, ) , Referred pregnancy) ( surgical history / Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Provocation NO Etiology IV Procedure or Vomiting if indicated Nausea and / etc.) Signs / Symptoms Suggesting Cardiac Past medical Age Medications Onset Palliation / Quality (crampy, constant dull, Region / Radiation / Severity (1-10) Time (durationrepetition / Fever Last mealeaten emesisLast bowel movement / Menstrual history Adult Pain Control Protocol I · History · · · · · · · · · · · · Adult Medical Section Protocols . . Neuro , , Extremities , Abdomen, Back, Lung , Heart or women especiallywith upperabdominal complaints Neck Protocol 23 diabetics and / , (Phenergan) forpatients likely to experience sedative effects (e.g., Age ≥ . > 50 Abdominal Pain Abdominal Mental Status, Skin, HEENT , : / poorperfusion . etc.) Whengiving promethazine IV dilute with 10 mL of normalsaline and administer slowly. Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Consider cardiac etiology inpatients Recommended Exam Document the mentalstatusand vitalsignsadministration prior to of anti-emetics Abdominal pain in womenofchildbearing age should be treated as pregnancy related until proven otherwise Antacids should be avoided inpatients withrenal disease. The diagnosis of abdominal aneurysm should beconsidered withabdominal pain especially in patients over 50 and / or patients with shock Repeat vital signs after each fluid bolus The useof metoclopramide (Reglan ) may worsen diarrhea and should be avoided in patientswith. this symptom Choose the lower doseof promethazine 60, debilitated , · Pearls · · · · · · · · Adult Medical Protocol Section 2012 ) 3 IO ) IO mg .5 mg 5 1000 1000 : : IM / Procedure / .5 – minutesno if 5 mg P .5 mg IM 0 .5 – druginduced Nebulizer systemic effect 2 if available if indicated if indicated improvement .3 – SEVERE 25 - 50 mg PO 0 if indicated Injector IM Auto-Injector (rash) only Ipratropium 0 Ipratropium if not already given Diphenhydramine Diphenhydramine - IV Albuterol Nebulizer Albuterol Epinephrine 1 Epinephrine Epinephrine 1 Epinephrine Albuterol 2 Repeat as needed x Repeat as neededx 3 25 - 50 mg IV AirwayProtocol (s) +/ Repeat in 5 Procedure I Shock (vascular) effect Angioedema ( AspirationAirwayobstruction / Vasovagal event Asthma or COPD CHF Urticarial Anaphylaxis ( P B · · · · · · Differential · · IO .5 mg 1000 1000 : : IM / / minutesno if 5 mg 5 mg .5 mg IM 0 wheezing or respiratory .5 – .5 – 2 2 if available Assess if indicated if indicated improvement IV Procedure .3 – Protocol 24 25 - 50 mg PO 0 MODERATE Injector IM Auto-Injector Ipratropium 0 Ipratropium Diphenhydramine Diphenhydramine - Albuterol Nebulizer Albuterol Nebulizer Albuterol Epinephrine 1 Epinephrine Epinephrine 1 Epinephrine Repeatx 3 as needed Repeat as neededx 3 25 - 50 mg IV Symptom Severity +/ if not alreadygiven PO if not Repeat in 5 Itching or hivesItching or Coughing / distress Chest or throat constriction Difficulty swallowing Hypotension or shock Edema N/V I P B Signs and Symptoms Signs · · · · · · · Notify Destination or Contact Medical Control detergent IO Anaphylaxis / Reaction Allergic IM / soap, / , IV Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 50 mg PO MILD 25 - 50 mg if indicated IV Procedure 25 - PO / Diphenhydramine Diphenhydramine Signs and Symptoms Monitor Worsening for Monitorand Reassess Onset and locationOnset and or bite Insect sting Food allergy / exposure Medication allergy/ exposure Newclothing Past history of reactions Past medical history Medication history I Cardiac Monitoring B B Revised 10/19/2012 andSevere Reactions Indicated Moderate for History · · · · · · · · Adult Medical Protocol Section . This . 2012 s who haves who Moderate / Severe skin involvement / AgencyMedical Director . typically end in -il -typically end in ) lips or airway structureslips . , or gastrointestinal hypoxia) or gastrointestinal or gastrointestinal hypoxia) or gastrointestinal lisinopril , , Epinephrine mayprecipitatecardiacEpinephrine .) Zestril ( 1000 . dyspnea : dyspnea , , mg of 1 wheezing wheezing .25 ( ( 0 MR administeringany medication. / 15 – EMT-Badministering any medication. / MR administeringany medication. / Lungs Protocol 24 B - but this should NOT delay this should but their care, in lead ECG at some point Heart, 12 erythema respiratory plus erythema respiratory plus . and perfusion pressure erythema normal blood with , , , with normal blood pressureand perfusion. normal blood pain) with abdominal vomiting, with hypotension and poor perfusion and poor hypotension pain) with abdominal vomiting, : , , itching itching itching , , , nausea nausea Mental Status, Skin, hives hives hives . for appropriate dosing Contact Medical Control , , , Anaphylaxis / Reaction Allergic Flushing symptoms ( Flushing Flushing symptoms ( These patients should receiveaThese patients should injector only and maysupply. Agency Medical only and administer from EMS IM as Auto-injector B mayadministerEpinephrine Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Moderate symptoms : Severe symptoms: Mild symptomsMild : ischemia. . of epinephrine administration half the dose of epinephrine (0. dose of epinephrine heart rates 150-half the ≥ give one have a history of cardiac or patient' are 50 years of age, have a history of disease, take Beta-Blockers Digoxin Patients who ≥ / Allergic reactions may occur with only respiratory and gastrointestinal symptoms rash no only respiratoryand gastrointestinal and have Allergic reactions mayoccur with Directormay requirecontact of medical control prior MR to . and may administer from EMS supply by oral route only EMT-B may administerdiphenhydramine may require contact of medicalcontrol prior to EMT . Agency Medical patient already prescribed and may administerfromEMS supply EMT-B may administerAlbuterol if Directormay requirecontact of medical control prior EMT-B to MR / EMT- : Recommended: Exam lethal multisystemallergic reaction acute potentially Anaphylaxis is an and acute anaphylaxis ( be administered in that should the first drug choice and of is the drug Epinephrine access. attempts or IO or during at IV before in priority be administered should Symptoms.) IM Epinephrine or by IV push administration mayrequireIV epinephrine repeat IM epinephrine doses of Anaphylaxis unresponsive to . infusion epinephrine Symptom Severity Classification Angioedema is seen in moderate to severe reactions and is swelling involving the face moderateto severe involving Angioedema is seen in reactions and is swelling pressure Prinivil / blood medications like patients taking can also be seen in Any patientwith respiratory symptoms or extensive reaction should receive or IM diphenhydramine IV . The shorter the onset from symptoms to contact, the more severe the reaction. Revised 10/19/2012 · · · · · Pearls · · · · · · · · Adult Medical Section Protocols 2012 ) infection) traumatic) seizure, ) , hypoglycemia ) / hypo) / tumor CHF , Alkalosis / (hyper Shock Seizure where circumstances Head trauma CNS (stroke Hypothermia Infection (CNSand other) Thyroid Shock (septic, metabolic, Diabetes (hyper Cardiac, (MI Toxicological orIngestion Acidosis Environmental exposure Pulmonary (Hypoxia Electrolyteabnormality Psychiatricdisorder / Exit to Exit to Exit to Exit to Exit to Exit to Protocol Protocol Protocol suggestamechanism of injury . Differential · · · · · · · · · · · · · · as indicated as indicated as indicated CVA Diabetic Protocol Overdose / Toxic Utilize Spinal Immobilization Protocol Exposure Protocol Hypo / Hyperthermia Hypotension / Appropriate Cardiac Protocol fruity ; warm, dry skin cool, diaphoretic ( ( Protocol 25 YES YES YES YES YES YES Notify Destination or Contact Medical Control Kussmaul respirations; signs ; breath skin) Hyperglycemia of dehydration) Irritability Decreased mentalstatus or lethargy Change baseline in mental status Bizarrebehavior Hypoglycemia · · Signs and Symptoms Signs · · · · Altered Mental Status Mental Altered ≥ 250 IO ProcedureIO STEMI 69 or / Toxicology P NO NO NO NO NO NO Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS if indicated 12 LeadProcedure ECG AirwayProtocol (s) Arrhythmia Signs of CVA Or Seizure Signs of OD / Blood Glucose ≤ Signs of Hypo / Hyperthermia Blood Glucose Analysis Procedure IV Procedure Signs of shock Poor perfusion / Known, medicalert diabetic tag Drugs drug , paraphernalia Reportof illicit drug use or toxic ingestion Past medical history Medications History of trauma Change in condition Changes in feeding or sleep habits I History · · · · · · · · B Adult Medical Section Protocols . . 2012 . , Neuro , Extremities Recheck blood glucose after Dextroseor Abdomen, Back , , , Lungs , Skin, Heart Protocol 25 Alcoholicsfrequently develop hypoglycemia and may have . s and/or personnel's protectionper the restraint procedure Mental Status, HEENT Altered Mental Status Mental Altered : Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS It issafer assumeIt to hypoglycemia than hyperglycemia if doubtexists . Glucagon Do notletalcohol confuse theclinical picture unrecognized injuries . Consider Restraints if necessary for patient' . or other injury examof bruising Pay careful to the head for signs attention Be awareas of AMS presenting signan of environmentaltoxin or Haz-Mat exposure and protect personal safety Recommended Exam · · · · · Pearls · Adult Medical Section Protocols .) 2012 YES 5 mg 3 s) ( .5 – Bronchitis) Protocol Adult Airway Allergic Reaction NO YES Carbon monoxide etc , Anaphylaxis Protocol Improving Improving STRIDOR Repeat as needed x Albuterol Nebulizer 2 Albuterol Asthma Anaphylaxis Aspiration COPD (Emphysema, Pleural effusion Pneumonia Pulmonary embolus Pneumothorax Cardiac (MI or CHF) Pericardial tamponade Hyperventilation Inhaled toxin ( NO YES I P B NO Differential · · · · · · · · · · · · IO ProcedureIO .5 mg 1000 : P 5 mg rhonchi .5 mg IM 0 Cardiac Monitor Lung Exam Protocol 26 .5 – AirwayPatent cough 2 if indicated , .3 – 12 LeadProcedure ECG 0 Ventilations adequate as indicated Ipratropium 0 Ipratropium Oxygenation adequate - Albuterol Nebulizer Albuterol Epinephrine 1 Epinephrine Repeat as neededx 3 Shortness of breath Shortness Pursedlip breathing Decreased abilityspeak to Increased respiratory rate and effort Wheezing, Tachycardia Use of accessorymuscles Fever +/ IV Procedure AirwayCPAPProcedure Allergic Reaction Anaphylaxis Adult Airway Protocol(s) Notify Destination or I Signs and Symptoms Signs · · · · · · · · P Contact Medical Control B I , P ) , NO steroids Asthma / COPD Adult 5 mg , .5 – chronic bronchitis oxygen nebulizer, congestive heart failure YES Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Improving or Asthma WHEEZING Repeat as needed x 3 Signs / Symptoms consistentwith COPD Albuterol Nebulizer 2 Albuterol Medications (theophylline inhalers) Toxic exposure, smoke inhalation -- Asthma; COPD emphysema, Home ( treatment Revised 12/13/2012 · · History · · P B Adult Medical Section Protocols . 2012 .) , Neuro :1000 Digoxin or / Digoxin mg of 1 lead ECG at some point 12 lead ECG at some point -Blockers (0.15 – 0.25 Abdomen, Extremities , , takeBeta , Lungs , Heart . These patients should receiveThese patients should a half the dose of epinephrine dose of epinephrine -half the , Skin, Neck Protocol 26 have a history of cardiac disease , 150 give one Mental Status, HEENT Asthma / COPD Adult : Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS ETCO2 should be used whenRespiratory Distress is significant and does not respond to initial Beta-Agonist dose Epinephrine mayEpinephrine precipitate cardiacischemia . . epinephrine NOT delay administration of their care should in , but this be monitored continuously Pulse oximetry should A silentchest in respiratory distress is a pre-respiratory arrest sign . patient already administer from EMSsupply. AgencyEMT-B may administerAlbuterol if prescribed and may medical director may require Contact of Medical Control priorto administration . Items in Red Text arekey performance measuresevaluate compliance and care used to protocol are 50 yearsage Patients who ≥ of have heart ratespatient's who ≥ Recommended Exam Revised 12/13/2012 · · · · · · Pearls · Adult Medical Section Protocols 2012 NO Fluid / NO YES Overload 250 dl mg / CHF Hypotension Blood Sugar Blood ≥ no evidence of Dehydration with drug use head injury ; I Alcohol / Toxic ingestion Trauma Seizure CVA Alteredbaseline status. mental YES I Differential · · · · · · Shock dl / Exit to Protocol Procedure Exit to IO ProcedureIO Hypotension / 249 mg Blood Sugar Blood P irritable Protocol 27 70 – if condition changes if condition Blood Glucose Analysis Appropriate Protocol Procedure Notify Destination or if indicated Contact Medical Control Cardiac Monitor Blood Glucose Analysis 12 LeadProcedure ECG Alteredmental status Combative / Diaphoresis Seizures Abdominal pain Nauseavomiting / Weakness Dehydration Deep / rapid breathing IV Procedure ; Adult Diabetic Signs and Symptoms Signs · · · · · · · · · YES I P B IO / dl 50 per minutes gm IV 25 gm IV 5 arm dl or greaterdl - mg / NO 5 YES Improving RepeatD ≤ 69 Every Symptomatic Blood Sugar Blood Until Blood Glucose Until 70 mg / Awake and alert / appropriate treatment Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS D5012 . I I Protocol if indicated Past medical history Medications Recentblood glucose check Last meal NO Revised 11/19/2012 History · · · · AlteredMental Status Adult Medical Section Protocols 2012 . : . Neuro Dextrose 50 % can be administered rectally . Not all insulins haveprolonged action so Contact MedicalControl for Protocol 27 . Skin, Respirations and effort, . Longer acting insulin places the patientat risk of recurrent hypoglycemia even ; Adult Diabetic : Mental Status, . Patient’s who meetcriteria to refuse care shouldbe instructed to contacttheir physician : : Patient’s who meetcriteria to refuse care shouldbe instructed to contacttheir physician immediately . They areatriskof recurrent hypoglycemiabe delayed that can for hours and require close monitoring Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS immediatelyand consume a meal. Manyforms of insulin now exist after a normal blood glucose is established Patient’s taking oral diabetic medications should bestrongly encouraged to allow transportation to a medical facility evennormal after blood glucoseisestablished . Not alloral agents have prolonged actionsoContact Medical Control for advice advice. and consumeameal . Insulin Agents Insulin Oral Agents Recommended exam Patientswith prolongedhypoglycemia my not respond to glucagon . Do notadminister oral glucose to patientsthat are not ableto swallow or protect their airway. In extreme circumstanceswith no IV and no response to glucagon, Contactmedical control for advice . Qualitycontrol checksshould be maintained permanufacturers recommendationfor all glucometers medicalfacilityafter Patient’s refusing transport to treatment hypoglycemia of Revised 11/19/2012 · · Pearls · · · · · · Adult Medical Section Protocols 2012 Exit to Diabetic Protocol Exit to Protocol Appropriate YES NO IO ProcedureIO sec Congestive heart failure Pericarditis Diabetic emergency Sepsis Cardiac tamponade P 250 ≥ symptoms as this will cause clotting of the shunt NO NO NO hours ≥ 0.12 YES Differential · · · · · Apply dressing but avoid bulky dressing 4 Serious Dressing must not compress fistula / shunt Blood Sugar ≤ 69 Or Apply firm finger tip pressure site tip to bleeding Apply firm finger QRS Cardiac Monitor Peaked Wave T Signs / Hemodialysis in past 12 LeadProcedure ECG IV Procedure Blood Glucose Analysis Procedure I P B YES YES Protocol 28 Exit to Protocol Notify Destination or Contact Medical Control NO YES CHF / Pulmonary Edema Hypotension Bleeding Fever Electrolyteimbalance Nausea and / or vomiting AlteredMental Status Seizure Arrhythmia Signs and Symptoms Signs · · · · · · · · YES Pressure < 90 Systolic Blood Renal Failure / Renal Dialysis I Fistula P / NO NO YES CHF / Arrest Exit to Cardiac Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Bleeding Shunt Pulmonary Edema Appropriate protocol Anemia Catheteraccess noted Shunt accessnoted Hyperkalemia Peritoneal or Hemodialysis · · · · History · P Adult Medical Section Protocols 2012 . IO if IO . . Ideally give in separate lines fistula in place fistula in / Hypertension and cardiac disease areprevalent . Protocol 28 . HeartNeurological. Lungs . : Mental status. Renal Failure / Renal Dialysis Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Recommended exam Do not take Blood Pressure or start IV in extremityhasshunt take PressureDo not Blood or start IV in which a dead patient only with no other available access with no the dead or near-dead patient only Access indicated in of shunt available. requires Contact of Medical Control. dialysis fistula bleeding uncontrolled with Useof tourniquet Always consider Hyperkalemia in all dialysis or renal failure patients. Sodium Bicarbonate and Calcium Chloride / Gluconate should not be mixed . Renal dialysis patients have numerousmedical problems typically. Pearls · · · · · · · Adult Medical Section Protocols 2012 need s) s) STEMI ( ( / Exit to Exit to Exit to Exit to Protocol Protocol . Protocol Protocol Appropriate Appropriate Cushing’s Response with Bradycardia and Hypertension eclampsia / Eclampsia Neuro Chest Pain - , Obstetrical Emergency . Hypertensive encephalopathy Primary CNS Injury Myocardial Infarction Aortic DissectionAneurysm / Pre CNS or renal systems. Differential · · · · · hospital cases. setting in most YES YES YES YES Back, Extremities , pulmonary edema or altered mental should be status AMS , . / or greater Abdomen NO NO NO NO Hypertension is usually transientandin response stress to IV Procedure . Pregnancy Chest Pain CVA Cardiac Monitor Dyspnea CHF / Heart, dyspnea 12 LeadProcedure ECG Obtain and BP Document Measurement Arms in Both Notify Destination or Contact Medical Control , Lung Protocol 29 , I Systolic BP 220 Systolic BP or greater DiastolicBP 120 Headache Chest Pain Dyspnea AlteredMental Status Seizure P B Neck · · these ANDat of least one · · · · · Signs and Symptoms Signs these One of This is very difficult to determine in the pre- Hypertension YES Renal CVA; s) ( Mental Status, Skin, treated based protocols on specific and consultation with Medical Control . CVA or renal. failure Specificcomplaints such aschestpain , or greater Diabetes; . Or NO Exit to A hypertensive emergency is based on blood pressure withsymptoms along which suggestan organ is suffering Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS . minutesapart Cardiac Problems Appropriate Protocol Systolic BP 220 Diastolic BP 120 orgreater damage, such as MI / or pain Pain and addressed Anxiety are Recommended Exam: Documented Hypertension Related diseases: Ensureappropriate size blood pressure cuff utilizedfor body habitus Medications for Hypertension Compliance with Hypertensive Medications ErectileDysfunction medications Pregnancy Failure; Elevated blood pressurethreesetsof vital signs is basedon two to . Symptomatic hypertensionistypicallyrevealed throughend organ dysfunction to the cardiac, All symptomaticpatients with hypertension should be transported with their headelevated at 30 degrees BP taken on 2 occasions5 at least onlysupportive care Hypertension is not uncommon especially in anemergency setting and Aggressivehypertension of evenwith treatment elevation can result in harm. Most patients, significant inblood pressure , Pearls · History · · · · · · · · · · Adult Medical Section Protocols - 2012 s) ( overdose YES Exit to if indicated Trauma Protocol Obstructive Protocol as indicated Procedure Needle Procedure if indicated if Multiple Trauma Chest Decompression Cardiac Arrhythmia / Spinal Immobilization I P P Hypovolemic Cardiogenic Septic Neurogenic Anaphylactic NO Shock Ectopic pregnancy Dysrhythmias Pulmonary embolus Tension pneumothorax Medication effect / Vasovagal Physiologic (pregnancy) NO Differential · · · · · · · · Shock YES Trauma Exit to Protocol Distributive Procedure if indicated if Multiple Trauma IO ProcedureIO Spinal Immobilization I P P confusion clammy skin NO , Cardiac Monitor if indicated Protocol 30 Type of Shock ground emesis rapid pulse - AirwayProtocol (s) History, Exam and , cool 12 LeadProcedure ECG Circumstances Suggest Notify Destination or Delayed capillary refill Hypotension Coffee Tarry stools Blood Glucose Analysis Procedure Restlessness, Pale, Weakness, dizziness Weak Contact Medical Control IV Procedure I · · · · Signs and Symptoms Signs · · · · P B YES Right Sided MI Cardiogenic fever , I I P P / Hypotension NO MI, CHF) vaginal or - vomiting, diarrhea Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS - if indicated YES Diabetic Protocol Procedure Exit to Procedures if indicated Trauma WoundCare Protocol as indicated Hypovolemic Control Hemorrhage Multiple Trauma Medications Allergic reaction Pregnancy History of poororal intake Infection Cardiac ischemia ( Blood loss gastrointestinal bleeding, , AAA ectopic Fluidloss Spinal Immobilization Revised 11/19/2012 I · · · · · · History · · Hypotension / Shock Adult Medical Section Protocols Adult Medical

Pearls · Recommended Exam: Mental Status, Skin, Heart, Lungs, Abdomen, Back, Extremities, Neuro · Hypotension can be defined as a systolic blood pressure of less than 90. This is not always reliable and should be interpreted in context and patients typical BP if known. Shock may be present with a normal blood pressure initially. · Shock often is present with normal vital signs and may develop insidiously. Tachycardia may be the only manifestation. · Consider all possible causes of shock and treat per appropriate protocol. · Hypovolemic Shock; Hemorrhage, trauma, GI bleeding, ruptured aortic aneurysm or pregnancy-related bleeding. · Cardiogenic Shock: Heart failure: MI, Cardiomyopathy, Myocardial contusion, Ruptured ventrical / septum / valve / toxins. · Distributive Shock: Sepsis Anaphylactic Neurogenic: Hallmark is warm, dry, pink skin with normal capillary refill time and typically alert. Toxins · Obstructive Shock: Pericardial tamponade. Pulmonary embolus. Tension pneumothorax. Signs may include hypotension with distended neck veins, tachycardia, unilateral decreased breath sounds or muffled heart sounds. · Acute Adrenal Insufficiency: State where body cannot produce enough steroids (glucocorticoids / mineralocorticoids.) May have primary adrenal disease or more commonly have stopped a steroid like prednisone. Usually hypotensive with nausea, vomiting, dehydration and / or abdominal pain. If suspected EMT-P should give Methylprednisolone 125 mg IV / IO or Dexamethasone 10 mg IV / IO. May use steroid agent specific to your drug list. · For non-cardiac, non-trauma hypotension, Dopamine should only be started after 2 liters of NS have been given.

