Airway, Adult

$VVHVV$%&¶V Legend -Respiratory Rate Supplemental Adequate -Effort MR Oxygen -Adequacy B EMT B Pulse Oximetry I EMT- I I Inadequate P EMT- P P

Basic Maneuvers First M Medical Control M -open airway

Unsuccessful Obstruction Protocols General -nasal or oral airway -Bag-valve mask (BVM)

Becomes Airway: Inadequate Successful Obstruction Long Transport Procedure or Need to Protect Direct Airway B Continue BVM B I Laryngoscopy I Blind Insertion B B Airway Device Oral-Tracheal Intubation I I Nasal-Tracheal Intubation 3 Attempts Failed airway protocol Post-Intubation, Consider Unsuccessful P Diazepam, Lorazepam, or P Midazolam for sedation If Available, Notify Destination or Successful P Consider P M Contact MC M Gastric Tube

Pearls This protocol is only for use in patients with an Age > 12 or patients longer than the Broselow-Luten Tape. Capnometry (Color) or capnography is mandatory with all methods of intubation. Document results. Continuous capnography (EtCO2) is strongly recommended for the monitoring of all patients with a BIAD or endotracheal tube. If an effective airway is being maintained by BVM with continuous pulse oximetry values of > 90, it is acceptable to continue with basic airway measures instead of using a BIAD or Intubation. For the purposes of this protocol a secure airway is when the patient is receiving appropriate oxygenation and ventilation. An Intubation Attempt is defined as passing the laryngoscope blade or endotracheal tube past the teeth or inserted into the nasal passage. Ventilatory rate should be 6-10 per minute to maintain a EtCO2 of 35-45. Avoid hyperventilation. It is strongly encouraged to complete an Airway Evaluation Form with any BIAD or Intubation procedure. Paramedics should consider using a BIAD if oral-tracheal intubation is unsuccessful. Maintain C-spine immobilization for patients with suspected spinal injury. Do not assume hyperventilation is psychogenic - use oxygen, not a paper bag. 6HOOLFN¶VDQGor BURP maneuver should be used to assist with difficult intubations.

Hyperventilation in deteriorating head trauma should only be done to maintain a EtCO2 of 30-35. Gastric tube placement should be considered in all intubated patients if available. It is important to secure the endotracheal tube well and consider c-collar to better maintain ETT placement. Protocol 1 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2009 General Protocols 2009 P M MS and Maintain Contact MC Surgical Airway t) SPO2 above 90% Ventilate at <12 BPM Notify Destination or ETCO2 between 35 and 45 P M Yes er: ry failure or to all patients with advanced airways. th an inadequate respiratory function. No or swelling ? SPO2 > 90% Facial trauma about the patient's difficult / failed airway. No with BVM Ventilation ? Protocol 2 Two (2) failed intubation attempts B inconsistent with intubation attempts. No Yes NO MORE THAN THREE (3) ATTEMPTS TOTAL by most proficient technician on scene or anatomy B AS EARLY AS POSSIBLE Airway, Adult-Failed Yes I P B with BIAD M SPO2 > 90% ? Continue Ventilation Blind Insertion Airway Device Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OE Continue BVM Medical Control MR EMT Apply BURP maneuver (Push tracheaChange Back head [posterior], positioning Up, and to patient's Righ Different laryngoscope blade Gum Elastic Bougie Different ETT size Change cricoid pressure EMT- I B EMT- P Legend to ventilate with BVM or it becomes difficult If SPO2 drops < 90% Notify Continuous pulse oximetry should beContinuous utilized EtCO2 in should all be patients applied wi to all patients with respirato If first intubation attempt fails, make an adjustment and then consid Medical Control I Pearls P B B M Airway, Drug Assisted Intubation

P Preoxygenate 100% O2 P Legend MR Ensure adequate IV P P B EMT B Suction equipment I EMT- I I P EMT- P P Yes Evidence of Head Injury or Stroke? M Medical Control M P Lidocaine P No P Etomidate P

