I Revised 20121 IGeneral Patient Care Guidelines I

1. Follow Universal BSI Precautions. 2. Assess for Scene Safety 3. Activate Additional Resources or Agencies for Assistance Early. 4. Assess for Presence of a Complaint or Diagnosis Covered by Current Treatment Protocol

Current Treatment Protocol Covering Complaint or Provisional Field Diagnosis?

In All patients:

1. Assess ABC's 2. Perform Primary Survey 3. Obtain SAMPLE history

Likely that Patient will require Medications or Fluids?

IV LRINS TKO

As Time Allows: Perform Secondary Survey/Full Exam

As Clinically Needed: 1. Contact Medical Control

2. Apply O2 by NRB or Nasal Cannula

Patient's Condition Deteriorates 1------">0( YES or Complaints Change?

Continue to Monitor and Transoort I Revised 20121

I MAJOR TRAUMA ~

1. Control Cervical Spine 2. ABC's

1. Monitor Airway Transport location decisions should 2. Oxygen be based on 2011 National Trauma Triage Protocols and judgement of personal on scene based on possible scene time.

1. Oxygen 2. Assist Ventilations as Needed

Consider terminitaion 1-----< of efforts if approved

1. Request ALS Backup 1. Request ALS Backup 2. Rapid Extrication, if Needed 2. Check Pelvic Stability, stabilize if needed 3. Place Patient on Long Board 3. Begin Rapid Transport to Hospital 4. Check Pelvic Stability, stabilize if needed. 5. Begin Rapid Transport to Hospital

( Page 1 ) IRevised 20121 I ECA I I MAJOR TRAUMA (Continued) I

Glasgow Coma Scale Continued From A Previous Page Eye Opening r Spontaneous =4 ~ Verbal =3 Painful =2 GCS<=8ompidly ~ FYES deteriorating neurologic NO None = 1 status Verbal Oriented =5 1 If Not Previously Done:. 11 . As Time Permits, Secondary Disoriented =4 1. Request ALS Backup Patient Assessment I Inappropirate =3 2. Rapid Extrication if Needed Incomprehensible =2 3. Place Patient on Long Board None = 1 4.Ventilate at 10 Breaths/Min 5. As Time Permits, Secondary Motor Patient Assessment Obeys Commands =6 6. Activate Trauma Team Localizes Pain =5 FlexionlWithdrawal =4 Abnormal Flexion =3 Extension =2 Chest & Abdomen Intact, Stable, None = 1 Treat All That Are Present : Not Tender, with Good Breath I ~ Sounds Bilaterally, Vital Signs Stable? ~ ~ I -Flail Chest : Stabilize:

1. Control Minor Bleeding ~ 1. Dress wound with occlusive dressing 2. Immobilize Fractures I-SUcking Chest Wound ~ (Vaseline gauze) unsealed 3. Complete Spinal Immobilization 2. Monitor for Tension Pneumothorax 4. Extricate, if Needed 5. Request ALS Backup, if needed

If Not Done Previously: I-TenSion pneumothorax: I I I Request ALS Backup I I Continue to I Monitor & Transport I

• Time on scene with Trauma patients should not exceed 10 minutes unless extrication is required. If time on scene exceeds 10 minutes, reasons for delay should be documented . • If extrication >15 minutes is required or if time to definitive care is likely to exceed 25 minutes, consider air transport.