Revised Protocol 30 11/19/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Adult Medical Section Protocols ) 2012 TCAs) ( -1222 OD 2 mg IN Exit to Protocol – Cyanide / Appropriate if indicated Tylenol) Control ( If NeededIf Carbon Monoxide (organophosphates 1-800-222 Carolinas Poison if indicated Naloxone 1 if indicated Tricyclic antidepressants Acetaminophen Aspirin Depressants Stimulants Anticholinergic Cardiac medications SolventsAlcohols, , Cleaning agents Insecticides AppropriateProtocol Airway (s) I /

B Hypotension/ Shock Protocol

Differential · · · · · · · · · if available Exit to WMD Antidote Kit Antidote Protocol Nerve Agent if indicated NerveAgent Organophosphate NO YES NO / .S hypertension dysrhythmias .L . IO ProcedureIO E sec < 90 OD .12 QRS YES Ventilation P / Protocol 31 Tricyclic ≥ 0 .U.D.G.E NO NO YES L Antidepressant Notify Destination or Cardiac Monitor Mental status changesMental status Hypotension / Decreased respiratoryrate Tachycardia, Seizures S. D.U.M.B.B. Contact Medical Control LeadProcedure ECG P Potential Cause Systolic BP 12 Signs and Symptoms Signs · · · · · · ·

AlteredMental Status Adequate Respirations Oxygenation IV Procedure Serious / Symptoms Symptoms

I P B OD criminal) , Calcium quantity YES Channel Blocker route, YES Toxic Ingestion / Toxic Overdose Consider Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Cardiac External Pacing Procedure Safe Procedure for Severe Cases Scene as indicated OD Diabetic / AMS resources Blood Glucose Analysis Behavioral Protocols I Ingestionor suspected ingestion of a potentially toxic substance Substance ingested, Time of ingestion Reason (suicidal accidental , Available medications inhome Past medical history, medications P P Beta Blocker Revised 8/22/2012 NO Stage until scene safe History · · · · · · Callhelp for / additional Adult Medical Section Protocols 2012 Renal . . specificpupils - pinpoint pupils , Agencymedical director may require . Lacrimation, Salivation , causesirreversible liver failure seizures , Emesis mental changes status , Neuro Abdomen, Extremities, decreased respirations, non , , , , dilated pupils, nausea, vomiting, diarrhea GI distressGI , . , , Lungs Bronchorrhea, Emesis , 600 mg of pralidoxime in anautoinjector for self administration or Heart, If notdetectedIf and treated May administer fromEMS supply Protocol 31 . Bradycardia /or personnel's protectionpertheRestraint Procedure. HEENT, Make sure patient is still not carrying other attemptsMakesure is still patient especially in suicide . increased secretions 's and , Urination, Defecation Miosis, . increased dilated temperature, pupils , Urination, , vomiting and, , mental status changes increased BP, increasedtemperature , Mental Status, Skin, dysrhythmias and mentalstatus changes : Toxic Ingestion / Toxic Overdose , emesis ED contents, to , Salivation, Lacrimation, decreased HR, decreased BP, decreased temperature increased or decreased HR , These kits may be availableof thedomestic preparedness as part for Weapons of Mass Destruction : rapid progressionalert to death from mental status increased HR : liver andorcerebral failure, edema amongother things can take place later. : . , Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Early signs consist of abdominal painand vomiting. Tachypnea and altered mental may occur status later . U.D.G.E : Recommended: Exam Depressants Stimulants: , history of ingestion relyon patient Do not . medications or has any weapons Bring bottles : increasedAnticholinergic HR S.L. CardiacMedications Solvents: nausea, coughing Insecticides D.U.M.B.B.E.L.S: Diarrhea, Nerve kits contain Agent Antidote 2 mg of Atropineand Consider restraints if necessary patient for patientcare Tricyclic: 4 major areas of toxicity: seizures, dysrhythmias, hypotension, decreased mental status or coma; Acetaminophen: initiallynormal or nausea/vomiting. B may administer naloxone by IN route only EMT-B may administernaloxone by Aspirin: dysfunction Contact of Medical Controlprior to administration. Centerfor guidance. Control the North Carolina Poison Consider contacting Revised 8/22/2012 Pearls · · · · · · · · · · · · · · · · · · Adult Medical Section Protocols 2012 Mg) , Ca , Na ( IO ProcedureIO or Renal failure P trauma if indicated as indicated ) YES Protect patient Cardiac Monitor Fever AirwayProtocol (s) Status Epilepticus -compliance YES Loosenclothing any constrictive Spinal Immobilization Procedure IV Procedure Blood Glucose Analysis Procedure CNS (Head Tumor Metabolic, Hepatic, Hypoxia Electrolyteabnormality Drugs, Medications, Non Infection / Alcohol withdrawal Eclampsia Stroke Hyperthermia Hypoglycemia I P Differential · · · · · · · · · · · · NO Or Activity Protocol Consider if indicated if indicated Active Seizure Protocol 32 Postictal State Diabetic Protocol Seizure AlteredMental Status Notify Destination or Monitor and Reassess Contact Medical Control Decreased mentalstatus Sleepiness Incontinence Observed seizure activity Evidence of trauma Unconscious Signs and Symptoms Signs · · · · · · NO NO Weeks Alert > 20 YES if indicated if indicated if indicated IV Procedure Protect patient Cardiac Monitor Awake, witnessed seizure Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Monitorand Reassess Normal Mental Status Loosenclothing any constrictive Spinal Immobilization Procedure Blood Glucose Analysis Procedure I Previousseizure history Medical tag information alert Seizure medications History of trauma History of diabetes History of pregnancy Time of seizureonset Document number of seizures Alcohol use, abuse or abrupt cessation Fever activity Reported / P Active Seizure in Knownor · · · · · · · · · · History · P Suspected Pregnancy Seizure Adult Medical Section Protocols Adult Medical

Pearls · Recommended Exam: Mental Status, HEENT, Heart, Lungs, Extremities, Neuro · Items in Red Text are key performance measures used to evaluate protocol compliance and care · Midazolam 5 – 10 mg IM is effective in termination of seizures. Do not delay IM administration with difficult IV or IO access. IM Preferred over IO. · Status epilepticus is defined as two or more successive seizures without a period of consciousness or recovery. This is a true emergency requiring rapid airway control, treatment, and transport. · Grand mal seizures (generalized) are associated with loss of consciousness, incontinence, and tongue trauma. · Focal seizures (petit mal) effect only a part of the body and are not usually associated with a loss of consciousness · Be prepared for airway problems and continued seizures. · Assess possibility of occult trauma and substance abuse. · Be prepared to assist ventilations especially if diazepam or midazolam is used. · For any seizure in a pregnant patient, follow the OB Emergencies Protocol. · Diazepam (Valium) is not effective when administered IM. Give IV or Rectally. Midazolam is well absorbed when administered IM. Protocol 32 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Adult Medical Section Protocols ) 2012 85%) 10 Minutes %) STROKE Renal Failure Hypertension / : Transport based on (Transient ischemicattack if indicated Concerning Treatment of Contact Receiving Facility Diabetic Protocol See Altered Mental Status TIA Seizure Todd’sParalysis Hypoglycemia Stroke Tumor Trauma Dialysis EMS Triage and Destination Plan EMS Triage and Immediate Notification of Facility Immediate Notification Keep SceneTime to ≤ Differential · · · · · · Thrombotic or Embolic (~ Hemorrhagic (~15 · · · YES YES 220 ≥ 120 Paralysis NO Dysarthria Dizziness / IV Procedure Protocol 33 Procedure SBP ≥ DBP Cardiac Monitor after 3 readings 12 LeadProcedure ECG at least 5 minutes apart Blood Glucose Analysis Notify Destination or Alteredmental status Weakness / Syncope Vertigo / Blindness or other sensory loss Aphasia Vomiting Headache Seizures Respiratory pattern change Hypertension / hypotension Contact Medical Control I P B Signs and Symptoms Signs · · · · · · · · · · · Suspected Stroke Suspected , YES P diabetes CAD Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS NO Exit to Stroke PREHOSPITAL STROKE SCREEN Appropriate Protocol Signs and Symptoms Signs , TIA's PreviousCVA, Previouscardiac / vascular surgery Associated diseases: Atrial fibrillation Medications (blood thinners) History of trauma hypertension, Consistent with Acute Consistent with PrehospitalScreen Stroke consistent with Stroke consistent with Revised 8/13/2012 History · · · · · · Suspected Stroke Adult Medical Section Protocols Adult Medical

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

Revised Protocol 33 8/13/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Adult Medical Section Protocols ) 2012 ) hypertension Shock Protocol Protocol Appropriate if indicated if indicated if indicated if indicated Cardiac Arrhythmia / Multiple Trauma Protocol Hypotension / Spinal Immobilization Protocol Vasovagal hypotensionOrthostatic Cardiac syncope MicturitionDefecation / syncope Psychiatric Stroke Hypoglycemia Seizure Shock (see ShockProtocol ) Toxicological (Alcohol Medication effect ( PE AAA

Altered MentalProtocol Status Differential · · · · · · · · · · · · · YES YES YES / NO NO NO Status IV Procedure Cardiac Monitor if indicated Suspected or Hypotension AlteredMental Poor Perfusion EvidentTrauma Protocol 34 AirwayProtocol (s) 12 LeadProcedure ECG Notify Destination or Syncope Contact Medical Control Blood Glucose Analysis Procedure Loss of consciousness withrecovery Lightheadedness, dizziness Palpitations, slow or rapid pulse Pulse irregularity Decreased blood pressure I P B Signs and Symptoms Signs · · · · · seizure , ectopic) (GI, vaginal bleeding , if indicated Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS nausea, vomiting, Diabetic Protocol Cardiac, stroke history Fluidloss : diarrhea Past medical history Medications Occult blood loss LMP Females : History · · · · · · Syncope Adult Medical Section Protocols Adult Medical

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

Protocol 34 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS ) Adult Medical Section Protocols 2012 PID) ) IO ProcedureIO Shock influenza , P Symptoms NO Procedure Exit to Etiology Protocol IV Procedure Improving trauma or hemorrhagetrauma or , vestibular Abdominal Pain , Signs / Nausea Vomiting / Blood Glucose Analysis Suggesting Cardiac Hypotension / Consider 2 Large Bore sites , narcotics, NSAID's, antibiotics IV Procedure I YES Infections (pneumonia Electrolyteabnormalities Food or toxin induced Medication or Substance abuse Pregnancy Psychological CNS (increased pressure, headache, stroke, CNS lesions Myocardial infarction Drugs ( chemotherapy) orRenal GI disorders Diabetic ketoacidosis Gynecologic disease (ovarian cyst, YES YES · · · · · · Differential · · · · · · , , Symptoms shock etc.) , ) dull, Protocol Appropriate if indicated if indicated as indicated , myalgiascough, , perfusion Protocol 35 Diabetic Protocol Adult Pain Control Hypotension, poor blurred vision Cardiac Protocol(s) Notify Destination or sharp, , Contact Medical Control Serious Signs / malaise, , dysuriamental status , P , headache , YES Pain painCharacter of (constant intermittent, Distention Constipation Diarrhea Anorexia Radiation NO YES Helpful to localize source Helpful Signs and Symptoms Signs · · Fever · · · · · Associatedsymptoms : ( weakness, headache changes, rash Vomiting and Diarrhea and Vomiting Symptoms NO pregnancy) Procedure ( Etiology IV Procedure Improving Abdominal Pain Signs / Nausea Vomiting / Blood Glucose Analysis Suggesting Cardiac Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS I I Travel history Bloody emesis / diarrhea Age meal Time of last Last bowel movement /emesis Improvementorworsening with food or activity Duration of problem Other sick contacts Past medical history Past surgical history Medications Menstrual history Revised 8/13/2012 · · History · · · · · · · · · · Vomiting and Diarrhea Adult Medical Section Protocols Adult Medical

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

Revised Protocol 35 8/13/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Adult Obstetrical Section Protocols 2012 Go to Go Crowning Delivery Protocol Newly Born Expedite transport Multiple gestation Multiple Protocol Priority symptoms: <36 weeks gestation Obstetrical Emergency as indicated Abnormal presentation Severebleeding vaginal Buttock Foot Hand Abnormal presentation Prolapsed cord Placenta previa Abruptio placenta YES Differential · · · · / Support pushing imminent Transport Do Not Pull to refrain from Unless delivery Presenting Parts Breech Birth Encourage Mother NO Crowning IV Protocol Inspect Perineum Protocol 37 No digital vaginal exam) Spasmodic pain Vaginal discharge or bleeding Crowning or urgepush to Meconium ( Childbirth Procedure >36 Weeks Gestation Notify Destination or Hypertension / Hypotension Signs and Symptoms Signs · · · · Abnormal Vaginal Bleeding Contact Medical Control Over cord I HipsElevated Kneesto Chest Saline Dressing vagina to relieve pressure on cord Insert fingers into Prolapsed Cord Shoulder Dystocia Shoulder / Labor Childbirth Left lateral position duration Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Para Status of contractions No Crowning fingersalong Monitorand Reassess from face Document and frequency part of infant. Duedate howoften Time contractions started / membranesRupture of Time / amount of any vaginal bleeding Sensationactivity of fetal Past medical and delivery history Medications Gravida / High Risk pregnancy Lateral Position Unable to DeliverUnable to Transport in Knee to Place 2 Chest Position or Left supporting presenting Createair passage by History · · · · · · · · · sidenose and pushaway Childbirth / Labor Adult Obstetrical Section Protocols Adult ObstetricalSection

Pearls · Recommended Exam (of Mother): Mental Status, Heart, Lungs, Abdomen, Neuro · Document all times (delivery, contraction frequency, and length). · If maternal seizures occur, refer to the Obstetrical Emergencies Protocol. · After delivery, massaging the uterus (lower abdomen) will promote uterine contraction and help to control post- partum bleeding. · Some perineal bleeding is normal with any childbirth. Large quantities of blood or free bleeding are abnormal. · Record APGAR at 1 minute and 5 minutes after birth. Protocol 37 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Adult Obstetrical Section Protocols 2012 94 % ≥ / 2 000 :10, minutesas kg IV / IO Maintain warmth kg IV / IO NO SupplementalOxygen Monitorand Reassess to 5 Maintain SpO needed 3 Secretions Respiratory drive May repeatx 1 .01 mg / Labored breathing Persistent Cyanosis 10 mL / 0 Monitorand Reassess Airwayfailure Infection Maternal medication effect Hypovolemia Hypoglycemia Congenitalheart disease Hypothermia NormalSaline Bolus Epinephrine 1 Epinephrine Clear airway if necessary Every / ProvideDry infant warmth / YES Differential · · · · · · · I NO YES NO YES s) ( abnormal) 60 60 IO ProcedureIO 100 100 Protocol 38 P YES YES YES NO Dry and Stimulate If noimprovementIf move , . Pulse Oximetry Cardiac Monitor BVM Ventilations BVM Ventilations Change in position or BVM normal) Heart Rate < Heart Rate < Newly Born Newly Chest Compressions Respiratory distress Peripheral cyanosis or mottling ( Central cyanosis ( Alteredlevel of responsiveness Bradycardia Heart Rate < Heart Rate < : Term Gestation Warm Clear airway if necessary Good Muscle Tone Breathing or Crying down algorithmto intubation Notify Destination or Signs and Symptoms Signs · · · · · Agonal breathing or Apnea Pediatric Airway Protocol IV Procedure If repeatingIf cycletakecorrective Contact Medical Control action Technique I P B NO NO ) / twins etc.) : ( : or or , / : BVM Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Suctioning substance abuse smoking epinephrine. Careof mother hypovolemia, may undergo recommended -vigorous newborns DirectEndotracheal Meconium Delivery difficulties Congenitaldisease Medications (maternal Maternal risk factors Duedateand gestational age Multiple gestation Suctiononly when Appropriate Protocol ventilations / Airway Suctioning or if BVM is needed. Meconium present hypoglycemia (< 40.) Clear fluid amniotic compressions and pneumothorax and / newborn is no longer is no newborn Non Most newborns requiring I · · · · · History · · If notrespondingIf consider obstruction and is present Routine suctioning of the suctioning Routine resuscitation will respond to Adult Obstetrical Section Protocols . ). 2012 . , Neuro , % 70

= 85 – 95%. = 65 – minutes 10 , Abdomen, Extremities %, 2 minutes % and = 60 - 65 = 80 – 85 , Chest, Heart ) Neck 3:1 compressiontoventilation ratio. NaloxoneLONGER recommended NO -supportivecare only Protocol 38 – 80 %, 5 minutes 75 Newly Born Newly . with 4 ml of Normal Saline breathing and with good muscle tone generally will need no resuscitation need no muscle generally will good tone with breathing and / 4 minutes = , Mental Status, Skin, HEENT , % : compressions/minute with a 120 = 70 – 75 1 and 5 minute Apgars in PCR Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS = D50 diluted (1 mlof D50 3 minutes Most important vital signs in the newly born arethe newly born respirations / respiratory effort and heart rate. signs in Most important vital Heartratebestassessed byauscultation of the precordial pulse followed palpation of the umbilical pulse Pulse oximetry should be applied to the right sidethebody of . Expectedpulse oximetry readings: Following birthat 1 minute CPR in infants is Consider hypoglycemia ininfant D10 Recommended Exam Term gestation, strong cry It isextremelyIt important to keep infant warm Maternal sedation or narcotics will sedate infant ( Document · · · · · · · Pearls · · · · · Adult Obstetric Section Protocols 2012 Exit to YES Protocol Childbirth / / IO ProcedureIO / P YES NO NO YES YES Labor Shock Activity Seizure Improving Pregnancy Hypotension Missed Period eclampsia / Eclampsia Poor Perfusion - Known or Suspected Placentaprevia Placentaabruptio Spontaneous abortion Pre YES Left lateral recumbant position IV Procedure YES · · · Differential · I I NO NO NO / Exit to Shock Protocol Exit to Hypotension Protocol Abdominal Pain / Abdominal Pain Or Exit to Protocol 39 Notify Destination or Appropriate Protocol Contact Medical Control Abdominal Pain Protocol Vaginal bleeding Abdominal pain Seizures Hypertension Severeheadache Visual changes Edemaof hands and face Exit to Vaginal Bleeding Diabetic Protocol Signs and Symptoms Signs · · · · · · · NO NO Obstetrical Emergency Obstetrical / Procedure YES YES YES Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS IV Procedure Cardiac Monitor Pregnancy Hypertension Missed Period Seizure Activity Blood Glucose Analysis Known or Suspected Left lateral recumbant position Past medical history Hypertension meds Prenatal care Prior pregnanciesbirths / Gravida / Para P P Revised I 12/13/2012 History · · · · · NO NO Obstetrical Emergency Adult Obstetric Section Protocols Adult ObstetricSection