P Cricoid Pressure P Protocols General

P Succinylcholine P

P Intubate P

Placement Verified May Repeat P P No M M with Capnography One Time

Yes P Restraint Procedure P

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

If Available P P Consider Gastric Tube

P Consider Long Acting Paralytic P Failed Airway Protocol M Notify Destination or Contact MC M Pearls This protocol is only for use in patients with an Age > 12 or patients longer than the Broselow-Luten Tape. Once a patient has been given a paralytic drug, YOU ARE RESPONSIBLE FOR VENTILATIONS! Items in Red Text are the key performance indicators used to evaluate protocol compliance. An Airway Evaluation Form must be completed on every patient who receives Drug Assisted Intubation. 7KLVSURFHGXUHZLOOWDNHDZD\WKHSDWLHQW¶VDLUZD\DZD\VR\RXPXVWEHVXUHRI\RXUDELOLW\WRLQWXEDWHEHIRUHJLYLQJGUXJV. Continuous Waveform Capnography and Pulse Oximetry and are required for intubation verification and ongoing patient monitoring Before administering any paralytic drug, screen for contraindications with a thorough neurologic exam. If First intubation attempt fails, make an adjustment and try again: Different laryngoscope blade Ɣ&KDQJHKHDGSRVLWLRQLQJ Different ETT size Ɣ&RQWLQXRXVSXOVHR[LPHWU\VKRXOGEHXWLOL]HGLQDOOSDWLHQWV. Change cricoid pressure Ɣ&RQVLGHUDSSO\LQJ%853PDQHXYHU(Back [posterior], Up, DQGWRSW¶V5LJKW3UHVVXUH) This procedure requires at least 2 EMT-Paramedics. Divide the workload - ventilate, suction, cricoid pressure, drugs, intubation. All equipment must be in place and ready for use prior to administering any RSI drugs. Protect the patient from self extubation when the drugs wear off. Longer acting paralytics may be needed post-intubation. Protocol 3 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2009 General Protocols I I P B M M 2009 MR EMT EMT- I EMT- EMT- P EMT- Legend Medical Control Airway: Obstruction Procedure Direct Laryngoscopy Contact MC I P B M of 30-35. of 2 Notify Destination or Notify Destination or Failed airway protocol Failed Obstruction I M P B Successful Maintain If Available, Consider Gastric Tube Protocol 4 Inadequate 3 Attempts Continue BVM Continue Unsuccessful Pulse Ox >Pulse Ox 94 $VVHVV$%&¶V -Respiratory Rate -Effort -Adequacy Pulse Oximetry Basic Maneuvers First -open airway -nasalor oral airway (BVM) -Bag-valve mask EtCO2 >and 35 < 40 Becomes P B Inadequate Airway, Pediatric I P B Adequate maneuver shouldassist be used with difficultintubations. to Successful or Need Long Transport to Protect Airway or BURP Any local EMS System changes to this must follow document the NC OEMS Protocol Policy and Change by be approved OEMS Unsuccessful Nasal-Tracheal Intubation Blind Insertion Blind Airway Device Oral-Tracheal Intubation Supplemental Oxygen Midazolam for sedation It isimportantIt to securetheendotracheal tubeand well consider c-collarplacement. to better maintain ETT 6HOOLFN¶VDQG Hyperventilationdeteriorating in head should trauma only be done maintaina to pCO Gastric tube placement should be consideredall in intubated patients. Maintain C-spineimmobilization patients with suspected for spinal injury. assumeDo not hyperventilation is psychogenic a papernot - use oxygen, bag. It is strongly encouraged to complete an Airway Evaluation Form with any BIAD or Intubation procedure. Intubation BIADany or Form with an Airway Evaluation encouraged to complete strongly It is Paramedics should considerusing a BIAD if oral-tracheal intubation is unsuccessful. An Intubation Attempt is defined as passing the laryngoscope blade or endotracheal tube past the teeth or or endotrachealtube past the teeth or the laryngoscope blade as passing defined Attempt is An Intubation passage.the nasal inserted into the for Adolescents and Age, School for Toddlers, 2530 for Neonates,be20 for should Ventilatory rate avoid hyperventilation. 