IF PATIENT'S CONDITION IS UNSTABLE OR DETERIORATES DURING TRANSPORT, REQUEST ASSISTANCE FROM RECEIVING AREA'S ADVANCED LIFE SUPORT SERVICE. ( Page 2 ) I Revised 20121 I BURNS (Moderate to Critical) ~

Ventilate with Bag-Valve-Mask & Oxygen

1. Estimate Burn Depth & Percent of Total Body Surface 2. Cover Burn with Dry Sterile Sheets 3. Request ALS Backup 4. Consider Requesting Air Transport for Critical Burns 5. CONTACT MEDICAL CONTROL

CRITICAL BURNS MODERATE BURNS

1. Inhalation Injuries 1. Adult: 2° 15-25% TBSA 2. All Burns of Face, Feet, Hands, Genetalia Child: 2° 10-20% TBSA 3. Adult: 2° >25% TBSA 2.3° 2-10% TBSA Child: 2° >20% TBSA 4.3° >10% TBSA 5. All Electrical Burns 6. All Burns with Associated Trauma (Fractures, etc.) 7. All Burns in Patients <11 Years Old or >50 Years Old 8. Patients with Serious Underlying Medical Disease

IF PATIENT'S CONDITION IS UNSTABLE OR DETERIORATES DURING TRANSPORT, REQUEST ASSISTANCE FROM RECEIVING AREA'S ADVANCED LIFE SUPORT SERVICE. ( Page3 ) I Revised 20121 I ECA I RESPIRATORY DISTRESS (Non-Traumatic)

Refer to Major Trauma Algorithm

Refer to Foreign Body Airway Obstruction Algorithm

NO

Refer to Allergic Reaction Algorithm

1. Oxygen 2. Assist Ventilations if Respirations Not Adequate

Asthma or Chronic Obstructive Pulmonary Disease?

1. Request Paramedic Backup 2. Expedite transport if backup >10 min away. Albuterol (Ventolin), 2.Smg/3cc NS, by Nebulizer if Approved by Medical Director

Respiratory Distress Relieved?

IF PATIENT'S CONDITION IS UNSTABLE OR DETERIORATES DURING TRANSPORT, REQUEST ASSISTANCE FROM RECEIVING AREA'S ADVANCED LIFE SUPORT SERVICE. (page4 ) I Revised 20121 ECA FOREIGN BODY AIRWAY OBSTRUCTION

1. Oxygen 2. Encourage to Cough 3. Monitor for Incresing Obstruction

Continue to Monitor & Transport

1. Oxygen 2. Continue to Monitor & Transport

1. 30 Chest Compressions 2. Check Airway, 1. Repeat Heimlich Maneuver Finger Sweep if Object Seen 2. Begin Transport to Hospital 3. Attempt to Ventilate

1. If Patient Becomes Unconscious, Attempt Finger Sweep 2. If Finger Sweep Not Successful, go to Beginning of Algorihm 1. 30 Chest Compressions 2. Check Airway Finger Sweep if Object Seen 3. Attem t Ventilation

1. Begin CPR 2. Request Paramedic Backup 3. Begin Rapid Transport to Hospital 1. Request ALS Backup 2. Begin Rapid Transport to Hospital 3. Continue to Repeat Chest Compressions, Finger Sweeps, & Attempts to Ventilate Until Airway Cleared

IF PATIENT'S CONDITION IS UNSTABLE OR DETERIORATES DURING TRANSPORT, REQUEST ASSISTANCE FROM RECEIVING AREA'S ADVANCED LIFE SUPORT SERVICE. ( pages) IRevised 20121

INEAR DROWNINGI

1. Protect Cervical Spine as Appropriate 2. Assess ABC's

1. ABC's 2. CPR 3. Oxygen 4. Request Paramedic Backup 5. Begin Rapid Transport to Hospital

NO

1. Ventilate with Bag-Valve-Mask & Oxygen 1. Monitor ABC's 2. Request Paramedic Backup 2. Oxygen

Continue to Monitor & Transport

• Consider spinal cord trauma, air embolism, hypothermia, alcohol or drug ingestion, hypoglycemia, seizures and myocardial infarction as accompanying problems or underlying causes .

• All near drowning patients, no matter how mild the episode appears to be, should be transported for observation & evaluation.