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

Revised Protocol 39 12/13/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Adult Trauma and Burn Section Protocols 2012 Don’tinclude in . . Degree Burn rd /3 ) blistering painful ( nd

- ) painless/charred or leathery compromise Criticial Burn ) red Degree : TBSA 2 nd / 2 Degree ( transport to a Burn Center) Burns withdefinitive airway Burns withMultiple Trauma rd When reasonably accessible, ( 3 Degree >15% if indicated if cc of fluid per hour cc of fluid st Electrical injury IV Procedure NormalSaline if indicated if indicated as indicated (More below) info Trauma and Burn Cyanide Exposure Carbon Monoxide for up to the first hours. 8 skin Thermal injury Chemical – Radiation injury Blast injury Full Thickness ( TBSA) PartialThickness Superficial (1 IO ProcedureIO Adult Airway Protocol(s) Dry Clean Dressings Sheet or 0.25 mL / kg ( x % / hr mL / ( x TBSA) 0.25 kg Lactated Ringers if available · · · · · · Differential · Adult Multiple Protocol Trauma Adult Pain Control Protocol EMS Triage and Destination Plan EMS Triage and TBSA will need 1000TBSA will Consider 2 IV sites if greater than 15 % Consider2 IV sites if greater than 15 % TBSA RemoveConstricting / Items Rings, Bracelets Degree Burn Rapid Transport to appropriate destination using rd / /3 nd if not change over once available if not Useif available, I I P swelling Protocol 40 Serious Burn , / transport to a Burn Center) patient with 50%patient with When reasonably accessible, ( 15% TBSA 2 Hypotension 13 or Less or GCS - intubationstabilization for airway Carbon 5 Cyanide Protocol Burns, pain Dizziness Loss of consciousness Hypotension/shock Airwaycompromise distress could be indicated by hoarseness/wheezing Monoxide Suspected inhalation injuryrequiring or Concomitant Injury SeverityAssess Burn / ConcomitantInjury Signs and Symptoms and Signs · · · · · 196 lbs.) Notify Destination or ( Contact Medical Control Adult Thermal Burn Thermal Adult 80 kg gas, , / / Degree Burn rd /3 nd Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS if available NormalSaline MinorBurn if indicated if indicated if indicated as indicated IV Procedure Constricting Items Lactated Ringers Normotensive (More info below) (More info Cyanide Exposure GCS 14 or Greater Carbon Monoxide for up to the first 8 hours. for up to the first 8 1. Lactated Ringers preferredover. Normal Saline Formula example2. Formula ; an Remove / Rings, Bracelets Transport Facilityof Choice Adult Airway Protocol(s) Dry Clean Dressings Sheet or 0.25 mL / kg ( x % TBSA) / hr / ( x% 0.25 mL kg TBSA) Type of exposure (heat chemical) Inhalation injury Time of Injury Past medical history and Medications Other trauma Loss of Consciousness Tetanus/Immunization status Adult Pain Control Protocol < 5% TBSA 2 No inhalationIntubated injury, Not , Adult MultipleTrauma Protocol I History · · · · · · · Adult Trauma and Burn Section Protocols . , , .

2012 and

st , th Report and 6 th 5 th 4 of burn, include only ) thickness burns ) rd and Neuro . , degree burn from those of , penetrates muscle tissue , destroys muscle issue st or full (3 . !) ) nd referring to a burn that destroys referring to a burn that destroys referring to a burn that destroys : Back th th th penetrates or destroys bone tissue. 4 the dermis and involves muscle tissue 5 dermis 6 andinvolves tissue around the bone dermis Seldom do you find isolated a complete body part that is injured as described in the Rule of Nines. More likely, it will be portions of one area Other burnclassifications in general include · portions of another, andan approximation will be needed For the purpose of determining the extent of serious injury, differentiate the area with minimal or 1 · · partial (2 the observa ion of other superficial (1 degree) burns but do not include those burns in your TBSA estimate. Some texts will refer to degree burns. Theresignificant is debate regarding heactual valueidentifying of a burninjury beyond that of the superficial, partial and full thickness burnatleast at the level of emergentand primary care. For our work, all are included in Full Thickness burns. For the purpose of determining Total Body Surface Area (TBSA Partial and Full Thickness burns. Rule of Nines · · · · · · . Extremities, , must maintain normalbody. temperature Stop the burning process or , , Abdomen JumpStart Triage System. , . . Lungs degree burns rd 3 Protocol 40 % or Neck, Heart, nd or , Local facility shouldbe utilized only if distance to Burn Centerisexcessive or critical never apply ice or cool the burn HEENT, - TBSA) 2 ( or evaluate for multisystem trauma , Adult Thermal Burn Thermal Adult or feetperineum, or

, TBSA for anyage group, or % TBSA for or size of the patient’spalm as 1 or hands , Estimate spotty areas of burn byusing the total body surfacetotal body area Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS degree burns > 5 rd circumferentialburns of extremities injuries, or electricalor lightning neglect, of abuse or suspicion , injury inhalation chemical burns, face burns of 3 > 5-15% Require direct transport to a Burn Center. interventions such as airway management are not available inthe field . Burn patients are trauma patients Recommended Exam: Mental Status, Yellow and Red In burn severity do not apply to the Start / severity not apply RedIn burn do and Green, Yellow Critical or Serious Burns: Assure whatever has causedtheburn is no longer contacting the injury( . Early intubation is required when the patient experiences significant inhalation injuries Circumferential burnsextremities dangerous to are dueto potential vascular compromisesecondary to soft tissue swelling. Burn patients are proneto hypothermia Evaluate the possibilityof child abusewith children and burn injuries Neveradminister IM paininjections to a burn patient. · · Pearls · · · · · · · · · Adult Trauma and Burn Section Protocols , 2012 2 ) ≥ 94 % 2 16 Breaths – 35 mmHg 45 mmHg Posturing / YES 35 – Maintain EtCO , ContusionConcussion, if indicated 2 30 – Supplementaloxygen Monitorand Reassess Maintain SpO AirwayProtocol (s) Brain Herniation Pupils EtCO per minutesmaintain to B Hyperventilate 14 Unilateral or Bilateral Dilation of Skull fracture Braininjury ( Hemorrhage or Laceration Epidural hematoma Subdural hematoma Subarachnoid hemorrhage Spinal injury Abuse Cough Able to Differential · · · · · · · 2 NO YES failure 45 mmHg / if available RSI Protocol 35 – Maintain EtCO bleeding AirwayProtocol (s) IO Procedure IO , B ≤ 8 Protocol 41 P swelling Notify Destination or GCS Contact Medical Control if indicated if indicated if indicated if indicated RecordGCS Alteredmental status Unconscious Respiratory distress Pain, Vomiting Majortraumatic mechanisminjury of Seizure Seizure Protocol Assess Mental Status · · · Signs and Symptoms and Signs · · · · Head Trauma Head Spinal Immobilization Protocol AlteredMentalProtocol Status Adult Multiple Trauma Protocol Blood Glucose Analysis Procedure IV Procedure ) I NO penetrating . bluntvs Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS DO NOT Monitorand Reassess Time of injury Mechanism ( Loss of consciousness Bleeding Past medical history Medications Evidence for multi-trauma HYPERVENTILATE EtCO2 35 – 45 mmHg per minute maintain to History · · · · · · · Ventilate 8 – 10 Breaths Head Trauma Adult Trauma and Burn Section Protocols BurnSection and Adult Trauma

Pearls · Recommended Exam: Mental Status, HEENT, Heart, Lungs, Abdomen, Extremities, Back, Neuro · GCS is a key performance measure used in the EMS Acute Trauma Care Toolkit. · If GCS < 12 consider air / rapid transport · In areas with short transport times, RSI/Drug-Assisted Intubation is not recommended for patients who are spontaneously breathing and who have oxygen saturations of ≥ 90% with supplemental oxygen including BIAD / BVM. · Increased intracranial pressure (ICP) may cause hypertension and bradycardia (Cushing's Response). · Hypotension usually indicates injury or shock unrelated to the head injury and should be aggressively treated. · An important item to monitor and document is a change in the level of consciousness by serial examination. · Consider Restraints if necessary for patient’s and/or personnel’s protection per the Restraint Procedure. · Limit IV fluids unless patient is hypotensive. · Concussions are traumatic brain injuries involving any of a number of symptoms including confusion, LOC, vomiting, or headache. Any prolonged confusion or mental status abnormality which does not return to normal within 15 minutes or any documented loss of consciousness should be evaluated by a physician ASAP. Protocol 41 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Adult Trauma and Burn Section Protocols 2012 ) ) Needle - : 10 minutes ≤ Cord injury to appropriate Tension pneumothorax Flail chest Pericardial tamponade Open chest wound Hemothorax Procedure if indicated Abnormal Femur fracture if indicated : abdominal bleeding destination using Monitorand Reassess Trauma and Burn Head Injury Protocol Chest Decompression Head injury (see Head Trauma DislocationExtremity fracture / HEENT (Airwayobstruction ) Hypothermia Chest Intra- Pelvis / Spine fracture / Provide Early Notification Splint Suspected Fractures Consider PelvicBinding Control External Hemorrhage Rapid Transport Limit Scene Time

EMS Triage and Destination Plan EMS Triage and · · · · Differential (Life threatening Differential · · · · I P / / IO ProcedureIO bleeding , P GCS Shock Protocol lesions Symptoms Cardiac Monitor Hypotension if indicated ABC and LOC VS / Perfusion / Protocol 42 AirwayProtocol (s) swelling Notify Destination or Contact Medical Control Pain, Deformity, Alteredmental status or unconscious Hypotension or shock Arrest Assessment of Serious Signs IV Procedure Spinal Immobilization Procedure Immobilization Spinal Signs and Symptoms Signs · · · · · I P Multiple Trauma Multiple : Normal protectiveequipment Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS / destination using Monitorand Reassess Trauma and Burn to appropriateTransport to Repeat Adult Procedure Assessment Splint Suspected Fractures Consider Pelvic Binding Control External Hemorrhage EMS Triage and Destination Plan EMS Triage and Time and mechanismTime and of injury Damage structure or vehicle to Location structure or vehicle in Others injured or dead Speed and detailsof MVC Restraints Past medical history Medications History · · · · · · · · Multiple Trauma Adult Trauma and Burn Section Protocols BurnSection and Adult Trauma

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

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

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

Airway Foreign Body NO Airway Patent Obstruction Procedure I Direct Laryngoscopy

YES Protocols Section Pediatric General Supplemental oxygen Complete Obstruction Breathing / Oxygenation BVM NO YES Unable to Clear Support needed Maintain Oxygen Saturation ≥ 90 % NO YES Monitor /Reassess Supplemental Oxygen Tension if indicated Pneumothorax P YES Exit to Appropriate Protocol NO Chest P Decompression Procedure

BVM / Oxygen Unable to Ventilate NO and Oxygenate ≥ 90% Effective during or after one (1) or more unsuccessful Airway Blind Insertion YES intubation attempts . B Device Procedure

Oral-Tracheal Anatomy inconsistent I Intubation Procedure Supplemental oxygen with continued attempts. BVM Maintain Oxygen Consider Sedation Three (3) unsuccessful Saturation ≥ 90 % If BIAD or ETT in place attempts by most experienced EMT-P/I. P

Exit to Pediatric Failed Airway Protocol Notify Destination or Contact Medical Control Protocol 44 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 Pediatric General Section Protocols . 2012 . maintain , . ) to better maintain ETT 35. . transfers. 30- of Regional EMS Office Regional 2 / They may worsen view in somecases . . establish a training program establish a training , evenin absence of trauma . years of age or any patient which can be measured within the within can be measured 11 yearsage or any patient which of Protocol 44 . avoid hyperventilation and 45 and tracheal intubationisunsuccessful and for Adolescentsnormal Adult rate and for the School Age, , 20 for 25 for Toddlers : . . use BIAD or endotracheal tube ) is strongly recommended with Pediatric Airway Pediatric last resort procedure in pediatric patients ≤ 11 yearsage last resortprocedurein pediatric of 30 for Neonates, . Maintain aEtCOMaintain 2 between 35 pediatric is defined as less than ≤ pediatric is defined . Document results intubation all methods of is mandatory with (color) or capnography Manual stabilization of endotracheal tube should be used duringall patient moves / . Luten tape. Luten Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS equipment and submit procedure and training plan to the StateMedical Directorplan to training and submit procedure and equipment Indicated as / Indicated a lifesaving Very little evidence to support it’s useand safety support it’s Verylittle evidence to A variety of alternative pediatric airway devices now available make the use of this procedure rareprocedure of this . A variety alternative airway devices available makethe use of pediatric now procedure this procedure must develop a written utilize Agencies who Cricoid pressure and BURP maneuver may be used to assist with difficultintubations Gastric tube placement shouldbe considered in all intubated patients. isimportantIt to secure the endotracheal tube well andconsider c-collar ( placement . Airway CricothyrotomyNeedle Procedure Continuous capnography (EtCO2 Continuous is acceptable to pulse oximetryvalues ≥ 90%, it of BVM continuous effective maintained by with If an airway is being . basicairwaymeasures a BIAD or Intubation with instead of using continue appropriate oxygenation and the patient is receiving protocol a secure airway is when purposes of this For the ventilation insertedinto endotrachealtube past the teeth or the laryngoscope blade or attemptdefined as passing is An intubation the nasal passage . of 12 per minute to maintain a pCO be done trauma only should deteriorating head Hyperventilation in Ventilatory rate should be Ventilatory rate should Broselow- Capnometry It is strongly encouraged to complete an Airway Evaluation Form with any BIAD or Intubation procedure. any BIAD or Intubation complete an Airway Evaluation Form with strongly encouraged to It is Do not attempt intubation in patientswho maintain a gag reflex. Paramedics shouldconsideroral using a BIAD if - For this protocol, For this · · · · · · · · · · · · · · Pearls · Pediatric General Section Protocols 2012 90 % 90 % Exit to Continue BVM Supplementaloxygen BVM Maintain Oxygen Saturation ≥ Supplementaloxygen BVM Maintain Oxygen Saturation ≥ Calladditional for Appropriate Protocol resources if availableresources if Supplemental Oxygen YES YES YES 90 % or Nasal Airway Ventilation / / NO NO BVM Adequate Successful Failed Aiway Significant Facial Adjunctive Airway Maintains Oxygen Saturation ≥ Airway BIAD Procedure Notify Destination or AirwayBIAD Procedure Oxygenation Contact Medical Control Place Oraland Trauma / SwellingDistortion / Protocol 45 B YES NO . ≥ 90%≥ during . /I P - Pediatric Failed Airway Failed Pediatric .

% attempts or equipment Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS experienced EMT Supplementaloxygen BVM Maintain Oxygen Saturation ≥ 90 Three (3) unsuccessful attempts by most P Anatomy inconsistent with continued attempts or after one (1) or moreunsuccessfulor after one intubation Each attempt should include changein approach Unable Ventilateand to Oxygenate ATTEMPTS TOTAL (3) ATTEMPTS NO MORE THAN THREE Pediatric Failed Airway Pediatric General Section Protocols Section Pediatric General

Pearls · For this protocol, pediatric is defined as less than ≤ 11 years of age or any patient which can be measured within the Broselow-Luten tape. · Capnometry (color) or capnography is mandatory with all methods of intubation. Document results. · Continuous capnography (EtCO2) is strongly recommended with BIAD or endotracheal tube use. · If an effective airway is being maintained by BVM with continuous pulse oximetry values of ≥ 90%, it is acceptable to continue with basic airway measures instead of using a BIAD or Intubation. · For the purposes of this protocol a secure airway is when the patient is receiving appropriate oxygenation and ventilation. · An intubation attempt is defined as passing the laryngoscope blade or endotracheal tube past the teeth or inserted into the nasal passage. · Ventilatory rate should be 30 for Neonates, 25 for Toddlers, 20 for School Age, and for Adolescents the normal Adult rate of 12 per minute. Maintain a EtCO2 between 35 and 45 and avoid hyperventilation.

· Hyperventilation in deteriorating head trauma should only be done to maintain a pCO2 of 30-35. · It is strongly encouraged to complete an Airway Evaluation Form with any BIAD or Intubation procedure. · If first intubation attempt fails, make an adjustment and then try again: Different laryngoscope blade; Gum Elastic Bougie; Different ETT size; Change cricoid pressure; Apply BURP; Change head positioning · Paramedics should consider using a BIAD if oral-tracheal intubation is unsuccessful. · Cricoid pressure and BURP maneuver may be used to assist with difficult intubations. They may worsen view in some cases. · Gastric tube placement should be considered in all intubated patients. · It is important to secure the endotracheal tube well and consider c-collar (even in absence of trauma) to better maintain ETT placement. Manual stabilization of endotracheal tube should be used during all patient moves / transfers. · Airway Cricothyrotomy Needle Procedure: Indicated as a lifesaving / last resort procedure in pediatric patients ≤ 11 years of age. Very little evidence to support it’s use and safety. A variety of alternative pediatric airway devices now available make the use of this procedure rare. Agencies who utilize this procedure must develop a written procedure, establish a training program, maintain equipment and submit procedure and training plan to the State Medical Director / Regional EMS Office. Protocol 45 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Pediatric General Section Protocols 2012 or if patient will ) IO ProcedureIO minutes P to 5 ) Severe Moderate every Cardiac Monitor minutesfollowing sedative 5 Monitorand Reassess Monitorand Reassess Per the specific protocolPer the specific Musculoskeletal Visceralabdominal ( Cardiac Pleural / Respiratory Neurogenic Renal (colic) IV Procedure Every Differential · · · · · · · , I P yrs) asneededto assess pain 7 - (0 respiration etc.) Specific Complaint , or respiratory distresshead injury . , Assess Enter from PainSeverity Protocol 46 Injury or Illness severity , MOI -16yrs) or FLACC scale 4 Severity (pain) scale dullQuality (sharp, , Radiation Relation to movement, Increased with palpation of area ( Protocol basedon Protocol Signs and Symptoms Signs · · · · · and at disposition with all pain medications. all pain with atdisposition minutes post, and 5 Use combination Painof Scale, Circumstances , Baker faces Pediatric Pain Control Pain Pediatric Mental Status, Area of Pain, Neuro - Wong Notify Destination or , should not be given if there is abdominal pain, history of gastritis, stomach ulcers fracture, , ) Contact Medical Control minutes 5 Baker faces scale . at disposition IM medication delivery and post IV or to be recorded pre and 10) is a vital sign - Mild > 9 yrs if indicated every Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Monitorand Reassess Consider IV Procedure I for nausea. Consider agency-specific anti-emetic(s) for and/or vomiting Recommended Exam: Pain severity (0 -Baker use Wong faces For children scale or the FLACC score(seeAssessment Procedure Pain Vital signs should be obtained pre be obtained should Vital signs Age Location Duration Severity (1 - 10) child If use Wong- Past medical history Medications Drugallergies include hypotension to Narcotic use include Contraindications All patients who receive or IV medicationsbe must observed IM 15 minutes for drugreaction . Ketorolac / Ibuprofen require sedation. Do not administer any PO medicationspatients for whomayneed surgical interventionsuch open fractures or fracture as deformities. UseNumeric ( B of maximum comfort unless contraindicated Allowposition for · Pearls · · · · History · · · · · · · · · · · · · Pediatric Cardiac Section Protocols ) 2012 . cardiac coronary pulmonary Go to Go Hyperkalemia Protocol Return of / Circulation 10 mg) Spontaneous Spontaneous ) ) AT ANY TIME Reversible Causes Post Resuscitation MI PE Thrombosis; ( Hypovolemia Hypoxia Hydrogen ion (acidosis Hypothermia Hypo Hypoglycemia Tension pneumothorax Tamponade; Toxins Thrombosis; ( dehydration) ( NO ) Respiratory failure Foreign body Hyperkalemia Infection (croup, epiglotitis) Hypovolemia Congenitalheart disease Trauma Tension pneumothorax Hypothermia Toxin or medication Hypoglycemia Acidosis → . Differential · · · · · · · · · · · · min) inches in inches in minutes 10 seconds / 2 2 / ≤ IO ProcedureIO Needle Procedure 000 100 -