35and and between 30 per minute. Maintain a EtCO2 rate12 of normal Adult For the purposes of this protocol a secure airway is when the patient is receiving appropriate oxygenation oxygenation receiving the patient is appropriate a secureof this protocol airway is when purposes For the and ventilation. Capnometry (color) or capnography is mandatory with all methods of intubation. Document results. Document intubation. all methods of is mandatory with (color) or capnography Capnometry use.BIAD tube or endotracheal with capnography (EtCO2) is strongly recommended Continuous > 94, it is pulse oximetry values of continuous by BVM with effectivemaintained If an airwayis being a BIAD or Intubation. airway measureswith basic instead of using continue acceptable to For this protocol, pediatric is defined as less than 12 years of age or any patient which can be measuredcan be which 12 years as less of age or any patient than protocol, pediatric is defined For this tape. the Broselow-Luten within Diazepam, Lorazepam, or Post Intubation, Consider I Pearls P B General Protocols 2009 B M and Maintain Contact MC Continue BVM Continue SPO2 above 94% Notify Destination or Notify Destination or ETCO2 betweenand 35 40 B M Yes No Placement. Improved? SPO2 > 90% aboutfailed the patient's airway./ difficult No with BVM Ventilation ? Protocol 5 NasopharyngealAirway Attempt Oropharyngeal or Two (2) failed intubation attempts B inconsistent with intubation attempts. No Yes NO MORE THAN THREE (3) THREE NO MORE THAN ATTEMPTS TOTAL by most proficient technicianscene onor anatomy B AS EARLY AS POSSIBLE ASAS EARLY Yes I P B with BIAD M Airway, Pediatric-Failed SPO2 > 90% ? Continue Ventilation (Per Packaging) Any local EMS System changes to this must follow document the NC OEMS Protocol Policy and Change by be approved OEMS Airway Device Insertion Blind Continue BVM Continue Medical Control MR EMT Differentlaryngoscope blade Gum Elastic Bougie DifferentETT size Change cricoid pressure Apply BURP maneuver (Push trachea Back [posterior], Up, and to patient's Right) Change head positioning EMT- I EMT- B EMT- P EMT- Legend to ventilate with BVM or it becomes difficult If SPO2If drops < 90% Continuousoximetry pulse should be utilizedall in patients with an inadequate respiratory function. Continuous should EtCO2 be appliedtoallwith patients respiratory to all or failure patients with advanced airways. Notify Ventilatory rate should be 30 for Neonates, 25 for Toddlers, 20 for School Age, and for Adolescents the for Adolescents and Age, School for Toddlers, 2530 for Neonates,be20 for should Ventilatory rate avoid hyperventilation. 35and and between 30 per minute. Maintain a EtCO2 rate12 of normal Adult If first intubation fails, makeIf attempt an adjustment and try again: then Medical Control I Pearls P B B M General Protocols 2009 MS Negative I M n, Back, Extremities, Neuro Muscle spasm / strain Herniated disc with nerve compression Sciatica Spine fracture Kidney stone Pyelonephritis Aneurysm Pneumonia Spinal Epidural Abscess Metastatic Cancer Differential lly immobilized. ld be considered. ch radiates around to the groin area. quires immediate medical evaluation No Positive IV Protocol Normal Saline Bolus Pain Control Protocol Protocol 6 Orthostatic Blood Pressure Injury or traumatic mechanism Universal Patient Care Protocol Notify Destination or Contact MC Back Pain I M Pain (paraspinous, spinous process) Swelling Pain with range of motion Extremity weakness Extremity numbness Shooting pain into an extremity Bowel / bladder dysfunction Signs and Symptoms