IF PATIENT'S CONDITION IS UNSTABLE OR DETERIORATES DURING TRANSPORT, REQUEST ASSISTANCE FROM RECEIVING AREA'S ADVANCED LIFE SUPORT SERVICE. ( Page6 ) I Revised 20121 CARDIAC CHEST PAIN B or SUSPECTED MYOCARDIAL INFARCTION

1. Oxygen 2. Aspirin 325mg, p.o. if Approved by Medical Director 3. Thrombolytic Checklist

Thrombolytic Checklist Patient Taken 3 or More Nitroglycerin ) Chest pain of probable Tablets in Last 10 Minutes? cardiac origin ( ) Patient> 30 years old ( ) Systolic BP < 180mmHg ( ) Diastolic BP <110mmHg ( ) Chest Pain Present >15min ( ) No CVA or other serious CNS problems in past 6mo ) No surgery or major trauma in the past 2 weeks ) No bleeding problems ) Not pregnant

Repeat Nitroglycerin, Every 5 min., Until 1. Pain Relieved 2. Total of 3 Given 3. Systolic BP<90

1. Request Paramedic Backup 2. CONTACT MEDICAL CONTROL

IF PATIENT'S CONDITION IS UNSTABLE OR DETERIORATES DURING TRANSPORT,

REQUEST ASSISTANCE FROM RECEIVING AREA'S ADVANCED LIFE SUPORT SERVICE. ~~-i' ) I Revised 20121

AUTOMATED EXTERNAL DEFIBRILLATION

1. ABC's 2. CPR 3. Oxygen 4. Request Paramedic Backup 5. Attach AED 6. Stop CPR 7. Clear Area 8. Analyze Rhythm

1. Clear Area 1. Continue CPR 2. Defibrillate x1 @ 200 Joules (Biphasic) 2. Begin Rapid Transport 3. Every 2 Minutes: 360 Joules (Monophasic) 'Stop CPR ·Analyze Rhythm

Refer to Post Resuscitation Management Algorithm NO

1. Continue CPR 2. Continue Transport 3. Every 2 Minutes: A 'Stop CPR 'Analyze Rhythm

1. Clear Area 2. Defibrillate x1 @ 200 Joules Biphasic 360 Joules Monophasic 3. Continue CPR

SCENE COORDINATION • ACLS Provider has Scene Authority • ACLS Provider Should Allow SAED Operator to Complete Defibrillation Protocol if Manual Unit is not Available • ACLS Provider Should use SAED for Additional Shocks & Monitoring if Manual Unit is not available • ACLS Provider Should Consider SAED Shocks 1. Repeat Shock as Part of ACLS Protocols @ 200 Joules Biphasic 360 Joules Monophasi 2. Await paramedic backup

IF PATIENT'S CONDITION IS UNSTABLE OR DETERIORATES DURING TRANSPORT, REQUEST ASSISTANCE FROM RECEIVING AREA'S ADVANCED LIFE SUPORT SERVICE. ( Page8 ) I Revised 20121

POST RESUSCITATION MANAGEMENT

Ventilate with Oxygen

If Not Done Previously, 1. Request Paramedic Backup 2. CONTACT MEDICAL CONTROL

IF PATIENT'S CONDITION IS UNSTABLE OR DETERIORATES DURING TRANSPORT, REQUEST ASSISTANCE FROM RECEIVING AREA'S ADVANCED LIFE SUPORT SERVICE. ( Page9 ) I Revised 20121

DECREASED LEVEL OF CONSCIOUSNESS or NEUROLOGIC SYMPTOMS* (NON- TRAUMATIC)

Patient Conscious?

1. ABC's 2. Oxygen Pulse Present? YES>---~ 3. Assist Ventilations if Respirations Inadequate

1.CPR 1. Diastolic BP >110 or 2. Oxygen Systolic BP >180, AND 3. Request Paramedic Backup 2. CNS Symptoms 4. Begin Rapid Transport to Hospital -Headache -Dizziness -Eye Pain -Blurred Vision Patient Able to Hold Head Upright, With Gag Reflex Present?