No 1 mL/kg) via (Maximum ETT . max 1mg) :10,000) ( :10, (0 1 1 IO / P /kg Unlike adults early airway intervention iscritical NO inches Infant inches Infant pulses checks 5 mL / kg of Cardiac Monitor / as indicated 1 Resuscitation Shockable Rhythm . Epinephrine 0 Protocol 48 ( kg IV .01 mg/kg Repeat every 3 – 5 minutes Criteriafor Death/ Notify Destination or 0 a cause must be identified and corrected. Pediatric DiabeticProtocol Review DNR Form / MOST Contact Medical Control Blood Glucose Analysis Procedure Children) Push Fast (≥ Searchfor Reversible Causes Begin Continuous CPR Compressions Begin Continuous Change Compressors every IV Procedure Push Hard Push (1. Limit changes Unresponsive Cardiac Arrest Signs of lividity or rigor ( Consider Chest Decompression I Signs and Symptoms Signs · · · P P YES YES PEA / Asystole Pediatric shaken baby Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS OD Arrest Protocol Follow Protocol Protocol Policy Follow Consider Pediatric Pulseless Do not begin Resuscitation In most cases pediatric airways canbe managed by basic interventions 1:1000 access 0.1no / IO may use Epinephrine If IV mg Respiratory arrestisa common causecardiac of arrest . In order to besuccessful inpediatric arrests, Beta Blocker OD syndrome, pattern of injuries SIDS Estimated downtimeEstimated Past medical history Medications Existenceof terminal illness Airwayobstruction Hypothermia Suspected abuse; Events leading to arrest Pediatic Toxicology Rhythm Appropriate Deceased Subjects Calcium Channel Blocker · · · Pearls · · · · · · · · · History · Pediatric Cardiac Section Protocols s) ( 2012 mg) 1 3 000 1000 kg IV / IO : / :10, to 1 mg 1 . minutesx 1 kg IV / IO 0 kg IV / IO / Or dehydration) ( .02 mg Neuro as indicated Consider kg via ETT (Max kg via ETT .01 mg 20 mL / PediatricProtocol AMS 0 Epinephrine 1 Epinephrine NormalSaline Bolus Repeat as needed x Epinephrine 1 Epinephrine Maximum Pediatric Airway Protocol Foreign body Secretions Infection (croup, epiglotitis) Repeat in 5 Cardiac Pacing Procedure Repeatminutes every 3 – 5 Atropine 0 .1 mg / Congenitalheart disease Trauma Tension pneumothorax Hypothermia Toxin or medication Hypoglycemia Acidosis Respiratory failure Hypovolemia 0 I · · · · · · · Differential · · P NO . YES , ExtremitiesAbdomen, Back, , , / IO ProcedureIO 60 . Shock / Ventilation P / NO NO YES Shock Adequate Continued cool skin Cardiac Monitor Protocol 49 AirwayPatent Heart Rate < Poor Perfusion Skin, Heart, Lungs Identify underlyingcause , Poor Perfusion Notify Destination or Oxygenation Hypotension or arrest Alteredlevel of consciousness Decreased heart rate Delayed capillary refillorcyanosis Mottled, Contact Medical Control IV Procedure Blood Glucose Analysis Procedure I · · Signs and Symptoms Signs · · · P YES mg IV. 0.1 Pediatric Bradycardia Pediatric . Mental Status, HEENT Exit to Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS year of age AMS 1 Arrest Protocol Pediatric Cardiac Protocol Bradycardia Toxicology Toxicology Follow Pediatric Follow Suspected Beta- Channel Blocker Recommended Exam: Past medical history Foreign exposure body Respiratory distress or arrest Apnea Possible toxic or poison exposure Congenitaldisease Medication (maternalorinfant ) Most maternalmedications pass breast milktheinfant through to The majorityof pediatric arrests are dueto airway problems. . dosages if applicable UseBroselow Tape for drug -Luten Infant ≤ Hypoglycemia, severe dehydration and narcotic effects may produce bradycardia Pediatric patients requiring external transcutaneous pacing require the use of padsappropriate pediatric for patientspere th manufacturers guidelines Minimum Atropinedose is Causing Hypotension / Poor Perfusion / Shock BlockerCalcium or Pearls · History · · · · · · · · · · · · · · Pediatric Cardiac Section Protocols 2012 s) ( Pediatric Protocol Pediatric Airway Allergic Reaction Anaphylaxis Protocol . / CHF Congestive heart failure Asthma Anaphylaxis Aspiration Pleural effusion Pneumonia Pulmonary embolus Pericardial tamponade Toxic Exposure 90° Differential · · · · · · · · · 40°) NO YES ).

2 avoid albuterol unless strong history recurrent of (ASD poor -position (25- : peripheral , , if indicated IO ProcedureIO chest pain Skin, Neuro P , : , mg/dose , Respiratory distress, weight, +/- gain 5 NO YES Cardiac Monitor Anaphylaxis AirwayPatent jugular vein distention Cardiac if available Protocol 50 Allergic Reaction Atrioseptal defects , / EtCO Pulse Oximetry / 12 LeadProcedure ECG 50 mcg. diaphoresis , Ventilations adequate ) Oxygenation adequate Notify Destination or if indicated IV Procedure Contact Medical Control heart blocks. I discusswith MedicalControl ) frothy sputum rare), pink, frothy P B , ( edema, Hypotension, shock Respiratory distressInfant: Respiratory feeding, lethargy, cyanosis Child/Adolescent : bilateral rales , apprehension, orthopnea, ( especially inacardiac child Pulmonary edema may vary depending on the underlying cause maythe underlying and Pulmonary edema may on vary depending Max single dose : . Respiratory SVT Titrate to age specific systolic blood pressureblood . Titrate to age specific systolic Transport to a PediatricSpecialty Center · Signs/Symptoms · · NO . IO. Position child withhead of bed in up / Max single dose Flexing hips with support under kneesso that they are bent IO. / kg IV / Pericarditis, . Mental status, : / 20 mcg Ventricular septal defects (VSD Pediatric Pulmonary Edema Edema Pulmonary Pediatric – : rales / kg IV mcg/kg IV / Tetralogyof Fallot Transpositionthe , of great arteries, Coarctationthe aorta of 1 : Myocarditis, Signs kg IV / IO mg/kg IV 1 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS known CHF History / Any age: 2 – 6 months < 1 month IV / IO : 0.1 mg/kg MorphineSulfate Fentanyl: Dose determined after consultation of Medical Control. Nitroglycerin: Dose determined afterconsultation Lasix Dopamine 2 with crackles Symptoms consistent with respiratory distress Treatmentof Congestive Heart / Failure Contact Medical Control early in the care of the pediatric cardiac. earlyin the care of the patient Contact Medical Control a precise past medicalhistory. CHFhave heart defect, obtain with a congenital Most children heartdiseaseCongenital varies by age include the following with consultation by Medical Control consultation with the following include Recommended exam CongenitalHeart Disease ChronicDisease Lung Congestive heart failure Past medical history wheezing secondary to pulmonary etiology Do not assume all wheezing is pulmonary, · · · · Pearls · History · · · · · Pediatric Cardiac Section Protocols , 2012 K) , VT / YES Follow VF Pediatric Protocols Glucose Exit to Exit to ( Protocol , cardiactamponade Pediatric Airway Pediatric Tachycardia Infection Infection Secretions, Adult Cardiac Arrest Newly Born Protocol dehydration) ( epiglotitis) croup, Shockable Rhythm Foreign, body ( ) YES YES YES Congenitalheart disease Trauma Tension pneumothorax pulmonary embolism Hypothermia Toxin or medication Electrolyteabnormalities Respiratory failure Hypovolemia Acidosis NO · · · · · · Differential · · · Follow Pediatric Protocols / PEA Asystole / min) inches in inches in Pediatric Airway minutes 10 seconds / 2 2 / ≤ 100

31 days old No Resuscitation / ≤ / NO NO NO years old inches Infant inches Infant Protocol 51 pulses checks 5 if available 16 / ALS Available ≥ (s) Unresponsive Cardiac arrest Minutes Defibrillation Automated Newly Born 2 MOST Form Review DNR / MOST YES / Children) Push Fast (≥ Signs and Symptoms Signs · · Protocol Begin Continuous CPR Compressions Begin Continuous Change Compressors every Criteriafor Death Pediatric Airway Push Hard Push (1. Limit changes Cycles ( Continue CPR 5 Repeat and reassess Defibrillation Automated NO YES Pediatric Pulseless Arrest Pulseless Pediatric Shockable Rhythm s) Notify Destination or Contact Medical Control Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS / 2 Minutes Protocol( NO Policy Follow Go to Go Pediatric Airway Protocol Return of resuscitation Do not begin Circulation Time of arrest Medical history Medications Possibility of foreign body Hypothermia Spontaneous Spontaneous Continue CPR 5 Cycles Repeat and reassess AT ANY TIME Deceased Subjects Revised Post Resuscitation 12/13/2012 History · · · · · Pediatric Cardiac Section Protocols . 2012 . 30:2. If Makeroom to 1.5 inches and . Airway Interventions. 2 joules / kg and increase to 4 , after every move, and at transfer of or difficult IV access IV / or difficult anticipated ) compressions ventilations are to 2 frequently . interruptions Consider BIAD firstto limit ETT . This should beaccomplished quickly withor BVM Procedures require space and patient access Refer to optionalprotocol or development of localagency protocol. Protocol 51 1/3 anterior-posterior diameter chest infants of , in a cause must be identified and corrected. uninterrupted compressions , uninterrupted continuous breathsperminute with 8 – 10 Compress ≥ If no advanced airway If no (BIAD ,

Mental Status : Patientsurvival isoftendependent on proper ventilation and oxygenation / Pediatric Pulseless Arrest Pulseless Pediatric Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS DO NOT HYPERVENTILATEDO NOT : in children 2 inches. Consider earlyIO placement if available and in Efforts should be directed at high quality and continuous compressions with limited interruptions and early and interruptions compressionswith limited continuous quality and high be directed at Efforts should indicated. when defibrillation Recommended Exam advancedairway place ventilate in to place endotracheal tube interrupt compressionsDo not Airway is a more important intervention in pediatricarrests . supraglottic device . Successis based on proper planning and execution. work. ConsiderTeamFocused Approach assigning responders to predetermined tasks. Team Focused Approach / Pit-Crew Approach . Reassess anddocument endotracheal tubeplacement and EtCO care. Monophasic and Biphasicwaveform defibrillators should use the same energy levels joules / kg on subsequent shocks . In order to besuccessful inpediatric arrests, Revised 12/13/2012 · · Pearls · · · · · · · · Pediatric Cardiac Section Protocols . 2012 YES see HX)

but preferred , Sepsis arrhythmia Emotional stress 12 Leadnot ECG diagnose and treatdiagnose when patient is stable necessary diagnose to andtreat Pain / Single lead ECG able to lead ECG able Single Exit to / Infection / NO Hyperthermia / / P Appropriate Protocol Fever Hypoxia Hypoglycemia Drugs ( MedicationToxin / / Pulmonary embolus Trauma Tension Pneumothorax Heart disease (Congenital ) Hypo HypovolemiaAnemia or Electrolyteimbalance Anxiety Cardioversion Procedure mg · · · · · · · Differential · · · · · Probable Sinus Tachycardia P Consider Adenosine kg IV / IO .1 mg / kg Maximum 6

0 /bpm bpm 220 P P YES Infant > Child/ > 180 : Rhythm Converts Protocol 52 12 LeadProcedure ECG Notify Destination or Contact Medical Control 12 mg YES Heart Rate Pale orCyanosis Diaphoresis Tachypnea Vomiting Hypotension AlteredLevel of Consciousness Pulmonary Congestion Syncope kg IV / IO kg IV / IO Signs and Symptoms Signs · · · · · · · · · B May repeat Adenosine Adenosine .1 mg / .2 mg / Maximum 6 mg Maximum Vagal Maneuvers 0 Probable SVT 0 > 180 Child

, ) IO ProcedureIO Pediatric Tachycardia Pediatric P P ) P .09 seconds NO 0 ≥ HR Typically HR Typically > 220Infant Cardiac Monitor QRS Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS / UnstableSerious / Signs andSymptoms nicotine, cocaine IV Procedure 12 LeadECG Procedure Thyroidsupplements , Decongestants, Digoxin (Aminophylline, Diet pills Exit to Go to Go Protocol I P B Pulseless Appropriate Tachycardia Drugs ( CongenitalHeart Disease Respiratory Distress Syncope or Near Syncope Past medical history Medications or Toxic Ingestion Probable Sinus Identify and Treat Underlying Cause Arrest Protocol AT ANY TIME NO Revised Pediatric Pulseless 12/13/2012 · · · · History · · Pediatric Cardiac Section Protocols . . 2012 beats / > 180 Neuro , . . , Extremities . Most children with have VT . Children usually . . .) P wavesabsent or abnormal . R-R / minute minute manycardiac drugs. : . cardiomyopathy. Abdomen, Back / -Luten color Purple if available 220 beats / (≤0.09 seconds Infants usually < 220 beats / minute. Childrenusually . > , hypokalemia , ) Tachycardia – the patient’s agein years , Heart , Lung , Havechild blow out “birthday candles” or through an obstructed ): Protocol 52 ): / long syndrome QT < 10 kg or Broselow . Infants usually Variable R-R waves / minute. seconds weak pulse 09 . 0 (≤ 0.09 seconds : beats . Ratesmaynear vary from normal to > 200 failure. Mental Status, Skin, Neck to 250 . multiple shapedPolymorphic (multiple . Pediatric Tachycardia Pediatric : 150 Blowing a glove intoaballoon . : / minute % of children withSVT will haveanarrow QRS 90 the maximum sinustachycardia rate is 220 . Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Uncommon inchildren minute AtrialFlutter / Fibrillation straw. Infants: Mayputabag of ice waterover the upperhalf face careful notto occlude of the the airway Rate istypically Breath holding . SVT with aberrancy Sinus tachycardiawaves : P present. VT: Respiratory distress / . hypotension without or perfusion with of shock / poor Signs AMS , rapid collapse with Sudden underlyingheart disease / cardiac surgery Associated with longsyndrome QT , hypomagnesaemia < 180 beats waves not variable. Usually abruptonset May quickly deteriorate to VT. SVT: > Wide ComplexWide Tachycardia (≥ Separating the child from the caregiver may worsen the child's clinical condition Pediatric paddles should beused in children Serious Signs and Symptoms Serious Signs NarrowComplexTachycardia Torsadesde Pointes / Recommended Exam Monitor for respiratory depression andhypotension associated if Diazepam or Midazolam is used Continuous pulseoximetry is required for allSVT Patientsifavailable Document allrhythm changes with monitor strips and obtain monitor strips with each therapeutic intervention Vagal Maneuvers Generally, Revised 12/13/2012 · · · · · · Pearls · · · · · · Pediatric Cardiac Section Protocols 2012 Airwayobstruction / Tosades de points Coronary / Pulmonary Embolism P hypokalemia ) ) . ) Respiratory failure Hyper / Hypovolemia Hypothermia Hypoglycemia Acidosis Tension pneumothorax Tamponade Toxin or medication Thrombosis: Congenitalheart disease min) inches in inches in kg IV / IO minutes minutes Differential · · · · · · · · · · · 10 seconds 10 seconds / 2 2 2 / (s) ≤ ≤ IO ProcedureIO 100

minutes .01 mg/ 5 ) 0 mg each dose P Epinephrine during during Epinephrine 1 / inches Infant inches Infant 10,000 Push Fast (≥ 100 / min : Continuous Compressions pulses checks pulses checks 5 1 compressions. / / If Rhythm Refractory Maximum Protocol 53 Repeat every 3 to Notify Destination or Pediatric Airway Protocol Contact Medical Control (≥ Children) Push Fast arrhythmics to defibrillate with device charged device with . to defibrillate Push Hard Push . Repeat pattern during resuscitationRepeatpatternduring High Quality, Begin Continuous CPR Compressions Begin Continuous Begin Continuous CPR Compressions Begin Continuous Change Compressors every Change Compressors every IV Procedure Epinephrine ( Epinephrine Push Hard Push (1. Limit changes Limit changes Continue CPRand give Agency specific Anti- Continue ( ( Continue CPR up to point where you are ready whereyou are point CPRup to Continue P P I P Signs and Symptoms Signs · Unresponsive · Cardiac Arrest Pediatric Ventricular Fibrillation Ventricular Pediatric Pulseless Ventricular Tachycardia Ventricular Pulseless kg /kg VT IO g / Joules Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2 10 Joules/ Go to Go Arrest Protocol Protocol Maximum Return of May repeat Pediatric Pulseless Circulation Maximum 2 Spontaneous Spontaneous every 5 minutes 40 mg/kg IV Estimated downtimeEstimated Past medical history Medications Existenceof terminal illness Airwayobstruction Hypothermia Events leading to arrest / PersistentVF / AT ANY TIME Magnesium Sulfate Post Resuscitation may increase energyin Revised After second defibrillation increments of 12/13/2012 P · · · · · · History · not to exceed Pediatric Ventricular Fibrillation Pulseless Ventricular Tachycardia Pediatric Cardiac Section Protocols Pediatric Cardiac

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

Revised Protocol 53 12/13/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Pediatric Cardiac Section 2012 Year 1 Years Days ) mmHgx age) mmHgx age) 10 28 2 2 60 mmHg 70 mmHg – to < < 0 Age Based + ( + ( Years older and 1 Month to Month Hypotension Utilized 1 11 < 70 < 90 to address specificdifferentials to address Arrhythmia Protocol Continue Antiarrhythmic Refer to Appropriate Pediatric Pediatic Diabetic Protocol Protocol Pediatric Tachycardia Continue associated with the original dysrhythmia P Differential · NO YES YES IO ProcedureIO 10 Paralysis / 94 % P ≥ 250 NO or ≥ NO NO NO NO Cardiac Monitor Age based ROSC After Bradycardia Protocol 54 Tachycardia Hypotension Symptomatic Symptomatic ≤ 69 Antiarrhythmic Blood Glucose 12 LeadProcedure ECG Defibrillation and / ReassessMonitorVital Signs / Remove ImpedenceThreshold Device Maintain SpO2 Advanced airway if indicated ETCO2 ideally 35 – 45 mm Hg Respiratory Rate 8 – Notify Destination or Consider Sedation RepeatPrimary Assessment Return of pulse Contact Medical Control · HYPERVENTILATE DO NOT Optimize Ventilation and Oxygenation Ventilation Optimize · · · · Use only with definitiveairway inplace IV Procedure Signs/Symptoms · P YES YES YES I P B B Pediatric Post Resuscitation Post Pediatric Pediatic Protocol Bradycardia Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS after ROSC follow Rhythm Respiratory arrest Cardiac arrest Appropriate Protocol If Arrhythmia If Persists andusually self limiting Arrhythmiasare common I History · · P P Pediatric Post Resuscitation Pediatric Cardiac Section Pediatric Cardiac

Pearls · Recommended Exam: Mental Status, Neck, Skin, Lungs, Heart, Abdomen, Extremities, Neuro · Hyperventilation is a significant cause of hypotension / recurrence of cardiac arrest in post resuscitation phase and must be avoided. · Appropriate post-resuscitation management may best be planned in consultation with medical control. Protocol 54 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Pediatric Medical Section Protocols 2012 ) s) ( ) IO IO .5 mg 1000 : 1000 Procedure : .3 mg kg IM minutes 0 / kg PO 5 5 mg 5 mg CHF P / kg IV / IM / .5 – .5 – druginduced mg / systemic effect 2 2 if indicated if indicated .01 mg SEVERE 1 if available 0 Auto-Injector if indicated if no improvement mg / rash only) Maximum Ipratropium 0 Ipratropium