Yes Yes I P B M No Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OE MR EMT EMT- I EMT- P Legend Signs of shock? Spinal Immobilization Protocol In patient with history of IV drug abuse a spinal epidural abscess shou Kidney stones typically present withPatients an with acute midline onset pain of overAny flank the bowel pain spinous or whi processes bladder should incontinence be is spina a significant finding which re Recommended Exam: Mental Status,Abdominal HEENT, aneurysms Neck, are Chest, a Lungs, concern Abdome in patients over the age of 50 Fever Improvement or worsening with activity Previous back injury Traumatic mechanism Location of pain Past surgical history Medications Onset of pain / injury Age Past medical history Medical Control I Pearls History P B M General Protocols I I P B M 2009 MR EMT EMT- I EMT- EMT- P EMT- Legend OralGlucose, Medical Control I P B M aspiration 50% Dextrose Adult 10% Dextrose Pediatric Glucagon if no IV access if no Glucagon see differential Mental Status Altered Intoxication Alcohol abuse / Substance Toxin / overdoseMedication effect syndromes Withdrawl Depression Bipolar (manic-depressive) Schizophrenia disorders Anxiety 1 to 2if awake tubes andno risk for If available,If consider Differential I < 60 P M Protocol 7 Behavioral Anxiety, agitation, confusion hallucinationsAffect change, Delusionalbizarre thoughts, behavior Combative violent Expression of suicidal / homicidal thoughts Signs and Symptoms and Signs Consider SceneSafety or if available If PatientCare RefusesIf Head TraumaHead Protocol Contact Medical Control Contact Medical Go to Appropriate Protocol Go Haloperidol or Ziprasidone Haloperidol Altered Mental Status Protocol StatusMentalAltered Any local EMS System changes to this must follow document the NC OEMS Protocol Policy and Change by be approved OEMS Checkany Glucose if there is suspicion of hypoglycemia Overdose/Toxic Ingestion Protocol Protocol Ingestion Overdose/Toxic GCS on all patients Removeenvironmentfromstressful patient Use verbal calming techniquesbecause communication(reassurance, important is very establishcalm, rapport) Restraint Procedure Universal Patient Care Protocol Midazolam, Lorazepam, or Diazepam Do not position any restrained or transport is suchawaycould patient the patients impact that respiratory or circulatory status. All patients who receive either physical or chemical restraint must be continuously observed by ALS personnel on on observed by ALS personnel who receive either physical or chemical restraintmustbe continuously All patients their arrival. upon or immediatelyscene Any patientwhorestrainedor is handcuffed by LawEnforcement and transportedbe by EMS must accompanied by law enforcement in the ambulance. Do not irritate the patient with a prolonged exam. Do not overlook the possibility of associated domestic violence or child abuse. patientIf is suspected of agitatedcardiacconsider delirium arrest, bolus a fluid suffers and sodium bicarbonate early. Consider Haldol or Ziprasidone for patients with history of psychosis or a benzodiazepine for patients with presumed with presumed for patients or a benzodiazepine psychosis history of for patients with or Ziprasidone Consider Haldol substance abuse. Be sure to consider all possible medical/trauma causesfor behavior overdose,(hypoglycemia, substance abuse, hypoxia,head injury, etc.) Recommended Exam: Mental Status, Skin, Heart, Lungs, Neuro Skin, Heart, Status, Lungs, RecommendedMental Exam: Your safety first!! Medicalert tag Substance abuseoverdose / Diabetes Injury to self or threats toInjury to selfor threats others Situational crisis Psychiatric illness/ medications Pearls History P M Fever / Infection Control