1. Request Paramedic Backup

Possible Hypothermia, Hyperthermia, or NO >------' Hypovolemia?

*NEUROLOGIC SYMPTOMS 1. Any Motor or Sensory Deficit 2. Any Altered Level of Consciousness

** ECA's with appropriate training may use glucometers to obtain baseline blood glucose before giving oral glucose.

IF PATIENT'S CONDITION IS UNSTABLE OR DETERIORATES DURING TRANSPORT, REQUEST ASSISTANCE FROM RECEIVING AREA'S ADVANCED LIFE SUPORT SERVICE. ( Page 10 ) I Revised 20121 HAZARDOUS/TOXIC MATERIAL EXPOSURE

1. Observe Hazmat Precautions" 2. Do Not Enter Incident Area Without Appropriate Protective Clothing! Respiratory Equipment 3. Evacuate Patients From Exposure Without Risking EMS Personnel Safety 4. In Cooperation With Police!Fire Authorities, Evacuatellsolate Scene 5. Attempt to Identify Nature of Hazardous Material as Soon as Possible 6. Request Paramedic Backup Vi p"", 0:''''0",' ~

1. ABC's I I Oxygen 1 2. Ventilate (~ith Oxygen) I t 1. Removellsolate Contaminated Clothing at Site, if Appropriate 2. Flush Eyes!Skin With Normal Saline if Appropriate (Brush Off Dry Chemicals First) 3. Wrap Patient in Blanket to Reduce Spread of Contaminant, if Appropriate 4. Continue to Monitor & Transport (Consider Need to Use Second EMS Unii io Transport) 5. Obtain Expert Advice for Personnel! Equipment Decontamination

HAZMAT PRECAUTIONS -In Multiple Patient Incidents, Use Triage to Determine Whichh Patients Receive IV's 1. Assume ALL Chemicals Hazardous Until Proven Otherwise ·AII Patients Should Be Transported for 2. Approach From Upwind Observation Regardless of how Mild 3. Stay Out of Low-Lying Areas; Stay Uphill if Possible the Episode Seems to be 4. Do Not Walk Into or Touch Spilled Chemicals; ·Rescue Attempts, Scene Management, & Wear Gloves When Touching Contaminated Patients Patient Care Should be Based on Best 5. Avoid Smoke, Gasses, Fumes, Vapors Information Available about the Material 6. Keep Combustibles Away ·Coordinate with Fire Authorities & Regional EMS 7. Keep Ignition Sources Away Communications Center to Obtain Information

IF PATIENT'S CONDITION IS UNSTABLE OR DETERIORATES DURING TRANSPORT, REQUEST ASSISTANCE FROM RECEIVING AREA'S ADVANCED LIFE SUPORT SERVICE. ( Page 11 ) I Revised 20121

I POISONING/OVERDOSE I

Refer to Decreased Level of Patient Conscious with Consciousness I Neurologic Intact Gag Reflex? Symptoms Algorithm

I Texas Poison Contro/1-BOO-222-12221

1. Observe for Vomiting; Save Emesis 2. Protect Airway 3. Suction as Necessary

Pulse <60, >100, or Irregular? f------...... ;~ YES

If Not Done Previously: NO Request Paramedic Backup

Bring Back ALL Potential Agent Containers and, if Possible, Samples of Agents to Emergency Department

IF PATIENT'S CONDITION IS UNSTABLE OR DETERIORATES DURING TRANSPORT, REQUEST ASSISTANCE FROM RECEIVING AREA'S ADVANCED LIFE SUPORT SERVICE. ( Page 12 ) I Revised 20121

!SEIZURESI

1. Remove Patient From Potentially Harmful Environment; Do NOT Forcefully Restrain Patient 2. Secure Airway; Oxygen 3. Assist Ventilations if Respirations Inadequate

Seizure Activity >5 min. Duration or 2 or More Seizure Without a Conscious Interval?