( Diphenhydramine Diphenhydramine - Repeat in IV Albuterol Nebulizer Albuterol Albuterol Nebulizer Albuterol Epinephrine 1 Epinephrine kg Epi Pen Jr IM 30 kg Epi 1 Repeat as neededx 3 Repeatx 3 as needed Epinephrine 1 Epinephrine +/ if not alreadygiven PO if not < kg Adult Epi Pen IM Adult Epi ≥ 30 kg Procedure AirwayPediatric Protocol I Shock (vascular) effect Angioedema ( AspirationAirwayobstruction / Vasovagal event Asthma / COPD Urticaria Anaphylaxis ( P B · · · · · Differential · · IO .5 mg 1000 1000 : : .3 mg kg IM 0 / kg PO minutesno if 5 mg 5 mg kg IV / IM / .5 – .5 – wheezing or respiratory mg / 2 2 if available Assess if indicated if indicated improvement IV Procedure .01 mg 1 Auto-Injector 0 Protocol 56 MODERATE mg / Maximum Ipratropium 0 Ipratropium kg Epi Pen Jr IM 30 kg Epi Diphenhydramine Diphenhydramine - Albuterol Nebulizer Albuterol Nebulizer Albuterol Epinephrine 1 Epinephrine Epinephrine 1 Epinephrine 1 Repeatx 3 as needed Repeat as neededx 3 < Symptom Severity +/ if not alreadygiven PO if not Repeat in 5 kg Adult Epi Pen IM Pen IM Adult Epi ≥ 30 kg Itching or hivesItching or Coughing / distress Chest or throat constriction Difficulty swallowing Hypotension or shock Edema I P B Signs and Symptoms Signs · · · · · · Notify Destination or Contact Medical Control detergent Pediatric Allergic Reaction Allergic Pediatric soap, , Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS MILD If indicated IV Procedure 1 mg / kg mg PO Diphenhydramine Diphenhydramine IM / IO IV / IM 1 mg / kg Signs and Symptoms Monitor Worsening for Monitorand Reassess Onset and locationOnset and or bite Insect sting Food allergy / exposure Medication allergy/ exposure Newclothing / reactionsPast medical history / Medication history I Cardiac Monitoring B B Revised 10/19/2012 andSevere Reactions Indicated Moderate for History · · · · · · · Pediatric Medical Section Protocols . This . 2012 Moderate / Severe skin involvement / Agency Medical AgencyMedical . typically end in -il -typically end in ) . lips or airway structureslips . , or gastrointestinal hypoxia) or gastrointestinal or gastrointestinal hypoxia) or gastrointestinal lisinopril , , . Zestril ( . dyspnea dyspnea , , wheezing wheezing ( ( MR administeringany medication MR administeringany medication. / / EMT-Badministering any medication. age in yearsage in x 2) mmHg / + ( Lungs Protocol 56 Heart, erythema respiratory plus erythema respiratory plus . and perfusion pressure erythema normal blood with , , , with normal blood pressureand perfusion. normal blood pain) with abdominal vomiting, with hypotension and poor perfusion and poor hypotension pain) with abdominal vomiting, : , , itching itching itching , , , nausea nausea Mental Status, Skin, hives hives hives . for appropriate dosing Contact Medical Control , , , Pediatric Allergic Reaction Allergic Pediatric Flushing symptoms ( Flushing Flushing symptoms ( injector only and maysupply. Agency Medical only and administer from EMS IM as Auto-injector B mayadministerEpinephrine Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS . patient already prescribedand maysupply from EMS B mayAlbuterol if administer administer Moderate symptoms : Severe symptoms: Mild symptomsMild : Fluids and Medication titrated to maintain a SBP >70 titrated to maintain and Medication Fluids Allergic reactions may occur with only respiratory and gastrointestinal symptoms rash no only respiratoryand gastrointestinal and have Allergic reactions mayoccur with : Recommended: Exam lethal multisystemallergic reaction acute potentially Anaphylaxis is an and acute anaphylaxis ( be administered in that should the first drug choice and of is the drug Epinephrine access. attempts or IO or during at IV before in priority be administered should Symptoms.) IM Epinephrine or by IV push administration mayrequireIV epinephrine repeat IM epinephrine doses of Anaphylaxis unresponsive to . infusion epinephrine Symptom Severity Classification Directormay requirecontact of medical control priorEMT-B to Angioedema is seen in moderate to severe reactions and is swelling involving the face moderateto severe involving Angioedema is seen in reactions and is swelling pressure Prinivil / blood medications like patients taking can also be seen in MR / EMT- Directormay requirecontact of medical control prior MR to . and may administer from EMS supply by oral route only EMT-B may administerdiphenhydramine Directormay requirecontact of medical control prior EMT-B to but this , but continually monitored be moderate severe receiveECG and should Patients with and reactions should a 12 lead . of epinephrine NOT delay administration should The shorter the onset from symptoms to contact, the more severe the reaction. The shorter the onset from exposure severe the reaction to symptoms the more . EMT- Revised 10/19/2012 · · Pearls · · · · · · · · · · · · Pediatric Medical Section Protocols ) 2012 ) . . Neuro Exit to . Protocol hypoglycemia / hypo) / , infectionmetabolic, , traumatic) Pediatric Diabetic Shock Alkalosis / (hyper Toxic Ingestion Hypoxia infection stroke, seizure, CNS (trauma, Thyroid Shock (septic- Diabetes (hyper Toxicological Acidosis Environmental exposure Electrolyteabnormatilities Psychiatricdisorder Exit to Exit to Exit to Exit to Protocol Protocol Protocol Pediatric as indicated . Differential · · · · · · · · · · YES Hypo / Hyperthremia Appropriate Pediatric Overdose / Cardiac ArrhythmiaProtocol / Pediatric Hypotension / , ExtremitiesAbdomen, Back, , Mat exposure and protect personal safety - , signsof , ≥ 250 fruity breath, 69 or Protocol 57 ≤ skin, Blood Glucose YES Skin, Heart, Lungs /or personnel's protectionperrestraint the procedure Notify Destination or , dry, Contact Medical Control YES YES YES , diaphoretic skin s and ' Decrease in mentation Change baseline in mentation Decrease in Bloodsugar Cool, Increasein Blood sugar Warm kussmaul respirations dehydration illicit drugs andOver the Counter preparations as a potentialetiology Signs and Symptoms Signs · · · · · · Mental Status, HEENT IO ProcedureIO sleeping Pediatric Altered Mental Status Mental Altered Pediatric P , prescription drugs, NO NO NO Hyperthermia related Signs of Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Toxicology if indicated if indicated Signs of OD Signs of shock Poor perfusion Cardiac Monitor Hypo / 12 LeadProcedure ECG Pediatric Airway Protocol(s) Spinal Immobilization Protocol Blood Glucose Analysis Procedure IV Procedure Recommended Exam: Pay careful attention to the head exam for signs of bruising or other injury bruising for signs of the head examPay carefulattention to Be awareAMS as presenting of signof anenvironmental toxin or Haz issafer to assumehypoglycemiaIt than hyperglycemiaif doubt Recheckblood exists. glucose after Dextrose or Glucagon Consider alcohol Consider Restraintsif necessary for patient Medications Recentillness Irritability Lethargy Changes in feeding / Diabetes Potential ingestion Trauma Past medical history I Pearls · · · · · · · · · · · · · · History · P B Pediatric Diabetic

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

Blood Glucose Analysis Pediatric Procedure Altered Mental Status Protocol I IV Procedure P IO Procedure if indicated Cardiac Monitor I P if indicated

Blood Sugar Blood Sugar Blood Sugar Protocols Section Pediatric Medical ≤ 69 mg / dl 70 – 249 mg / dl ≥ 250 mg / dl

Awake and alert Dehydration with NO Monitor Blood but symptomatic no evidence of Glucose CHF/ Fluid Q 15 minutes YES Overload Exit to Appropriate Protocol

I

I

Repeat Dextrose per appropriate treatment arm

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

Notify Destination or Contact Medical Control

Protocol 58 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 Pediatric Medical Section Protocols 2012 Neuro , . mL of D50 and mL of 25 , Extremities % canbe administered rectally . . Make D25removing by . Patientmusthave known history of diabetes and , Abdomen, Back, Lungs . Blood sugarmust be 100 or greater and patienthas mL of NS40 mL of . , Skin, Heart Protocol 58 HEENT and dilute with with 50 and dilute Pediatric Diabetic Pediatric mL of D 10 mL of : Mental Status, : Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Adultcaregiver mustbe present withpediatric patient ability to eat and availability of food withresponders on scene not be taking any oral diabetic agents. Otherwise contact medical control Patientswith prolongedhypoglycemia my not respond to glucagon . Do notadminister oral glucose to patientsthat are not ableto swallow or protect their airway. Make D10 byremoving NS with 25 mL of . dilute In extreme circumstanceswith no IV and no response to glucagon Dextrose 50 Contactmedical control for advice . Qualitycontrol checksshould be maintained permanufacturers recommendationfor all glucometers Patient Refusal Recommended Exam · · · · · · Pearls · Pediatric Medical Section Protocols 2012 YES Exit to Trauma Protocol Pediatric Obstructive Pediatric Procedure if indicted if Multiple Trauma if indicated Diabetic Protocol Spinal Immobilization I P Hypovolemic Cardiogenic Septic Neurogenic Anaphylactic NO NO Shock Trauma Infection Dehydration Congenitalheart disease Medication or Toxin Shock Differential · · · · · · Or YES Trauma Exit to s) Protocol ( Anaphylaxis Distributive Procedure if indicted if IO Procedure IO Appropriate Pediatric Spinal Immobilization I P confusion, weakness clammy skin , Cardiac Monitor if indicated Protocol 59 Type of Shock History, Exam and cool tarry stools Circumstances Suggest Notify Destination or Pediatric Airway Protocol Delayed capillary refill Dark- Blood Glucose Analysis Procedure Restlessness, Dizziness Tachycardia Hypotension (Latesign ) Pale, Contact Medical Control IV Procedure I · · Signs and Symptoms Signs · · · · · P Cardiogenic as indicated ArrhythmiaProtocol Appropriate Pediatric I NO Pediatric Hypotension / Hypotension Pediatric Shock x Age Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS YES Procedure Exit to Procedures if indicated Trauma Hypotension WoundCare Protocol as indicated Pediatric Age Specific VS Hypovolemic SBP < 70 + 2 Control Hemorrhage Multiple Trauma Blood loss Fluidloss Vomiting Diarrhea Fever Infection Spinal Immobilization Poor perfusion / Revised I 11/19/2012 History · · · · · · Hypotension / Shock Pediatric Medical Section Protocol Section Pediatric Medical

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

Revised Protocol 59 11/19/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Pediatric Medical Section Protocols 2012 / / -1222 ) OD Exit to Carbon Control Cyanide / If NeededIf .1 mg/kg IN Monoxide Cyanide Protocol Carbon Monoxide 1-800-222 Carolinas Poison Maximum 2 mg as indicated Shock Protocol AirwayProtocol (s) Naloxone 0 Appropriate Pediatric (organophosphates Pediatric Hypotension I B if available Exit to Antidote Kit Antidote Nerve Agent Tricyclic antidepressants Acetaminophen Depressants Stimulants Anticholinergic Cardiac medications SolventsAlcohols, , Cleaning agents Insecticides / NerveWMD / Severity Arms Agent Protocol Follow Symptom Organophosphate Differential · · · · · · · · NO YES ; NO ; , Toxic Ingestion / Toxic , Urination / sec I Upset GI , .09 QRS YES IO ProcedureIO cramping Tricyclic / ≥ 0 NO hypertension Ventilation dysrhythmias P Potential Cause Protocol 60 / Antidepressant OD P Lacrimation, loss of control uscleTwitching YES M Notify Destination or Contact Medical Control LeadProcedure ECG Age Specific Hypotension Serious / Symptoms Symptoms Cardiac Monitor

12 AlteredMental Status Seizures Salivation, Decreased respiratoryrate Tachycardia, increased, Abdominal pain Mental status changesMental status Hypotension / Defecation / Diarrhea Emesis, Adequate Respirations Oxygenation IV Procedure

· · · · Signs and Symptoms Signs · · I P B OD YES , YES Pediatric Overdose Overdose Pediatric / route, P Calcium Channel Blocker s) AMS / past psychiatric If not improvementIf Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Cardiac External Pacing Procedure for Severe Cases Safe Scene Blood Glucose Appropriate as indicated resources OD Analysis Procedure P Substance ingested, quantity importantTime of Ingestionis Reason (suicidal accidental , criminal) Available medications inhome Past medical history, medications, Ingestionor suspected ingestion of potentially toxic substance history Behavioral( Protocol Beta Blocker Pediatric Diabetic NO Stage until scene safe I Callhelp for / additional · · · · · History · Pediatric Medical Section Protocols 2012 Renal . . . x age)mmHgand 2 + ( > 70 specificpupils non- , pinpoint pupils , - 10 years 1 , causesirreversible liver failure seizures , . mental changes status , Neuro Abdomen, Extremities, decreased respirations , , 1 year > 70 mmHg - Toxic Ingestion / Toxic nausea, vomiting, diarrhea , Lungs emesisto ED. , 600 mg of pralidoxime in anautoinjector for self administration or dilated pupils Heart, , If notdetectedIf and treated Protocol 60 contents , /or personnel's protectionpertheRestraint Procedure. HEENT, Make sure patient is still not carrying other attempts Makesure is still especially in suicide . patient , decreased temperature, increased secretions 's and , Bring bottles 28 days > 60 mmHg, 1 month increased temperature , , vomiting andmental, , status changes increased BP, increasedtemperaturedilated , pupils, , mmHg. Mental Status, Skin, andorcerebral edema among otherthings can take place later. Pediatric Overdose Overdose Pediatric , dysrhythmias and mentalstatus changes : increased or decreased HR decreased HR, decreased BP These kits may be availableof the domestic preparedness as part for Weapons of Mass Destruction : increased HR : liverfailure . , Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Early signs consist of abdominal painand vomiting. Tachypnea and altered mental may occur later status Recommended Exam: Stimulants: , history of ingestion relyon patient Do not . medications or has any weapons : increasedAnticholinergic HR Cardiac Medications Solvents: nausea, coughing Insecticides Age specific blood pressure 0 – Age specific blood 11 years > 90 and older Tricyclic: 4 major areas of toxicity: seizures, dysrhythmias, hypotension, decreased rapid mental status or coma; progression from alert mentalstatus to death. Acetaminophen: initiallynormal or nausea/vomiting. Nerve kits contain Agent Antidote 2 mg of Atropineand Consider restraints if necessary patient for patientcare Aspirin: dysfunction Consider contactingNorth the Carolina PoisonControl Center for guidance Depressants Pearls · · · · · · · · · · · · · · · Pediatric Medical Section Protocols NO 2012 1000 : .3 mg s) kg IM ( 0 / .5 mg 2 YES Pediatric Protocol Pediatric .01 mg STRIDOR Worsening 0 Pediatric Airway as indicated Allergic Reaction Maximum Albuterol Nebulizer Albuterol Epinephrine 1 Epinephrine Anaphylaxis Protocol AirwayProtocol (s) I I P P B Toxic ingestion / CHF Asthma / ReactiveAirway Disease Aspiration Foreign body Upperlower airway or infection Congenitalheart disease OD / Anaphylaxis Trauma NO YES YES Differential · · · · · · · · .5 mg Rales mg Symptoms / x 3 .5 mg Lung Exam 0 .5 - 5 Albuterol Albuterol Nebulizer Ipratropium Ipratropium 2 Signs Worsening +/- Nebulizer 2 Repeat as needed YES I P B Distractability Anaphylaxis / AirwayPatent Protocol 61 Allergic Reaction YES NO Ventilations adequate Oxygenation adequate NO Notify Destination or Contact Medical Control .5 mg / Stridor / CracklesWheezing/ / Nasal / Retractions / Grunting Flaring Increased Heart Rate AMS Anxiety Attentiveness Cyanosis Poor feeding Frothy Sputum JVD / Hypotension NO s) ( Signs and Symptoms and Signs · · · · · · · · · · x 3 months .5 mg NO 0 YES Albuterol Ipratropium Ipratropium ≥ 12 Protocol Worsening +/- as indicated Nebulizer 2 Repeat as needed WHEEZING Pediatric Airway Age I I if indicated IO ProcedureIO YES / Pediatric Respiratory Distress Respiratory Pediatric P Signs NO .5 mg .5 mg Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Cardiac Monitor (s) x 3 12 LeadProcedure ECG History / 0.5 mg NO Albuterol Albuterol if indicated Symptoms consistent Episode IV Procedure with respiratory distress with wheezing orstridor Protocol Ipratropium +/- Ipratropium Possibility of foreign body Past Medical History Medications Fever / Illness Sick Contacts History of trauma History / possibilitychoking of IngestionOD / Congenitalheart disease Time of onset as indicated Nebulizer 2 Nebulizer 2 Repeat as needed First Wheezing Pediatric Airway I P B Revised 11/7/2012 I · · · · · · · · · History · P B Pediatric Medical Section Protocols 2012 agonists . . , patient wantsto sit up . Neuro Extremities, no droolingisnoted , rapid onset, possiblestridor They will protect their airway by theirbody position. Abdomen , . , , Lungs with fever Heart, afterfirstbeta agonist treatment. , 92 % Protocol 61 Skin, Neck It isviral possibleIt , fever, gradual onset, , Airwaymanipulation may worsen the condition. . you may useAlbuteroltreatmentthenuse supply for the first the patient’s for repeat It is bacterial> 2 years of age. It , allow them to assume positioncomfort. of , < 2 years of age. (Xopenex) Mental Status, HEENT Pediatric Respiratory Distress Respiratory Pediatric Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Recommended Exam: Do not force a child into a position Items in Red Text are key performance measures used to evaluate protocol compliance and careItems in Red Text are keyperformance evaluate compliance and . measures used to protocol respiratorypatient with distress. in the be monitored continuously Pulse oximetry should patient already prescribed and may administer. Agency medicalfromEMS supply EMT-B may administerAlbuterol if directormay require Contactof Medical Control prior to administration. access oximetryConsider IV when Pulse remains ≤ Consider Epinephrine nebulizer if patient < 18 months and not responding to initial beta-agonist treatment Croup typically affects children The most important component of respiratory distressisairway control Bronchiolitis is a viral infection typically affecting infants which results in wheezing which may not respondto beta- Epiglottitis typically affects children to keep airway open, drooling is common In patients using levalbuterol nebulizers or agency’s supply. Revised 11/7/2012 Pearls · · · · · · · · · · · Pediatric Medical Section Protocols 2012 . s) ( This is a true . IO ProcedureIO acidosis 20 Weeks P YES if indicated Protect patient Cardiac Monitor as indicated Status Epilepticus Pregnancy > Loosenclothing any constrictive Pediatric Airway Protocol Spinal Immobilization Procedure IV Procedure Blood Glucose Analysis Procedure Active Seizure in Knownor Suspected Exit to Obstetrical EmergencyProtocol I Febrile seizure Infection Head trauma Medication or Toxin Hypoxia or Respiratory failure Hypoglycemia Metabolic abnormality / Tumor P toxins and fever. / NO Differential · · · · · · · · YES Avoiding hypoxemia is extremelyimportant . . . Extremities, Neuro , Or Activity overdose or ingestion , Lungs Pediatric Pediatric Consider Reassess if indicated if indicated Monitorand Active Seizure Protocol 62 Postictal State AlteredMental andtransport Status Protocol dry skin Diabetic Protocol , Heart, hot, ; NO Fever Seizure activity Incontinence Tongue trauma Rash Nuchal rigidity Alteredmental status HEENT, NO Signs and Symptoms Signs · · · · · · · Pediatric Seizure Pediatric Notify Destination or Contact Medical Control Do not delay IM administration with delay IM administration termination of seizures. Do not Maximum 10 mg) IM is effective in ( Alert YES /multiple if indicated Protect patient .2 mg/kg if indicated if indicated Awake, IV Procedure Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Cardiac Monitor Montiorand Reassess Normal Mental Status Loosenclothing any constrictive Spinal Immobilization Procedure Blood Glucose Analysis Procedure I Recommended Exam: Mental Status, difficult IV or IO access IM Preferredover. IV or . IO difficult Addressing the ABCs andverifying blood glucose is as important than stopping the seizure. Be prepared to assist ventilations especially if a benzodiazepine is used Items in Red Text are key performance measures used to evaluate protocol compliance and careItems in Red Text are keyperformance evaluate compliance and measures used to protocol Midazolam 0 In an infant, a seizure may be the only evidence a closed head of injury Status epilepticus is definedmore successive as two or seizures without aperiod of consciousness or recovery emergency requiring rapidairway control, treatment Assess possibility of occult trauma andsubstance abuse Sick contacts of seizuresPrior history Medication compliance Recenthead trauma Wholebody vs unilateral seizure activity Duration, Single CongenitalAbnormality Fever P Pearls · · · · · · · · · · · · · · · History · Pediatric Medical Section Protocols or , Neuro , tumor, 2012 , , ) tumors , headache IO ProcedureIO , Shock influenza P years > 70 + (2 x , Extremities NO Pediatric 10 Exit to if indicated Protocol Pediatric Improving Diabetic Protocol , 1 - Hypotension / IV Procedure mmHg Abdomen, Back I P 70 YES , CNS (Increased pressure trauma or hemorrhagetrauma or ) Drugs Appendicitis Gastroenteritis orRenal GI disorders Diabetic Ketoacidosis Infections (pneumonia, Electrolyteabnormalities YES and CNS processes (bleeding Diarrhea , Differential · · · · · · · · , Lungs - 1 year > , Heart almost alwaysincreased heart rate, tachycardia Symptoms shock . , Neck , 1 month bowel obstruction very unlikely to be significantly dehydrated if heart rateis very to be significantly unlikely Procedure , Notify Destination or , Contact Medical Control . Protocol Pediatric mmHg if indicated perfusion Protocol 63 Pain Control Hypotension, poor Blood Glucose Analysis Serious Signs / > 90 mmHg days > 60 Pain Distension Constipation Diarrhea Anorexia Fever Cough, Dysuria . Pyloric stenosis 28