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

Universal Patient Care Protocol Legend MR Contact, Droplet, and Airborne Precautions B EMT B I EMT- I I Yes Orthostatic Blood Pressure P EMT- P P ProtocolsGeneral M Medical Control M IV Protocol I I No Normal Saline Bolus

Temperature Measurement Temperature greater than 100.4°F (38° C) B If available B Ibuprofen (if age > 6 months) or Acetaminophen (if age > 3 months)

Appropriate protocol by complaint

M Notify Destination or Contact MC M

Pearls Recommended Exam: Mental Status, Skin, HEENT, Neck, Heart, Lungs, Abdomen, Back, Extremities, Neuro Febrile seizures are more likely in children with a history of febrile seizures and with a rapid elevation in temperature. Patients with a history of Liver failure should not receive acetaminophen. Droplet precautions include standard PPE plus a standard surgical mask for providers who accompany patients in the back of the ambulance and a surgical mask or NRB O2 mask for the patient. This level of precaution should be utilized when influenza, meningitis, mumps, streptococcal pharyngitis, and other illnesses spread via large particle droplets are suspected. A patient with a potentially infectious rash should be treated with droplet precautions. Airborne precautions include standard PPE plus utilization of a gown, change of gloves after every patient contact, and strict handwashing precautions. This level of precaution is utilized when multi-drug resistant organisms (e.g. MRSA), scabies, or zoster (shingles), or other illnesses spread by contact are suspected. All-hazards precautions include standard PPE plus airborne precautions plus contact precautions. This level of precaution is utilized during the initial phases of an outbreak when the etiology of the infection is unknown or when the causative agent is found to be highly contagious (e.g. SARS). Rehydration with fluids increased the patients ability to sweat and improves heat loss. All patients should have drug allergies documented prior to administering pain medications. Allergies to NSAID's (non-steroidal anti-inflamatory medications) are a contraindication to Ibuprofen. NSAID's should not be used in the setting of environmental heat emergencies. Do not give aspirin to a child. Protocol 8 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2009 General Protocols 2009 I P B M I I P M MR EMT EMT- I EMT- P Legend Medical Control 8 yo) for prior to accessing prior dialysis I • P B M ( (ped device) adult or I I P Unsuccessful X 3 Unsuccessful X attempts with any method Contact Medical Control Contact Medical Peripheral IV Peripheral IV ExternalJugular Intraosseous for life-threateningevent life-threatening event contact medicalcontact control 8 yo) for • ( (ped adult or I I Protocol 9 P M IV Access IV Assess need for IV I B Intraosseous IV Intraosseous device)event for life-threatening Peripheral IV Peripheral IV ExternalJugular life-threatening event medical or trauma condition Emergent or potentially emergent Universal Patient Care Protocol , any preexisting, dialysisshunt or external venous central may catheter be used. I I P 8 years of age). • Monitor med-lock Monitor infusion Monitor Successful Any local EMS System changes to this must follow document the NC OEMS Protocol Policy and Change by be approved OEMS I In post-mastectomy patients,In post-mastectomyavoid IV, blood draw, injection, or blood pressure in arm on affectedside. Any venous which catheter already hasbeen accessed EMS arrivalto prior may be used. Upper extremity IV sites are preferable to lower extremity sites. discouragedLower extremity IV sites are in with patients vasculardiseaseor diabetes. External jugular lines can be attempted initially in life-threatening events where no obvious peripheral site is noted. whoIn patients are hemodynamically unstable or in extremis, External jugular ( Any prehospital fluids or medicationsuse, approved may be for IV given throughintraosseous an IV. (minimalAll IV rates shouldat KVO be keep vein rate to open) unless administeringfluid bolus. Use microdrips all6 years old patients for or less. In the setting of cardiac arrest Intraosseousappropriate with the orpediatric adultdevice. shuntsorexternal central venous catheters. B Pearls General Protocols P B I P B M 2009 MR EMT or EMT- I EMT- EMT- P EMT- or Legend Ibuprofen Medical Control Nitrous Oxide Acetaminophen I P B M Consider if Available Per the specific protocol Per the specific Musculoskeletal Visceral(abdominal) Cardiac Pleural / Respiratory Neurogenic Renal (colic) Differential P B No I P P B B M Protocol 10 Protocol includehypotension, head injury, respiratory distress or severe COPD. Severity (painSeverity scale) dull,(sharp,Quality etc.) Radiation Relation to movement, respiration Increased with palpation of area Signs and Symptoms and Signs to patients with to patients a history of liverdisease. narcotic or Yes Specific Complaint Specific Pain Control:Pain Adult should be given not for headachesor abdominal pain, history of gastritis, stomach ulcers, basedon Pain Severity >Pain Severity 6 10 of out Must reassess every at least patient 15sedative minutesmedication after Pulse oximetry if IV medicationIV protocol availableIf consider Ketorolac availableIf consider Nitrous Oxide Fentanyl or, Fentanyl Acetaminophen Patient carePatient according to UniversalCare Protocol Patient Indication for IV / for IV Indication IM Medication Notify Destination or Contact MCContact or Notify Destination Morphine or, Morphine Dilaudid Any local EMS System changes to this must follow document the NC OEMS Protocol Policy and Change be approved by OEMS I P P B B M See drug list for other contraindications for Narcotics, Acetaminophen, NitrousKetorolac, Oxide, and Ibuprofen. fracture, or if patient will require sedation administerDo notmedications any PO for patients who may need surgical interventionopen such as fractures or fracture deformities,headaches, or abdominal pain. administerDo not All patients should have drug allergiesdocumented to administering prior pain medications. All patientsreceive whoIM or IV medications must be observed for drug 15 minutes reaction. or Ketorolac Ibuprofen Patients withPatients presumed kidney stone should first receive A narcotic Toradol. may then beconsidered. Contraindications a to the use of renaldisease known or renal patients with be used in not should and Ibuprofen (Toradol) Ketorolac NSAID's anti-inflammatory (non-steroidal to drug allergies known who have transplant, in patients fractures such as open intervention surgical may need patients who or in active bleeding, medications), with or fracture deformities. Pain severity (0-10) is a vital sign to be recorded pre and post IV or IM medication delivery and at IM medication delivery post IV or be recorded and pre to sign Pain severity(0-10) a vital is disposition. medications. all pain with at disposition and pre, post, 15 minutes be obtained should Vital signs Recommended Status, Exam:Mental Areaof Pain, Neuro Drug allergies Past medical history Medications Duration Severity(1 - 10) child useIf Wong-Baker faces scale Age Location Pearls History General Protocols I P B M 2009 P B M MR EMT EMT- I EMT- EMT- P EMT- Legend or or Medical Control Ibuprofen Ibuprofen I Nitrous Oxide P B M Acetaminophen Acetaminophen (Age > 3 Months) (Age > 6 months) Consider if Available (Age greater 5(Age greater years) Per the specific protocol Per the specific Musculoskeletal Visceral(abdominal) Cardiac Pleural / Respiratory Neurogenic Renal (colic) Differential Contact Medical Control Contact Medical P B M No No I P B B M