Go to "Decreased Level of Consciousness Request Paramedic Backup or Neurological Symptoms" Algorithm

Continue to Monitor & Transport

IF PATIENT'S CONDITION IS UNSTABLE OR DETERIORATES DURING TRANSPORT, REQUEST ASSISTANCE FROM RECEIVING AREA'S ADVANCED LIFE SUPORT SERVICE. ( Page 13 ) I Revised 20121

IALLERGIC REACTION I

1. ABC's 2. Oxygen 3. Assist Respirations as Needed

Systolic BP >90 with Adequate Perfusion

Request Paramedic Backup

Epinephrine 0.3mg, 1M, Using Auto-Injector

Signs & Symptoms Relieved?

If Not Done Previously: Request Paramedic Backup

PEDIATRIC DOSE

-Epinephrine, O.15mg, 1M, Using Auto-Injector

IF PATIENT'S CONDITION IS UNSTABLE OR DETERIORATES DURING TRANSPORT, REQUEST ASSISTANCE FROM RECEIVING AREA'S ADVANCED LIFE SUPORT SERVICE. ( Page 14 ) 1 Revised 20121

iOBSTETRIC EMERGENCYI

Patient in Active Labor?

Patient History or Scene Situation Suggestive of Volume Loss?

If There is Time Before Delivery: 1. Take Vital Signs 1. Oxygen 2. Obtain Patient History Refer to NO 2. Obtain Vital Signs & Patient History 3. Oxygen Hypovolemia (Non-Traumatic) Algorithm Assist Delivery 1. Suction Infant's Mouth & Any of the Following Present: Nose as Head Presents 'Swelling of Face/Hands 2. ABC's for Infant 'Severe or Continuous Headache 3. Dry Infant 'Dimmed or Blurred Vision 4. Clamp & Cut Cord 'Chills or Fever 5. Keep Infant Warm 'Dysuria 6. Note APGAR (1 Minute) ·Escape of Fluid From Vagina 7. Repeat APGAR @ 5 Minutes (If <7, Repeat Every 5 Minutes for 20 Minutes)

1. Massage Uterus 2. Allow Infant to Breast Feed 1. Oxygen 3. Monitor Vital Signs of Both Patients 2. Request Paramedic Backup 4. Assist Delivery of Placenta

Continue to Request Paramedic Backup Monitor & Transport

APGAR Score

Sign o Poinis 1 Point 2 Points

Appearance Blue or Pale Body Pink Completely Pink Extremities Blue

Pulse Rate Absent Below 100 Above 100

Grimmace No Response Grimmaces, or Active Cries Whimpers

Activity Absent Some Flexion of Active Extremity (Flaccid) Extremities Motion

Respiratory Absent Slow and Strongly Crying Effort Irregular

IF PATIENT'S CONDITION IS UNSTABLE OR DETERIORATES DURING TRANSPORT, REQUEST ASSISTANCE FROM RECEIVING AREA'S ADVANCED LIFE SUPORT SERVICE. ( Page 15 ) I Revised 20121

COLD EXPOSURE (SYSTEMIC HYPOTHERMIA)

Patient Conscious? 1. ABC's 2. CPR 3. Oxygen 1. Oxygen 4. Request Paramedic Backup 2. Remove Wet Clothing 5. Begin Rapid Transport to Hospital 3. Wrap in Blankets

1. Ventilate with BVM & Oxygen 2. Remove Wet Clothing 3. Wrap in Blankets 4. Request Paramedic Backup

'Suspect Hypothermia in any Patient with An Altered Level of Consciousness in a Cool Environment ·Move ALL Patients Gently, to Avoid Serious Arrhythmias ·00 Not Actively Rewarm Patient in Prehospital Environment ·Avoid Extensive Advanced Life Support in Prehospital Environment 'Resuscitate ALL Cardiac Arrest Patients who are Hypothermic