Signs and Symptoms Signs · · · · · · · · NO YES 0 – Mental Status, Skin, HEENT , : years and older / Vomiting Pediatric NO NO if indicated IV Procedure Improving One of the first clinical signs of dehydration, the first clinical signs One of Abdominal Pain Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS I P increases as dehydration becomesmore severe age) mmHgand 11 close to normal. pressureAge specific blood Recommended Exam Heart Rate: Beware of vomiting only inchildren increased CSF pressures) all oftenpresent with vomiting Time of last meal Time of last emesisLast bowel movement / Improvementorworsening with food or activity Other sick contacts Past Medical History Past Surgical History Medications Travel history Bloody Emesis or diarrhea Age · Pearls · · · · · · · · · · · · History · Pediatric Trauma and Burn Section Protocols , 2012 year) or , >1 bradycardia, , Diabetic

/ . Protocol vomiting Pediatric . Protocol , Pediatric Pediatric 15 minutes or any as indicated AMS Multiple Trauma Seizure Protocol ). . , ContusionConcussion, Neuro , Back decerebrate posturing / Skull fracture Braininjury ( Hemorrhage) Epidural hematoma Subdural hematoma Subarachnoid hemorrhage Spinal injury Abuse YES YES x the age in years Differential · · · · · · · Cushing's Response minute for children for children year 25 / minute and . / ) if indicated IO Procedure IO failure Shock / x Age / , Abdomen, Extremities, , P + 2 decorticate , decorticate pupil blown bleeding intubation should beanticipated. should intubation NO NO , YES YES Trauma Lungs . minute for infants <1minute for if indicated Hypotension Oxygenation IsolatedHead / Seizure Activity Protocol 65 SBP < 70 swelling ( Adequate Ventilation Poor Perfusion Heart, Notify Destination or Obtain and Record GCS Obtain , Contact Medical Control Blood Glucose Analysis Procedure if indicated Spinal Immobilization Procedure Alteredmental status Unconscious Respiratory distress Pain, Vomiting Majortraumatic mechanism of injury Seizure 35 mmHg IV Procedure - 30 · · · Signs and Symptoms Signs · · · · I NO ) ICP) may cause hypertensionand bradycardia ( NO rapid transport and if GCS < 9 rapid transport and Mental Status, HEENT Pediatric Head Trauma Head Pediatric penetrating . If hyperventilation is needed (35If hyperventilation ). bluntvs Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS . Any prolonged. confusion abnormality or mental status which does not returnto normal within < 12 consider air / Protocol Pediatric Pediatric AirwayProtocol Multiple Trauma Recommended Exam: Time of injury Mechanism ( Loss of consciousness Bleeding Past medical history Medications Evidence for multi-trauma Hypotension usually indicates injuryor shockunrelated to the head injury and shouldbe treated aggressively An importantitemto monitor and documentisachange inthelevel of consciousness by serial examination Concussions are traumaticbrain injuries involvinganyof a number of symptoms including confusion, LOC headache documented loss of consciousness should be evaluated by a physician ASAP Fluidresuscitation should maintain be titrated to leasta at systolic BP of > 70 + 2 should be maintained between be maintained EtCO2 should Increased intracranial pressure ( GCS is a key performance measure used to evaluate protocol compliance and care GCS is a key performancemeasurecompliance used to evaluate protocol If GCS ( if evidence of herniation Hyperventilate patient only the decreasing GCS Pearls · History · · · · · · · · · · · · · · · Pediatric Trauma and Burn Section Protocols 11 2012 ) mmHg and Needle 90% ) . Rapid . - : ≥ Hemothorax , 10 minutes x age 2 ≤ to appropriate Procedure 70 + ( Abnormal if indicated Tension pneumothorax Flail chest Pericardial tamponade Open chest wound if indicated destination using Monitorand Reassess Consider Pelvic Binding Trauma and Burn , Spinecord injury fracture, Femur / SplintSuspected Fractures Control External Hemorrhage : Chest Decompression abdominal bleeding Provide Early Notification Pediatric Protocol Head Injury 10 years > Rapid Transport Limit Scene Time EMS Triage and Destination Plan EMS Triage and Chest Intra- Pelvis / Head injury (see Head Trauma DislocationExtremity fracture / HEENT (Airwayobstruction ) Hypothermia I P Differential · · · · · · · 70 mmHg, 1 - s) / ( IO ProcedureIO / / year > - 1 P bleeding Pediatric GCS , as indicated Hypotension These should be performed en route when possible be performed en route when These should Shock Protocol Perfusion Assess VS Cardiac Monitor Protocol 66 if indicated lesions swelling Pediatric Airway Protocol 60 mmHg, 1 month IV Procedure Spinal Immobilization Procedure Immobilization Spinal Pain, Deformity, Alteredmental status or unconscious Hypotension or shock Arrest Signs and Symptoms Signs · · · · · days > I P 28 – Notify Destination or 0 Contact Medical Control : mmHg. Pediatric Multiple Trauma Multiple Pediatric 90 Procedure Normal protective Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS / destination using Monitorand Reassess Consider PelvicBinding Trauma and Burn SplintSuspected Fractures Control External Hemorrhage Repeat Pediatric Assessment to appropriateTransport to years and older > Consider Chest Decompression with signs of shock andinjury to torso and evidencepneumothorax of tension . See Regional Trauma Guidelines when declaring Trauma Activation. Severebleeding rapidly from an extremity not controlled with direct pressure maynecessitate application the of a tourniquet . Do not overlook the possibilityabuse of child . transport of the unstable trauma patient to the appropriate facility is the goal. appropriate facility is the unstable trauma patient to the transport of the airwayif pulse oximetry can be maintained Bag valvemaskacceptableof managing the is an method Age specific bloodpressure Items in Red Text are keyperformance the EMS Acute Trauma Care measures used in Toolkit delayedfor procedures. not be Scene timesshould Damage structure or vehicle to Location structure or vehicle in Others injured or dead Speed and detailsof MVC Restraints Time and mechanismTime and of injury equipment Past medical history Medications EMS Triage and Destination Plan EMS Triage and · · · · · · Pearls · · · · · · · History · · · Pediatric Trauma and Burn Protocols 2012 . . Degree Burn rd /3 charred or leathery skin nd

blistering compromise Criticial Burn painless/ TBSA 2 : red - painful (Don’tinclude in TBSA) / Degree) transport to a Burn Center) Burns withdefinitive airway Burns withMultiple Trauma When reasonably accessible, nd ( cc of fluid per hour cc of fluid Degree) rd >15% if indicated if Degree) st NO IV Procedure NormalSaline if indicated if indicated as indicated (More below) info Trauma and Burn Cyanide Exposure Superficial (1 Thermal Chemical – Electrical Full Thickness (3 Partial Thickness (2 Carbon Monoxide for up to the first hours. 8 IO ProcedureIO Dry Clean Dressings Sheet or 0.25 mL / kg ( x % / hr mL / ( x TBSA) 0.25 kg Lactated Ringers if available Pediatric Airway Protocol(s) Differential · · · · · EMS Triage and Destination Plan EMS Triage and Pediatric MultipleTrauma Protocol Pediatric Pain Control Protocol TBSA will need 1000TBSA will Consider 2 IV sites if greater than 15 % Consider2 IV sites if greater than 15 % TBSA RemoveConstricting / Items Rings, Bracelets Degree Burn rd Rapid Transport to appropriate destination using YES if not change over once available if not Useif available, /3 distress nd I P / Protocol 67 Serious Burn shock Notify Destination or patient with 50%patient with Contact Medical Control , pain, swelling transport to a Burn Center) Carbon Cyanide Protocol When reasonably accessible, ( 15% TBSA 2 Monoxide Hypotension 13 or Less or GCS - intubationstabilization for airway 5 Dizziness Loss of consciousness Hypotension/ Airway compromise/ could be indicated by hoarseness/wheezing Burns Suspected inhalation injuryrequiring or 196 lbs.) Concomitant Injury SeverityAssess Burn / ConcomitantInjury ( · · · · Signs and Symptoms Signs · YES 80 kg Pediatric Thermal Burn Thermal Pediatric / / , chemical) gas , Degree Burn rd /3 NO nd Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS if available if indicated IV Procedure NormalSaline MinorBurn if indicated if indicated as indicated Constricting Items Lactated Ringers Normotensive (More info below) (More info /Immunization status 1. Lactated Ringers preferredover. Normal Saline Formula example2. Formula : an Cyanide Exposure GCS 14 or Greater Carbon Monoxide for up to the first 8 hours. for up to the first 8 Remove / Rings, Bracelets Transport Facilityof Choice Dry Clean Dressings Sheet or 0.25 mL / kg ( x % TBSA) / hr / ( x% 0.25 mL kg TBSA) Pediatric Airway Protocol(s) Type of exposure (heat Inhalation injury Time of Injury Past medicaland history Medications Other trauma Loss of Consciousness Tetanus < 5% TBSA 2 No inhalationIntubated injury, Not , Pediatric PainControl Protocol I History · · · · · · · Pediatric Multiple Trauma Protocol Pediatric Thermal Burn

Rule of Nines · Seldom do you find a complete isolated body part that is injured as described in the Rule of Nines. · More likely, it will be portions of one area, portions of another, and an approximation will be needed. · For the purpose of determining the extent of serious

injury, differentiate the area with minimal or 1st degree BurnProtocols and Pediatric Trauma burn from those of partial (2nd) or full (3rd) thickness burns. · For the purpose of determining Total Body Surface Area (TBSA) of burn, include only Partial and Full Thickness burns. Report the observation of other superficial (1st degree) burns but do not include those burns in your TBSA estimate. · Some texts will refer to 4th 5th and 6th degree burns. There is significant debate regarding the actual value of identifying a burn injury beyond that of the superficial, partial and full thickness burn at least at the level of emergent and primary care. For our work, all are included in Full Thickness burns. · Other burn classifications in general include: · 4th referring to a burn that destroys the dermis and involves muscle tissue. · 5th referring to a burn that destroys dermis, penetrates muscle tissue, and involves tissue around the bone. · 6th referring to a burn that destroys dermis, destroys muscle tissue, and penetrates or destroys bone tissue.

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

Pearls · Recommended Exam: Mental Status, HEENT, Neck, Heart, Lungs, Abdomen, Extremities, Back, and Neuro · Green, Yellow and Red In burn severity do not apply to the Start / JumpStart Triage System. Critical or Serious Burns: · > 5-15% total body surface area (TBSA) 2nd or 3rd degree burns, or · 3rd degree burns > 5% TBSA for any age group, or · circumferential burns of extremities, or · electrical or lightning injuries, or · suspicion of abuse or neglect, or · inhalation injury, or · chemical burns, or · burns of face, hands, perineum, or feet, or · any burn requiring hospitalization. · Require direct transport to a Burn Center. Local facility should be utilized only if distance to Burn Center is excessive or critical interventions such as airway management are not available in the field. · Burn patients are trauma patients, evaluate for multisystem trauma. · Assure whatever has caused the burn is no longer contacting the injury. (Stop the burning process!) · Early intubation is required when the patient experiences significant inhalation injuries. · Circumferential burns to extremities are dangerous due to potential vascular compromise secondary to soft tissue swelling. · Burn patients are prone to hypothermia - never apply ice or cool the burn, must maintain normal body temperature. · Evaluate the possibility of child abuse with children and burn injuries. · Never administer IM pain injections to a burn patient. Protocol 67 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 Adult / Pediatric General Section Protocols 2012 IMMEDIATE Secondary Triage Evaluate Infants FIRST FIRST Evaluate Infants DECEASED Repeating Triage Process DELAYED IMMEDIATE IMMEDIATE IMMEDIATE YES NO YES Adult NO NO (Adult) (Pediatric) Triage Protocol 69 NO Adult Minor Pediatric Breathing Resultsin > 30 / minute Spontaneous Obeys Commands Appropriate to AVPU Ped < 15 or > 45 Position Upper Airway Adult Cap Refill > 2 Sec No palpable Pulse No palpable YES YES Pulse Pediatric Breathing Rescue Breaths NO YES IMMEDIATE 5 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS NO Rate YES Status Mental < 30 / minute Perfusion Breathing Respiratory Able to Walk Ped > 15 or < 45 Adult Adult / Pediatric General Section Protocols 2012 . Age-appropriate heart rate may also be Triage Protocol 69 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS First evaluate all childrenwho did not walk under their onpower where possible and safety allows Capillary canbe refill alteredbymany factors including skin temperature . used in triage decisions. Pearls · · Adult / Pediatric General Section Protocols ). 2012 hoursif the tooth wisdom) Exit to Exit to Appropriate Cardiac Protocol Appropriate Protocol Trauma Decay Infection Fracture Avulsion Abscess Facialcellulitis Impacted tooth ( TMJ syndrome Myocardial infarction Differential · · · · · · · · · / See below if indicated , Neuro , Lungs , Monitor and Reassess pressure Notify Destination or Pressure Appropriate Pain Protocol Chest Contact Medical Control Cardiac Monitor , contamination Normal Saline / May rinse gross . Protocol 70 Place tooth in Milk 12 LeadProcedure ECG Neck Treat Dental Avulsion: CommercialPreparation andplacedwith into socket Do notrub or scrub tooth Control Bleeding with Direct , patientclosing to exert teeth Control Bleeding with Direct Pressure Small gauze rolled into a square Bleeding Pain Fever Swelling Tooth missing or fractured P B Signs and Symptoms Signs · · · · · YES Dental Problems Dental YES YES YES YES tooth " Mental Status, HEENT - injury / knocked out " Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS NO NO NO NO NO Exit to Bleeding Transport Dental Avulsion System Trauma Dental or Jaw Pain Significant or Multi Appropriate Protocol Suspicious for Cardiac Recommended Exam: Age Past medical history Medications Onset of pain Trauma with Location of tooth Wholevs. partial tooth injury All pain associatedwith teeth shouldbe associated withatoothwhich is tenderto tapping or touch (or sensitivity to cold or hot Significanttissueswelling soft theface ororal cavity can represent to a cellulitisabscess or . Sceneand transport times should be minimized in complete tooth avulsions Reimplantation. ispossible within 4 is properly cared for. Occasionally cardiacpainjaw chest canradiate to the Pearls · History · · · · · · · · · · · Adult / Pediatric General Section Protocols . 2 x ) 2012 ) can + ( 70 (Ticlid < ), rivaroxaban ulcers) Exit to , Exit to Appropriate YES – 10 years Hypotension Protocol If indicated IV Procedure HeadForward Tilt Position Comfort of Appropriate Trauma Protocol Bleeding Controlled I Trauma viralorInfection ( Sinusitis URI Allergic rhinitis Lesions (polyps Hypertension , 1 year YES Differential · · · · · dabigatran (Pradaxa Compresswith DirectPressure Nostrils diastolic or known coronary arteryor known coronary diastolic (Aggrenox), and ticlopidine NO < 70 mmHg . Neuro , < 90 – 1 year Lungs NO aspirin/dipyridamole IV Procedure DirectPressure , Heart, Protocol 71 SuctionActiveBleeding HavePatientNose Blow . Hypotensive SBP heparin, enoxaparin (Lovenox), Evaluate for posteriorblood loss by examiningtheposterior pharnyx Notify Destination or Age specific hypotension mmHg, 1 month Epistaxis Contact Medical Control Bleedingfrom nasal passage Pain Nausea Vomiting I Signs and Symptoms Signs · · · · B < 90 mmHg days < 60 (Coumadin ), YES , 28

YES YES 0 – Mental Status, HEENT : . - anticoagulants , yearsand greater 11 , and many over thecounter headache relief powders. Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS NO NO HeadForward Tilt PositionComfort of )mmHg Active Bleeding Active Bleeding System Trauma Significant or Multi Into posterior pharynx (Xarelto), Anti-platelet agents likeaspirin , clopidogrel (Plavix), contribute to bleeding Avoid Afrin in patients who have a blood pressuregreater have a blood of than 110 patients who Avoid Afrin in disease. Age specific hypotension : age Recommended Exam It isveryIt difficult to quantifytheamount of blood loss withepistaxis Bleeding alsobeoccurring may posteriorly . Anticoagulants include warfarin Age Past medical history Medications (HTN aspirin, NSAIDs) Previous episodesofepistaxis Trauma Duration of bleeding Quantity of bleeding Leavepresent Gauze in place if · · · Pearls · · · · History · · · · · · · Adult / Pediatric General Section Protocols , or 2012 A patient with . Neuro Lymphomas / MRSA), scabies, . Sepsis .g This levelprecaution of is e Tumors . / Exit to Arthritis Vasculitis / Infections Cancer Medication or drugreaction Connective tissue disease · · Hyperthyroidism Heat Stroke Meningitis Back, Extremities, Appropriate Protocol , Differential · · · · · · · MR administeringany medication , / Abdomen B YES drugresistant organisms ( - B This levelprecaution of should be utilized when influenza ) . . ) are a contraindication to Ibuprofen. IO ProcedureIO If indicated .4 F chest pain, 100 C) , dysuriaabdominal, pain P , Neck, , Heart Lungs , andAirborne Precautions , 38 ( if available Protocol 72 Rigors Temperature mask for the patient HEENT, Droplet, Greater than andother illnessesspread via large particledroplets are suspected . headache Warm Flushed Sweaty Chills/ myalgiascough, , , rash mental changes status , , Helpful to localize source Helpful Signs and Symptoms Signs · · · · AssociatedSymptoms ( · Temperature MeasurementProcedure inflammatory medications Contact, IV Procedure If indicated ). , NO I SARS . B This levelprecaution of isutilized when multi . . include standard plus PPE airborne precautions plus contact precautions .g steroidal anti- - Mental Status, Skin, e ( Infection Control Infection / Fever include standard PPE plusastandardsurgicalproviders mask for who accompany patients in the back of streptococcal pharyngitis or other illnesses spread suspected by contact are , ) mumps, Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS , Exit to NSAIDs should not be used inthesettingof environmental heat emergencies. giveDo not aspirinto a child Rehydration withfluids increased the patients abilitysweatand to improves heat loss. All patients shouldhave drug allergies documented prioradministering to pain medications. Allergies to NSAIDs (non AgencyMedical Directorof medical may requirecontact control priorEMT to - a potentially infectious rash shouldbe treated with dropletprecautions . Airborne precautions include standardplus utilization PPE gown change of a , of gloves after every patient, and strict contact hand washing precautions zoster (shingles All-hazards precautions meningitis utilized duringinitial the phases of an outbreakwhen the etiologytheinfection of is unknown or whencausative the agentis found to be highly contagious Recommended Exam: Febrile seizures aremore likely inchildren with a history of febrile seizures and with a rapid elevation in temperature. Patients withahistory liver of failureshould not receive acetaminophen. Droplet precautions the ambulance andsurgical a maskor NRB O2 Age Duration fever of fever Severity of Past medical history Medications Immunocompromised (transplant ) HIV, diabetescancer , Environmental exposure Last acetaminophen or ibuprofen Appropriate Protocol

· · · · · · · · Pearls · · · · History · · · · · · · · Adult / Pediatric General Section Protocols 2012 YES NO s) ( / / Or Exit to YES Dyspnea if indicated as indicated if indicated Chest pain Palpitations / Cardiac History Removal Procedure Behavioral Protocol RestraintProcedure Appropriate Protocol Taser entry point Significant Injury WoundCare -Taser Probe WoundCare Procedure Multiple Trauma Protocol AgitatedDeliriumSecondary to IllnessPsychiatric AgitatedDeliriumSecondary to Substance Abuse Traumatic Injury Closed HeadInjury Asthma Exacerbation Cardiac Dysrhythmia TASER Differential · · · · · · YES NO NO NO NO /Substance Abuse NO Protocol 73 Medical Illness? NO Notify Destination or Excited Delerium Syndrome Contact Medical Control Use of Pepper or Taser? Spray Externalsigns of trauma Palpitations of breath Shortness Wheezing AlteredMental Status Intoxication Evidence of Traumatic Injury or Signs and Symptoms Signs · · · · · · Police Custody Police YES COPD History Asthma / Minutes Wheezing? Dyspnea or Observe 20 YES NO YES s) PEPPER SPRAY / eyes Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS s) Exit to Protocol( Appropriate clothing YES Remove Exit to Wheezing Dyspnea / contaminated Protocol( Appropriate Traumatic InjuryTraumatic DrugAbuse Cardiac History History of Asthma PsychiatricHistory Irrigateface Revised Respiratory Distress 11/7/2012 History · · · · · Police Custody Adult Pediatric General Section Protocols / PediatricGeneral