Protocol 11 Protocol Severity (painSeverity scale) dull,(sharp,Quality etc.) Radiation Relation to movement, respiration Increased with palpation of area Signs and Symptoms and Signs include hypotension, head injury, or respiratory distress. or if IV medicationif IV Yes Yes Specific Complaint Specific based on Pain Severity >Pain Severity 6of 10 out Must reassess every at least patient 15sedative minutesmedication after Pulse oximetry IV protocol Pain Control:Pain Pediatric Patient carePatient according to UniversalCare Protocol Patient Indication for IV / for IV Indication IM Medication Notify Destination or Contact MCContact or Notify Destination If no contraindication If to sedation or, Morphine or, Fentanyl Dilaudid Isolated Extremity Traumatic PainExtremity Traumatic Isolated should not be given if there is abdominalor if patient pain, fracture, ulcers,history of gastritis, stomach Any local EMS System changes to this must follow document the NC OEMS Protocol Policy and Change be approved by OEMS I P B B M See drug list for other contraindications for Narcotics, Oxide,Acetaminophen,Nitrous and Ibuprofen. Do not administerDo notmedications any PO for patients who may need surgical interventionopen such as fractures or fracture deformities. All patients should have drug allergiesdocumented avoid and medications with a history of an allergyreaction. or All patientsreceive whoIM or IV medications must be observed for drug 15 minutes reaction. Ibuprofen For children use Wong-Baker For children faces(see score scale or the FLACC Assessment Procedure) Pain medications. all pain with at disposition and pre, post, 15 minutes be obtained should Vital signs to Narcotic use Contraindications will require sedation. Recommended Status, Exam:Mental Areaof Pain, Neuro and at IM medication delivery post IV or be recorded and pre to sign Pain severity(0-10) a vital is disposition. Drug allergies Past medical history Medications Duration Severity(1 - 10) child useIf Wong-Baker faces scale Age Location Pearls History General Protocols I P B M 2009 B MR EMT EMT- I EMT- EMT- P EMT- Legend Medical Control I P B M Spinal Immobilization Required Immobilization Spinal