IF PATIENT'S CONDITION IS UNSTABLE OR DETERIORATES DURING TRANSPORT, REQUEST ASSISTANCE FROM RECEIVING AREA'S ADVANCED LIFE SUPORT SERVICE. ( Page 16 ) I Revised 20121

HEAT EXPOSURE (HEAT STROKE)

1. Consider Other Reasons for Unconsciousness 2. ABC's 3. Oxygen 4. Cool Patient RAPIDLY WITH ·Tub of Ice Water, if Available ·Air Conditioning ·Cool, Wet Sheets

Suspect Heat Stroke in any Patient with an Altered Level of Consciousness in a Hot Environment

IF PATIENT'S CONDITION IS UNSTABLE OR DETERIORATES DURING TRANSPORT, REQUEST ASSISTANCE FROM RECEIVING AREA'S ADVANCED LIFE SUPORT SERVICE. ( Page 17 ) I Revised 20121

HYPOVOLEMIA* (NON- TRAUMATIC)

Any of the Following Present: -Tachycardia -Skin Pale, Cool, or Diaphoretic -Capillary Refil >2 sec.

1. Oxygen 1. Oxygen 2. Begin Rapid Transport 2. Head-to-Toe Assessment 3. Request Paramedic Backup 4. Head-to-Toe Assessment

1. Oxygen Continue to 2. Begin Rapid Transport Monitor & Transport 3. Request Paramedic Backup

IF PATIENT'S CONDITION IS UNSTABLE OR DETERIORATES DURING TRANSPORT, REQUEST ASSISTANCE FROM RECEIVING AREA'S ADVANCED LIFE SUPORT SERVICE. ( Page 18 ) I Revised 20121

iNEONATAL RESUSCITATIONI

1. Place Patient on Back or Side, with Neck in Neutral Position 2. Suction Mouth/Nose with Bulb Syringe 3. Dry Infant & Keep Warm 4. Stimulate Infant by Rubbing Back & Lightly Tapping Soles of Feet

Heart Rate >60 (Assess by Palpating Umbilical Stump)? Heart Rate <100 or Persistent Central Cyanosis?

YES >------l

Evidence of Bleeding From Fetal-Maternal Unit with: 1. CPR (120 Compressions/min.) 1. Pallor After Oxygenation 2. Request Paramedic Backup 2. Faint Pulses with Good Heart Rate 3. Poor Response to Resuscitation with Adequate Ventilation

If Not Done Previously: Continue to 1. Request Paramedic Backup Monitor & Transport 2. Begin Rapid Transport to Hospital

IF PATIENT'S CONDITION IS UNSTABLE OR DETERIORATES DURING TRANSPORT, REQUEST ASSISTANCE FROM RECEIVING AREA'S ADVANCED LIFE SUPORT SERVICE. ( Page 19 ) I Revised 20121

Snake Bite or Suspected Snake Bite

1. Remove patient from danger. Assume venomous snake until proven otherwise. 2. Assess ABC's 3. Oxygen 4. Do not transport a live snake 5. Do not spend excessive time in search for snake, but bring snake if possible for identification.

Patient conscious and Alert?

Patient conscious and Alert?

Refer to Decreased Level of Consciousness Algorithm

1. For Extremity bites: 1. For Extremity bites: a. Keep extremity at lower level than heart a. Keep extremity at lower level than heart b. Attempt to mark and monitor swelling b. Attempt to mark and monitor swelling 2. Restrict voluntary patient movement 2. Contact Medical Control

As part of the patient history, determine any allergies to horses or horse serum.

Question regarding pervious doses of antivenim

IF PATIENT'S CONDITION IS UNSTABLE OR DETERIORATES DURING TRANSPORT, REQUEST ASSISTANCE FROM RECEIVING AREA'S ADVANCED LIFE SUPORT SERVICE.

( Page20 )