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

Revised Protocol 73 11/7/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Adult / Pediatric General Section Protocols 2012 . Fever Hemorrhage Reactionsormedication from home nutrient Respiratory distress Shock Differential · · · · · kg s) position Clamp catheter Continue infusion Exit to Stop infusion if ongoing Stop infusion if ongoing Stop infusion if ongoing Notify Destination or Do not exceed 20 mL / Contact Medical Control Protocol 74 Place onside headdown left in warmth or drainage Appropriate protocol( Ask family orcaregiver if it is appropriate stopchange to or infusion. Clampdisruption catheter proximal to May use hemostat wrapped in gauze Apply direct around pressure catheter Apply direct around pressure catheter I I I I aboutcathetersiteindicating infection Externalcatheter dislodgement Complete catheter dislodgement Damaged catheter Bleeding at catheter site Internalbleeding Blood clot Air embolus Erythema, Emergencies Involving Involving Emergencies Indwelling Central Lines Central Indwelling Signs and Symptoms Signs · · · · · · · · YES YES YES YES YES YES (IV nutrition): If stoppedfor anyreason monitor for hypoglycemia . caregiversasand skills they have specific knowledge , Access central catheter and utilizeif functioning properly. Hickman) / site NO NO NO NO NO Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Chest Pain Ongoing infusion Tunneled Catheter Hickman(Broviac ) / PICC (peripherally inserted central catheter Implanted catheter (Mediport partially dislodged Circulation Problem Damage to catheter Airway, Breathing or Suspect Air Embolus Tachypnea Dyspnea, Cathetercompletely or Hemorrhage at catheter Cardiac arrest : Hyperalimentationinfusions Use strict sterile technique when accessing manipulating / an indwelling catheter. Do notplace a tourniquet or BP cuff on the sameside where a PICC line is located. Do notattemptto force catheter openif occlusion evident . Someinfusions may be detrimental to stop. Always talkto family / Occlusionline of Complete or partialdislodge Complete or partialdisruption Central CatheterType Venous · · · · · · Pearls · · · · · · History · Adult / Pediatric General Section Protocols 2012 NO / . to insert s) Equipmentfailure . ( . Or stoma Exit to YES Protocol Continued TracheostomyTube Respiratory Distress Appropriate Pediatric Allow Caregiver Respiratory Distress Place Appropriatelysized monitoring if available Place Trachesotomy Tube AppropriatelyETT into sized endotracheal tubeinto stoma neumothorax and Allergic reaction Asthma Aspiration Septicemia Foreign body Infection Congenitalheart disease Medication or toxin Trauma P 3 mL of NS before suctioning. I I – Differential · · · · · · · · · 2 ETT, / ) Instill YES oxygenate before andbetween attempts - cm typically. to 6 Protocol 75 3 then tracheostomy tube should be changed. Continual pulse oximetry andEtCO2 Notify Destination or , . NO Contact Medical Control Assist Ventilations via Remove Speaking Valve Obstructed tracheostomy tube Remove Inner Cannula Tracheostomy Tube / ETT SuctionTracheostomy Tube Remove Decannulationplug Remove Obturator Trachesotomy SuctionTracheostomy Tube Tube available Attempts to cough Attempts to Copious secretionsnoted coming out of the tube Faint breath sounds on both sides of chest despitesignificant respiratory effort AMS Cyanosis Nasal flaring Chest wall retractions (withor withoutabnormalbreath sounds Respiratory Distress Respiratory ETT, I I I No morethan B / . · · · · · Signs and Symptoms Signs · · With a Tracheostomy Tube Tracheostomy a With If unableIf to pass . NO NO YES seconds each attempt and pre YES NO . caregivers and skills. as they have specific knowledge / , muscular (bronchialor ) traumatic brain or - ) tracheal, atresia Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS NO NO YES YES YES in place Removed Continued Tube inplace Inner Cannula Trachesotomy (Double lumen) Speaking Valve Monitorand Reassess Decannulation plug Obturator Removed Respiratory Distress Always talk to family DO NOT forcesuctionDO NOT catheter Use patients equipmentavailable if and functioning properly. Estimate suctioncatheter size by doubling the inner tracheostomy tube diameter and rounding down. Suctiondepth Ask family / caregiver : Alwaysdeflate trachealtubecuff before removal Do not suction more than 10 DOPE: Displaced tracheostomy tube SuctionTracheostomy Tube spinal cord injury Surgical complications (accidental damage to phrenic nerve) Trauma (post Medical condition Birth defect ( Birth defect tracheomalacia, craniofacial abnormalities pulmonary dysplasia dystrophy) I Pearls · · · · · · · · · · · History · Adult / Pediatric General Section Protocols s) 2012 . demand Exit to . Take patient’s ventilator YES Equipmentfailure . Appropriate protocol( / neumothorax and Disruption of oxygensource Dislodgedorobstructed tube tracheostomy Detached or disrupted circuit ventilator Cardiac arrest Increased oxygen requirement / Ventilator failure P Differential · · · · · · NO leakin circuit or aroundsite tracheostomy ETT, , / . Other problems Notify Destination or Problem with Circulation Contact Medical Control andmaintain currentsettings Transport onpatients ventilator . P with a Protocol Protocol 76 Correct cause TracheostomyTube Respiratory Distress Emergencies Emergencies obstructed airway or circuit monitoring must be utilized during assessment andtransport Loosedisconnected or circuit : Obstructed tracheostomy tube . Transport requiringTransport maintenance of a mechanical ventilator Powerorequipmentfailure at residence Involving Ventilators Involving ETT, Apnea / NO Remove patient from ventilatorand manually ventilate using BVM. YES Signs and Symptoms Signs · · YES : YES YES Internalbattery depleted YES caregivers and skills. as they have specific knowledge , (damage / LowPressure / LowPower : High Plugged Pressure: / mmHg What is : ) ETT ETT / / traumatic brain or ) - 94 % Or tracheal, atresia NO NO NO NO NO YES Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS ≥ Tube Tube Cause corrected Problem with Airway Remove patient from ventilator EtCO2 35 – 45 Oxygenation saturation andmanually ventilate with BVM (Ask Caregiver DislodgedTracheostomy Detached Oxygen Source Obstructed Tracheostomy DetachedCircuit Ventilator Ventilation or Oxygengation Always talk to family Alwaysuse patient’s equipment if available and functioningproperly . Continuous pulse oximetry andend tidal CO2 DOPE: Displaced tracheostomy tube Unable to correct ventilator problem to hospital even if not functioning properly Typicalalarms : Surgical complications Birth defect ( Birth defect tracheomalacia, craniofacial abnormalities to phrenic nerve) Trauma (post spinal cord injury Medical condition (bronchopulmonary dysplasia, muscular dystrophy) baseline saturation for patient) Pearls · · · · · · · History · · · Adult / Pediatric Environmental Section Protocols : 2012 NO ant, tick) , / Officer contact Control Shock wasp Document with Animal ) Contactand , Animal bites Cat bee ( / -222-1222 Protocol Protocol YES If NeededIf Appropriate Anaphylaxis bite Dog Transport Human Bite if indicated Immobilize Injury 1-800 Allergic Reaction Trauma Protocol(s) Hypotension / Carolinas Poison Control Extremity Trauma Protocol Animal bite Human bite Snakebite (poisonous ) Spider bite (poisonous Insect sting / Infection risk Rabies risk Tetanus risk YES YES Differential · · · · · · · · / redness , if indicated IO Procedure IO wheezing , Severe P wound / , hivesitching, if able Notify Destination or , NO NO Pain Contact Medical Control Allergy / SnakeBite clothing bands / Anaphylaxis Immobilize Injury Hypotension Remove all jewelry Redness and Time Serious Injury / DO NOT apply ICE DO NOT Protocol 78 from affected extremity Moderate Elevatewound location Remove any constricting Mark MarginSwelling of skin break, Identification of Animal soft tissue swellingsoft tissue , if indicated General Wound Care Procedure IV Procedure Allergic reaction Blood from the bite wound oozing Evidence of infection Shortnessof breath Rash Pain, Hypotension or shock I · · · · Signs and Symptoms Signs · · · / photo YES sting YES / Bites and Envenomations and Bites jewelry / Wasp Sting if able size of bite / Spider Bite bands Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Safe Apply Ice Packs Immobilize Injury Scene Bee Elevatewound location resources Appropriate Pain Protocol Remove any constrictingclothing NO Description or bring / creature identificationwith patient for Time, location, Type of bite / sting Type of bite / sting Previous reaction to bite / DomesticWild vs. Tetanus and Rabies risk Immunocompromised patient Stage until scene safe Callhelp for / additional Revised 8/22/2012 · · History · · · · · P Adult / Pediatric Environmental Section Protocols , ." , Heart 2012 Lung , - venom lack ). , transplant patients. . ). ). , red on black -84-TOXIN , and a complete Neck chemotherapy , kill a fellow , muscular pain and severe abdominal pain - : rattlesnake andcopperhead . Redon yellow 25 % of snakebites are “dry” bites. , fever, redstreaks proximal to wound. Protocol 78 (brown spider with fiddle shapeon back , drainage , redness Very littlepain but very toxic " . Location of injury) Mental Status, Skin, Extremities of (Location : swelling envenomation is unlikely . About Bites and Envenomations and Bites , and Neuro examif systemic effects are noted Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Evidence of infection : Amountof envenomation is variable , generallywith worse largersnakes and early inspring noIf painorswelling , BlackWidow spider bites tendto beminimally painful, but overafewhours may develop (spiderisblack withred hourglass on belly). Brown Recluse spiderbites are minimally painful painless to Little reaction. is noted initially but tissue necrosis at the site of the bite develops over the next few days Recommended Exam Immunocompromised patients are at an increasedriskinfection for : diabetes Consider contacting the NorthCarolina Poison Control Center for guidance (1-800 Human bites have higher infection rates than animal bitesdue to normalmouth bacteria . Carnivore bites are muchmore likelyto become infected and all have riskof Rabies exposure . Cat bitesmay progressto infection rapidlyspecific duea to bacteria (Pasteurella multicoda Abdomen, Back Poisonous snakes in thisarea are generallythepit of viper family Coral snakebites are rare: Revised 8/22/2012 · · · · · Pearls · · · · · · · · Adult / Pediatric Environmental Section Protocols 2012 Diabetic related Infection MI Anaphylaxis Renal failure dialysis problem / Headtrauma injury / Co-ingestant or exposures Differential · · · · · · · . , Extremities Shock Oxygen flu like illness children and the elderly . Protocol , Continue Care Appropriate Appropriate Appropriate if indicated if indicated , Abdomen Continue High Flow Monitorand Reasses Diabetic Protocol Trauma Protocol(s) Hypotension / Protocol 79 Lungs weakness, P Notify Destination or Contact Medical Control AMS Malaise, Dyspnea cramping N/V; Symptoms; GI Dizziness Seizures Syncope Reddened skin Chest pain , Heart, YES YES YES Signs and Symptoms and Signs · · · · · · · · · , Skin (s) IO ProcedureIO : Neuro Age Shock P + 2 x , criminal, NO NO NO Cyanide / Monoxide Carbon SBP <90 Cardiac Monitor < 70 Adequate if indicated Continue Care of Cyanide as indicated High Suspicion Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS High Flow Oxygen Age Specific VS Monitorand Reasses 12 LeadProcedure ECG Suicide, SBP Poor Perfusion / Continue High Flow Oxygen Oxygenation Ventilation IV Procedure Spinal Immobilization Protocol Blood Glucose Analysis Procedure Immediately Removefrom Exposure AppropriateProtocol Airway I Recommended exam Scene safety. is priority Consider CO and Cyanide with any product of combustion Normal environmentallevel CO does not exclude CO poisoning Symptoms present with lower CO levels in pregnancy Continue high flow oxygen regardlessof pulse ox readings. accidental Past Medical History Time / Durationof exposure Ingestion of cyanideIngestionof Eatinglarge quantityof fruit pits Industrialexposure Trauma Reason: Smoke inhalation P B Pearls · · · · · · · · · · · · · History · Adult / Pediatric Environmental Section Protocols 2012 ) s) ( . Pulseless / Consider NO Pulse if indicated Exit to Skin, Neuro Arrhythmia Protocol Arrest and / or Unresponsive Hypothermia Protocol Age Appropriate Cardiac immersion syndrome Barotrauma Decompressionsickness existingproblem medical - YES Pressure injury (diving Post- Trauma Pre · · · · Differential · · Back, Extremities, . IO ProcedureIO P NO Warm Patient / if indicated Protocol 80 as indicated Wheezing ), consideravailability transport to or hyperbaric of a chamber. Dyspnea / Cardiac Monitor Age Appropriate as indicated These patients have an increased chance of survival Dry Neck Abdomen, Pelvis, , Chest, Notify Destination or Age Appropriate Remove wet clothing , AirwayProtocol (s) ,Stridor Contact Medical Control Mental Exam Status Awake but with AMS Awakebut with AlteredMentalProtocol Status IV Procedure Spinal Immobilization Procedure Head Unresponsive changesMental status Decreased or absentvital signs Vomiting Coughing , WheezingRales, , Rhonci Apnea I P s) ( YES Signs and Symptoms Signs · · · · · · Age . resuscitate. all Distress Protocol Respiratory Appropriate Trauma Survey, -be rescuerswould . cause of death among is a leading Drowning (decompression barotrauma / YES Submersion Injury / Submersion Drowning Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS NO symptoms if indicated if indicated IV Procedure to 6 hours for asymptomatic Wheezing Dyspnea / developmentof Cardiac Monitor drowning victims Dry / Warm Patient Asymptomatic near- Encourage transport Remove wet clothing Allow appropriately trained and certified rescuers appropriately trained and to removevictims areasof danger. Allow from time limit -- cold water no With Ensure scenesafety . Recommended Exam: All victims should be transportedevaluation for due to potentialworsening for over the next several hours. With pressureinjuries Submersion in waterregardless of depth Possible of trauma ie: history diving board Duration of immersion Temperaturewater of or possibility of hypothermia Degree of water contamination Haveahigh indexsuspicion of for possible spinal injuries Hypothermia is often associated with drowning andsubmersion injuries should be observed 4 andevaluation even if Awakeand Alert Monitorand Reassess Monitorand Reassess I · · · Pearls · · · History · · · · · · · P Adult / Pediatric Environmental Section Protocols NO 2012 104 stroke , ) Coma s) / IO ProcedureIO usually > , P ) dry skin , Cardiac Monitor Hot as indicated as indicated Hypotension Poor perfusion if indicated Infection HEAT STROKE Age Appropriate Age Appropriate ( AirwayProtocol (s) Age Appropriate Active cooling measures 12 LeadProcedure ECG Diabetic Protocol Hypotension/ , AMS IV Procedure Dehydration Medications Hyperthyroidism (Storm Delirium tremens (DT' Heat cramps, exhaustion CNS lesions or tumors Fever AlteredMentalProtocol Status I I High body temperature P B · · · · · · Differential · YES YES / coma / IO ProcedureIO Shock Tachypnea P Exit to moist skin Procedure as indicated Cardiac Monitor Protocol 81 Age Appropriate coolenvironment Monitorand Reassess Hypotension dry or sweaty skin dry or sweaty Poor perfusion Trauma Protocol(s) Cool, , Remove tight clothing Hypotension / Blood Glucose Analysis Active cooling measures Notify Destination or 12 LeadProcedure ECG HEAT EXHAUSTION Passivecooling measures Alteredmental status / Hypotension or shock Seizures Nausea Hot Remove from heat source to Contact Medical Control Assess Symptom Severity Elevated body temperature IV Procedure Weakness, Anxious, Signs and Symptoms Signs · · · · · I I P B Hyperthermia NO Muscle cramping Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS , Procedure if available Hyperthermia HEAT CRAMPS , moist skin Warm, PO Fluids as tolerated Monitorand Reassess / or humidity Signs / Symptoms of Go to Temperature Measurement Age, very young and old increasedExposure to temperatures and Time andduration of exposure Poor PO intake, extreme exertion Fatigueand / or muscle cramping / MedicationsPast medical history / Weakness Seizure Activity Seizure Protocol Revised 10/30/2012 History · · · · · · Normalelevated body to temperature B Hyperthermia Adult Pediatric Environmental Section Protocols / Pediatric Environmental

Pearls · Recommended Exam: Mental Status, Skin, HEENT, Heart, Lungs, Neuro · Extremes of age are more prone to heat emergencies (i.e. young and old). Obtain and document patient temperature if able. · Predisposed by use of: tricyclic antidepressants, phenothiazines, anticholinergic medications, and alcohol. · Cocaine, Amphetamines, and Salicylates may elevate body temperatures. · 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.

Revised Protocol 81 10/30/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 Adult / Pediatric Environmental Section Protocols 2012 NO Pulse Exit to Cardiac / Protocols See Pearls Unresponsive andArrhythmia Age Appropriate Pulseless Arrest if indicated YES s) Age Appropriate ( Diabetic Protocol Stroke Head injury Spinal cord injury Age Sepsis Environmental exposure Hypoglycemia CNS dysfunction Distress Protocol Respiratory Appropriate Differential · · · · YES Systemic Hypothermia coma

IO ProcedureIO Frost Bite / P Warm Patient without AMS without Procedure / / clammy Protocol 82 Dry Cardiac Monitor Remove wet clothing as indicated as indicated as indicated Blood Glucose Analysis Age Appropriate Age Appropriate Age Appropriate Monitorand Reassess AirwayProtocol (s) Passivewarming measures Alteredmental status / Cold, Shivering Extremity pain orsensory abnormality Bradycardia Hypotension or shock Hypothermia 12 LeadProcedure ECG Respiratory Distress Active warming measures Hypotension/ Shock or Notify Destination or Multiple Trauma Protocol Awakewith Signs and Symptoms Signs · · · · · · Contact Medical Control IV Procedure AlteredMentalProtocol Status I I P B Wind / / Frostbite Hypothermia Sepsis Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS or Frostbite Procedure if available / Hypothermia General Wound Care Monitorand Reassess and DO NOT allowDO NOT refreezing Localized Cold Injury Localized DO NOT RubDO NOT Skin to warm Signs / Symptoms of Temperature Measurement Lengthofexposure / Wetness Age, very young and old decreasedExposure to temperatures innormalbut may occur temperatures MedicationsPast medical history / DruguseAlcohol : , barbituates Infections / chill Revised 10/30/2012 · History · · · · · B Hypothermia / Frostbite

Adult Pediatric Environmental Section Protocols / PediatricEnvironmental Section

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

Revised Protocol 82 10/30/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 Adult / Pediatric Environmental Section Protocols 2012 -222-1222 If NeededIf if indicated if indicated if indicated Immobilize injury Allergy Protocol Large Organism Age Appropriate Age Appropriate Age Appropriate 1-800 Pain Control Protocol Multiple Trauma Protocol Extremity Trauma Protocol Carolinas Poison Control Injury Jellyfish sting Sea Urchin sting Sting ray barb Coral sting Swimmers itch Cone Shell sting Fish bite Lion Fish sting YES Differential · · · · · · · · if indicated IO Procedure IO P SeverePain / 114 Degrees NO NO if available Lion Fish Sting Ray if indicated Immobilize injury Hypotension Sea Creature 110 – Serious Injury / Identification of Urchin / Starfish Age Appropriate Protocol 83 Immerse in HotWater Remove Barb or Spine If largeIf Barb in thoraxor abdomen stabilize object Allergy Anaphylaxis / Pain Control Protocol Moderate Notify Destination or if indicated General Wound Care Procedure Contact Medical Control IV Procedure P I Intense localized pain Increased oral secretions Nausea vomiting / Abdominal cramping Allergic reaction / anaphylaxis Signs and Symptoms Signs · · · · · YES YES s) Marine Envenomations / Envenomations Marine

War Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS -O- DO NOT If available Protocol PainProtocol JellyFish Anemone clean seawater Man Age Appropriate if indicated Immobilize injury Lift away tentacles Do Not brush or rub Apply Vinegar Rinse Otherwisewash with Age Appropriate Age Appropriate use fresh water orice Trauma Protocol( Hypotension / Shock Pain Control Protocol Type of bite / sting Type of bite Identification of organism Previousreaction to marine organism Immunocompromised Householdpet P History · · · · · Marine Envenomations / Injury Adult Pediatric Environmental Section Protocols / Pediatric Environmental