B Yes Yes Yes Yes Yes Yes Protocol 12 P P No No No No No No pain to ROM? Not Required Spinal Immobilization Clearance Immobilization Spinal Patient > 65 or < 5 or Spinal Immobilization Spinal over thespinal process or Any local EMS System changes to this must follow document the NC OEMS Protocol Policy and Change be approved by OEMS ntoxication: Any evidence? I euro Exam: Any focal deficit? pinal Exam: Pointtenderness that might distractthepatientthat might N S istracting Injury: Any painful injury lertness: Any alteration in patient? from the pain of a c-spinefrom the pain injury? of a IGNIFICANT traumatic mechanism?IGNIFICANT D A S P P In very old and very young patients, a normal exam may not be sufficient to rule out spinal injury. to rule out sufficient and very patients, a normal examvery may not be young old In "S" = Spinal exam. Look"S" = Spinal tenderness for point exam. any in spinal process or spinal process tenderness with range of motion. of the paramedic. is the responsibility in a patient spinal immobilization implement to NOT The decision "S" = Significant mechanism age. of or extremes oriented"A" = Alertness. Is patientperson,to time, and place, situation? Any change to alertness with this incident? there any indication = Intoxication.Is "I" intoxicated person is that the (impaired decision making ability)? Is there any"D" = Distracting other injury injury. which is capable of producing significant pain in thispatient? The acronym"NSAIDS" should be used to remember protocol.this the steps in "N" = Neurologic exam. deficitsLook for focal such as tingling, reduced strength, on numbness in anextremity. Rangeshould of motionassessedNOT be if patient has midline spinal tenderness. range Patient's motion of should patientnot be assisted.The should touch their chin to their chest,(looktheir extend and neck up), turn theirhead to side(shoulderfrom side shoulder) to without spinal process pain. RecommendedExtremities, Back,Abdomen, Status, Exam:Mental Neuro Skin, Neck, Heart,Lungs, disease. or bone spinal underlying arthritis, cancer,or other any patient with in Consider immobilization Significant mechanismincludes high-energyas ejection, events suchhigh falls, and deceleration abrupt crashes and may indicatespinal the need immobilization for in the absence of symptoms. Pearls General Protocols I I P B M 2009 MR EMT EMT- I EMT- EMT- P EMT- Legend M Oral Glucose, Oral Medical Control I P B M Protocol aspiration 50% Dextrose Adult 10% Dextrose Pediatric Cardiac Arrest Glucagon if no IV access if no Glucagon 1 to 2awakeif tubesno and risk for If available,If consider Cardiac Arrest I < 60 Contact Medical Control Contact Medical Patient doesn't fit a protocol? fit Patientdoesn't P B B M Protocol 13 Oxygen (Adult or Pediatric) or(Adult Cardiac Monitor Glucose Measurement ECG12 Lead Scene safety Initial assessment Universal Patient Care Protocol Care Patient Universal Adult Assessment Procedure Airway Protocol Any local EMS System changes to this must follow document the NC OEMS Protocol Policy and Change be approved by OEMS Consider Pulse oximetry Consider Consider Supplemental Consider Vital signs (Temperature if appropriate) Consider Spinal Immobilization Consider Spinal Pediatric Assessment Procedure Go to Appropriate Protocol to Appropriate Go

Demonstrate Professionalism and Courtesy %ULQJDOOQHFHVVDU\HTXLSPHQWWRSDWLHQW¶VVLGH PPE (Consider Airborne Droplet or if indicated) (The Broselow-Luten patient) tape defines the pediatric Orthostatic vital sign procedure should beperformed in where situationsvolume question. status is in Timing of transportTiming of should be based on patient's clinical conditiontransportthe and policy. Never medical hesitate to contact control who for patient refuses transport. Required vital signs on every patient include blood pressure, pulse, respirations, pain / severity. pain / respirations, pressure, pulse, every blood on patient include Required vital signs the specific complaint. temperatureis dependent on and Pulse oximetry documentation are they the tape, fit on does not If the patient Broselow-Luten tape. defined by the A pediatric patient is considered adult. Recommended Exam: Minimal exam if not noted on the specific protocol is vital signs, mental status with status signs, mentalvital with protocol is the specific on Recommended Exam: not noted Minimal exam if complaint. of injury or location GCS, and form.transportin an EMS have a completed disposition must result does not Any patient contact which Pearls P B B General Protocols I P B M 2009 Yes Yes P MR EMT EMT- I EMT- EMT- P EMT- Legend Medical Control I P B M and/or No Consider Appropriate Protocol and Transport Palpitations? Taser after Taser Use? Behavioral Protocol Restraint Procedure Removal Procedure Agitated Delirium Secondary to Delirium Secondary Agitated Psychiatric Illness to Delirium Secondary Agitated Substance Abuse Injury Traumatic Injury Closed Head Asthma Exacerbation Cardiac Dysrhythmia Cardiac History with Yes Wound Care-Taser Probe Care-Taser Wound , transportthe patient to the hospital for Point of Taser or from Fall or Taser of Point Differential Pacemaker,Pain, Chest or Significant Entry from Injury P No No No No Control Protocol 14 Medical Illness? with patient, law Agitated Delirium? Coordinate disposition enforcement personnel, andnecessary Medical if No External trauma signs of Palpitations Shortness of breath Wheezing Altered Mental Status Intoxication/SubstanceAbuse Evidence of TraumaticInjury or Use of Pepper Spray or Taser?of Pepper SprayUse or Universal Patient CarePatient Universal Protocol Signs and Symptoms and Signs Police Custody Police Yes Yes Asthma? History ofHistory No I I No Pepper Spray Any local EMS System changes to this must follow document the NC OEMS Protocol Policy and Change be approved by OEMS Yes Yes 20 min. clothing Remove Observe Distress Wheezing? Wheezing? Appropriate Protocol Appropriate Protocol and Transport Transport Respiratory contaminated If extremity/chemical/lawIf enforcementapplied, are restraints completed Restraint procedure in call reporting system. evaluation. an asthmatic patientIf is exposed to pepperreleased spray andlaw all enforcement, to should partiesbe advised to immediatelyrecontact EMS if wheezing/difficulty breathing occurs. All patients in police custody request retain the right transport.This should to be coordinated with law enforcement. ,IWKHUHLVDQ\GRXEWDERXWWKHFDXVHRIDSDWLHQW¶VDOWHUDWLRQLQPHQWDOVWDWXV Agitated delirium is characterizedmarkedby restlessness, and/or irritability, exhibiting Patientsfever. high these signs are at high risk for suddenand death should transported be to hospital by ALS personnel. restrainedPatientsby law enforcement devicesbe cannotin transported the ambulance without a law enforcement officer inthepatient compartment capable who isremoving of devices. the For this protocol to be used, the patient does not have to be under police custody. be under police to does not have be used, the patient to protocol For this Cardiac History Historyof Asthma Psychiatric History Traumatic InjuryTraumatic Drug Abuse Protocol and Protocol and Irrigate face/eyes I I Pearls History