Pearls · Ensure your safety: Avoid the organism or fragments of the organism as they may impart further sting / injury. · Patients can suffer cardiovascular collapse from both the venom and / or anaphylaxis even in seemingly minor envenomations. · Sea creature stings and bites impart moderate to severe pain. · Arrest the envenomation by inactivation of the venom as appropriate. · Ensure good wound care, immobilization and pain control. Protocol 83 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 Adult / Pediatric Environmental Section Protocols , ., , .g 2012 , , VX ., .g e , Mustard ., ( .g .5 mg dose if : .) Seizures, IO ProcedureIO Nerve Agent Kits and 2 mgdose kg), and 2 etc , .) P . etc , .) 18 to 40 if available ( Arrest ). Use the 0 Soman, Doses Rapidly etc , , 3 NerveIM Agent Kit vesicants, etc.) , Major Symptoms yearsage of pesticide) Sarin Organophosphateexposure ( Vesicantexposure (e Hydrogen Sulfide, Ammonia Chlorine Gas RespiratoryExposure Irritant (e Nerveagent exposure 7 Neuro , administer or administerapatient to if available pounds 90 pounds - · · · Differential · IV Procedure ( Altered Mental Status, to Respiratory, Respiratory Distress narcotics , . I P .g e ( mg of Atropine. mg of cramping / Gastrointestinal B may carry, self , . and 2 loss of control Lungs : use pediatric atropines or decontamination PAM) SLUDGEM - IO ProcedureIO 2 Diarrhea Heart, increased, Abdominal pain P as indicated. ; ; Protocol 84 Symptom Severity if available Notify Destination or Doses Rapidly 2 Obtain history of exposure Obtain uscleTwitching Contact Medical Control HEENT, mesis alivation acrimation NerveIM Agent Kit L Urination Defecation / Upset GI E M Seizure Activity Respiratory Arrest S Minor SymptomsMinor Observe for specific toxidromes Observe for specific mg dose if patient weighs between 40 patient weighs mg dose if Initiate triage and/ Initiate · · · · · · · · Signs and Symptoms Signs · IV Procedure >40 kg). ( kg), 1 I begin with 1 Nervefor patients less than begin Agent Kit P Respiratory + Distress , 18 600 Pralidoxime ( mg of ( YES and 3 Nervepatients 15 yearsof age and over. Agent Kits for , Mental Status, Skin, contains contains Kit Any benzodiazepine by any route is acceptable by any route Any benzodiazepine : Nerve Agent Protocol Agent -Nerve WMD publicand safety officers Medical Responders / EMT- PPE Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS SceneSafe Appropriate 14 yearsage of pralidoximebyprotocol Agency medical . director may require of Medical Contact Controlprior to administration. MCI issues exhaust supply of NerveKits, /MCI issues exhaust supply Agent symptoms Appropriate Arm resources Go to Every 15 minutes for Asymptomatic Initiate Treatment per Monitorand Reassess atropine / Recommended Exam: Follow local HAZMAT protocols for decontamination and use of personal protective equipment and use of for decontamination local HAZMAT protocols Follow fide attack the face a bona In of Exposure to chemicalExposure to , biologic, radiologichazard or nuclear , Potentialexposureto unknown substance/hazard The mainsymptomthat the atropine addresses is excessive secretions so atropineshould begiven untilsalivation improves . EMS personnel, from 8 to Seizure Activity Each Nerve Agent pounds for patients greater than 90 pounds If Triage pounds less 40 pounds patient is than For patients with major symptoms, there is no limit for atropine dosing. Carefully evaluate not from exposure patients to ensure they to another agent Seizure Activity Seizure Protocol Revised NO Stage until scene safe 11/19/2012 Pearls · · · History · · · · · · · · · Callhelp for / additional Adult / Pediatric Trauma and Burn Section Protocols Don’t 2012 ) blistering painful (

- ) painless/charred ) red Degree nd Protocol(s) TympanicMembrane 2 Degree Maintain Oxygen Protocol ( as indicated Saturation 94% ≥ / rd Protocol 3 . Thermal Burn / Degree Age Appropriate st Adult Pediatric/ Airway Trauma Protocol CrushSyndrome Radiation Incident Electrical injury Treatment Enroute Chemical andElectrical Burn / Concussion g Trauma. or leathery skin Thermal injury Chemical – Radiation injury Blast injury Full Thickness ( include TBSA) in PartialThickness Superficial (1 YES YES · · · · · · Differential · YES YES if indicated IO ProcedureIO : Traumatic Brain Injury / / P /distress could Load and Go with Assessment Go Load and if indicated / Exposure Exposure Cardiac Monitor if indicated if indicated swelling Protocol 86 CrushInjury as indicated , Hypotension Blast Lung Injury / Electrical Burn or Radiation Burn or Trauma and Burn Thermal Chemical/ / Other environmental hazards, Notify Destination or Contact Medical Control Adult / PediatricAdult Airway Protocol(s) EMS Triage and Destination Plan EMS Triage and if indicated Burns, pain be indicated by hoarseness/ wheezing Dizziness Loss of consciousness Hypotension/shock Airwaycompromise Adult Pediatric/ PainControl Protocol IV Procedure Adult / PediatricAdult MultipleTrauma Protocol Compartment Syndrome Signs and Symptoms Signs · · · · · . Rapid Transport to appropriate destination using I P Industrial Explosion. Terrorist Incident. Improvised Explosive Device Explosive Closed Incident / Injury Blast / / gas, Quantify and Triage Patients Quantify , Amount. Incendiary ) : Agent / : Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Scene Safety / Accidental / (See Pearls Rupture Abdominal / hemorrhage, Blast LungInjury or Evisceration Penetratin and TriageProtocol Type of exposure (heat chemical) Inhalation injury Time of Injury Past medical history / Medications Other trauma Loss of Consciousness Tetanus/Immunization status Intentional Explosions Revised 10/30/2012 History · · · · · · · Natureof Device Method of Delivery Method of : Open Natureof Environment DistancefromDevice : Intervening protective barrier. CrushInjuryEvaluate for: Blunt Trauma / / Blast Injury / Incident Adult Pediatric Trauma and Burn Section Protocols BurnSection and / Pediatric Trauma

Pearls · Types of Blast Injury: Primary Blast Injury: From pressure wave. Secondary Blast Injury: Impaled objects. Debris which becomes missiles / shrapnel. Tertiary Blast Injury: Patient falling or being thrown / pinned by debris. Most Common Cause of Death: Secondary Blast Injuries. · Triage of Blast Injury patients: Blast Injury Patients with Burn Injuries Must be Triaged using the Thermal / Chemical / Electrical Burn Destination Guidelines for Critical / Serious / Minor Trauma and Burns · Care of Blast Injury Patients: Blast Injury Patients with Burn Injuries Must be cared for using the Thermal / Chemical / Electrical Burn Protocols. Use Lactated Ringers (if available) for all Critical or Serious Burns. · Blast Lung Injury: Blast Lung Injury is characterized by respiratory difficulty and hypoxia. Can occur (rarely) in patients without external thoracic trauma. More likely in enclosed space or in close proximity to explosion. Symptoms: Dyspnea, hemoptysis cough, chest pain, wheezing and hemodynamic instability. Signs: Apnea, tachypnea, hypopnea, hypoxia, cyanosis and diminished breath sounds. Air embolism should be considered and patient transported prone and in slight left-lateral decubitus position. Blast Lung Injury patients may require early intubation but positive pressure ventilation may exacerbate the injury, avoid hyperventilation. Air transport may worsen lung injury as well and close observation is mandated. Tension pneumothorax may occur requiring chest decompression. Be judicious with fluids as volume overload may worsen lung injury. · Accident Explosions: Attempt to determine source of the blast to include any potential threat for particalization of hazardous materials.· Evaluate scene safety to include the source of the blast that may continue to spill explosive liquids or gases. Consider structural collapse / Environmental hazards / Fire.· Conditions that led to the initial explosion may be returning and lead to a second explosion. Patients who can, typically will attempt to move as far away from the explosive source as they safely can. · Intentional Explosions: Attempt to determine source of the blast to include any potential threat for particalization of hazardous materials. Greatest concern is potential threat for a secondary device. Evaluate surroundings for suspicious items; unattended back packs or packages, or unattended vehicles. If patient is unconscious or there is(are) fatality(fatalities) and you are evaluating patient(s) for signs of life: Before moving note if there are wires coming from the patient(s), or it appears the patient(s) is(are) lying on a package/pack, or bulky item, do not move the patient(s), quickly back away and immediately notify a law enforcement officer. If no indications the patient is connected to a triggering mechanism for a secondary device, expeditiously remove the patient(s) from the scene and begin transport to the hospital. Protect the airway and cervical spine, however, beyond the primary survey, care and a more detailed assessment should be deferred until the patient is in the ambulance. If there are signs the patient was carrying the source of the blast, notify law enforcement immediately and most likely, a law enforcement officer will accompany your patient to the hospital. Consider the threat of structural collapse, contaminated particles and / or fire hazards.

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

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

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

Assess Burn / Concomitant Injury Severity Pediatric Trauma and Burn Section Protocols BurnSection and / Pediatric Trauma

Minor Burn Serious Burn Critical Burn

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

P Cardiac Monitor if indicated Age Appropriate Cardiac Arrest / Pulseless Arrest / Irrigate Involved Eye(s) with Age Appropriate Arrhythmia Normal Saline for 15 minutes Eye Involvement Protocol(s) May repeat as needed as indicated

Flush Contact Area with Normal Saline for 15 minutes Identify Contact Points

Exit to Age Appropriate Thermal Burn Protocol

Pearls · Recommended Exam: Mental Status, HEENT, Neck, Heart, Lungs, Abdomen, Extremities, Back, and Neuro · Green, Yellow and Red In burn severity do not apply to the Start / JumpStart Triage System. · Refer to Rule of Nines: Remember the extent of the obvious external burn from an electrical source, does not always reflect more extensive internal damage not seen. · Chemical Burns: Refer to Decontamination Procedure. Normal Saline or Sterile Water is preferred, however if not available, do not delay irrigation using tap water. Other water sources may be used based on availability. Flush the area as soon as possible with the cleanest readily available water or saline solution using copious amounts of fluids. · Electrical Burns: DO NOT contact patient until you are certain the source of the electrical shock is disconnected. Attempt to locate contact points (generally there will be two or more.) A point where the patient contacted the source and a point(s) where the patient is grounded. Sites will generally be full thickness. Do not refer to as entry and exit sites or wounds. Cardiac Monitor: Anticipate ventricular or atrial irregularity including VT, VF, atrial fibrillation and / or heart blocks. Attempt to identify then nature of the electrical source (AC / DC,) the amount of voltage and the amperage the patient may have been exposed to during the electrical shock. Protocol 87 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 Adult / Pediatric Trauma and Burn Section Protocols 2012 / s) / hour VT > 1 / YES VF Exit to Pulseless Arrest / PEA Asystole / Hypotension / as indicated Entrapped Arrhythmia Protocol( I P Age Appropriate Cardiac Arrest Entrapment withoutEntrapment crush syndrome withoutEntrapmentcrush significant Alteredmental status YES Differential · · · / IO Procedure IO P NO as indicated Cardiac Monitor Age Appropriate Abnormal ECG Protocol 88 Monitorand Reassess AirwayProtocol (s) Monitorfor fluid overload Notify Destination or 12 LeadProcedure ECG Hemodynamically unstable Contact Medical Control IV Procedure I I P P P B Hypotension Hypothermia Abnormal ECG findings Pain Anxiety Signs and Symptoms Signs · · · · · YES , YES Crush Syndrome Trauma Syndrome Crush trench s) .12 seconds bodycrushed Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS YES .46 seconds Hyperthermia / Safe Scene Loss of P wave Consider resources Peaked Waves T Protocol( QT ≥ 0 as indicated 0 QRS ≥ Trauma Protocol Building collapse , Extremity collapse, industrial accident pinned under equipment heavy Entrapped and crushed under heavyload > 30 minutes NO Stage until scene safe Callhelp for / additional Revised Age Appropriate Multiple 8/13/2012 Hypothermia / · · History · P Crush Syndrome Trauma Adult Pediatric Trauma and Burn Section Protocols BurnSection and / Pediatric Trauma

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

Revised Protocol 88 8/13/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 Adult / Pediatric Trauma and Burn Section Protocols 2012 Shock (s) if indicated IO ProcedureIO . Protocol P Protocol NO as indicated Multiple Trauma Age Appropriate Abrasion Contusion Laceration Sprain Dislocation Fracture Amputation Amputation Hypotension / if indicated Pain Protocol Age Appropriate Differential · · · · · · · Monitorand Reassess YES YES if indicated IV Procedure , so that the appropriate destination I YES . . , Wrap , shock Dressings / Symptoms available. Woundcare , Neuro swelling air tightcontainer . Splinting as required Protocol 89 6 hourstime from the of injury Place container onice if Notify Destination or Bleeding Controlled by Pain, Deformity motor function Alteredsensation / Diminished capillary refill pulse / Decreased extremity temperature Clean amputatedpart in normal saline and place in Contact Medical Control part in sterilesoaked dressing DirectPressure Control Hemorrhage with Pressure Serious Signs / Signs and Symptoms Signs · · · · · Extremity Hypotension, poor perfusion Transportand notify medical control immediately YES . Extremity Trauma Extremity / : Mental Status, fracture NO / if indicated IO ProcedureIO penetrating / time is critical P , NO crush WoundCare - : Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Amputation if indicated Pain Protocol Age Appropriate Tourniquet Procedure if indicated IV Procedure Recommended Exam Peripheralneurovascular status isimportant In amputations Type of injury Mechanism canbe determined. Hipdislocations and knee and elbow fracture / dislocations have a high incidenceof vascular compromise. Urgently transport anyinjury with vascular compromise. Blood loss may be concealed or not apparent withextremity injuries Lacerations must be evaluated for repairwithin Multiple casualty incident : Tourniquet Proceduremaybe considered first instead of direct pressure amputation Time of injury Open vs. closed wound Woundcontamination Medical history Medications I Revised 8/13/2012 Pearls · · · History · · · · · · · · · · · · Adult / Pediatric Trauma and Burn Section Protocols 2012 ) Each of 7 ? Defaultis Any doubt always immobilize always immobilize alcohol, drugs Neuro . s rangeof motion shouldnot be Any injury which the patientseems to -making ability ( andturn their head from side to side Extremities, , , . Patient' . andabrupt deceleration crashes and may look up) ( Exit to Any changealertness to with this incident? ? impaired decision high falls, , appropriate protocol Spinal Immobilization Procedure Spinal Immobilization Procedure Spinal Immobilization Procedure Spinal Immobilization Procedure Spinal Immobilization Procedure Spinal Immobilization Procedure very youngand or obese / patients reduced on numbness strength, in an extremity. , Abdomen, Back , Lungs extendtheir neck , andsituation dialysis or other underlying spinal or bone disease. spinal or underlying cancer dialysis or other , , Heart, Protocol 90 time , , Yes Yes Yes Yes Yes Yes ) (Optional Neck place , ? energy events such as ejection - ? ? es) or or less 5 Mental Status, Skin, / spine injury should be used to rememberprotocol be used to the stepsin this " should Lookfor focal deficitssuch as tingling, . . Is there any other injury. producing significant pain in this patient? Any painful injury ) without spinal processpain . Any evidence No No No No No No : Is there any indication that the personisintoxicated , Selective Spinal Immobilization Spinal Selective Entry from appropriateEntry from protocol . or greater Not Required painROM? to 65 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS The patientshould touch theirchintheir chest to Spinal Immobilization . . Intoxication Age that might distract the patient : NeuroAny focal deficit Exam: ? Spinal Exam: Point tenderness over the spinous process( Significant mechanisminjury of ? cervical spinal processes must be palpated during the exam. focus on and rate 6 or greateronpain the scaleislikely distracting. from the painof a c- Circumstances warrant spinal immobilization consideration Distracting Injury: Alertness: Alteration inmental status "N" = Neurologic exam Recommended Exam: Consider immobilization in any patient with arthritis, in any patient Consider immobilization the paramedicsolely. of patient is the responsibility a in immobilization implement spinal to NOT The decision . injury rule out spinal a normal exambe sufficient to very and very young, may not In old Significant mechanism includes high indicate the needfor spinal immobilization in the absenceof symptoms. Range of motion shouldbeassessed if patient hasmidline NOT spinal tenderness "S" = Significant mechanism or extremes of age. "A" = Alertness. Is patient orientedperson to (shoulder to shoulder The acronym "NSAIDS Intoxication"I" = assisted "D" = Distracting injury Apply appropriatepadding fill to voids especially in the elderly, "S" = Spinal exam. Look for point tenderness in any spinal processorspinal process tendernesswith. range of motion P P P P P P P Pearls · · · · · · · · Adult / Pediatric Trauma and Burn Section Protocols Don’t 2012 ) blistering painful (

trauma from - / (s) ) painless/charred Degree Burn ) red rd Degree Arrest /3 nd Protocol 2 nd Degree ( as indicated rd Age Appropriate Critical Burn 3 compromise Degree st Cardiac Arrest / Pulseless Electrical injury TBSA 2 Age Appropriate Arrhythmia transport to a Burn Center) Treatment Enroute Burns withdefinitive airway Burns withMultiple Trauma When reasonably accessible, / ( >15% or leathery skin Thermal injury Chemical – Radiation injury Blast injury Full Thickness ( include TBSA) in PartialThickness Superficial (1 such as heatfrom the blast , · . , · · · · · · Differential · . Exposure / Degree Burn rd /distress could /3 Gy). Information may be available those from on site who have / Exit to nd Load and Go with Assessment Go Load and / Serious Burn swelling Protocol 91 Age Appropriate Eye Involvement , Hypotension external contamination with radioactive material, internalcontamination / , Thermal Burn Protocol Cardiac indicated Monitor if Radiation Burn transport to a Burn Center) When reasonably accessible, ( 15% TBSA 2 Hypotension 13 or Less or GCS - intubationstabilization for airway 5 Burns, pain be indicated by hoarseness/ wheezing Dizziness Loss of consciousness Hypotension/shock Airwaycompromise Suspected inhalation injuryrequiring or Assess Burn / ConcomitantInjurySeverity Signs and Symptoms Signs · · · · · P Flush Contact Area with Normal Saline for 15 minutes Radiation Incident Radiation external irradiation ; (generally measured in Grays gas, Quantify and Triage Patients Quantify , .· do not delay transport to acquirethis information , Degree Burn rd : Most allinjuries immediatelyseen willbe a result of collateralinjury /3 nd Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Scene Safety / MinorBurn Normotensive : Determine exposure GCS 14 or Greater : Determine exposure type May repeatasneeded Irrigate Involved with Eye(s) Type of exposure (heat chemical) Inhalation injury Time of Injury Past medical history / Medications Other trauma Loss of Consciousness Tetanus/Immunization status Normal minutes Saline 15 for < 5% TBSA 2 No inhalationIntubated injury, Not , Collateral Injury monitoring equipment concussioncollateral, treat injury based on typical care for the type of injurydisplayed Qualify with radioactive material Quantify History · · · · · · · Radiation Incident Adult Pediatric Trauma and Burn Section Protocols BurnSection and / Pediatric Trauma

Pearls · Dealing with a patient with a radiation exposure can be a frightening experience. Do not ignore the ABC’s, a dead but decontaminated patient is not a good outcome. Refer to the Decontamination Procedure for more information. · Normal Saline or Sterile Water is preferred, however if not available, do not delay irrigation using tap water. Other water sources may be used based on availability. Flush the area as soon as possible with the cleanest readily available water or saline solution using copious amounts of fluids. · Three methods of exposure: External irradiation External contamination Internal contamination · Two classes of radiation: Ionizing radiation (greater energy) is the most dangerous and is generally in one of three states: Alpha Particles, Beta Particles and Gamma Rays. Non-ionizing (lower energy) examples include microwaves, radios, lasers and visible light. · Radiation burns with early presentation are unlikely, it is more likely this is a combination event with either thermal or chemical burn being presented as well as a radiation exposure. Where the burn is from a radiation source, it indicates the patient has been exposed to a significant source, (> 250 rem). · Patients experiencing radiation poisoning are not contagious. Cross contamination is only a threat with external and internal contamination. · Typical ionizing radiation sources in the civilian setting include soil density probes used with roadway builders and medical uses such as x-ray sources as well as radiation therapy. Sources used in the production of nuclear energy and spent fuel are rarely exposure threats as is military sources used in weaponry. Nevertheless, these sources are generally highly radioactive and in the unlikely event they are the source, consequences could be significant and the patient’s outcome could be grave. · The three primary methods of protection from radiation sources: Limiting time of exposure Distance from Shielding from the source · Dirty bombs ingredients generally include previously used radioactive material and combined with a conventional explosive device to spread and distribute the contaminated material. · Refer to Decontamination Procedure / WMD / Nerve Agent Protocol for dirty contamination events. · If there is a time lag between the time of exposure and the encounter with EMS, key clinical symptom evaluation includes: Nausea/ Vomiting, hypothermia/hyperthermia, diarrhea, neurological/cognitive deficits, headache and hypotension. · This event may require an activation of the National Radiation Injury Treatment Network, RITN. UNC Hospitals, Wake Forest- Baptist and Duke are the NC hospitals, with burns managed at UNC and Wake Forest. Protocol 91 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012