Table of Contents Protocol 1. Universal Patient Protocol 2. Airway Adult 3. Airway Adult Failed 4. Airway Drug Assisted Intubation 5. Airway Pediatric 6. Airway Pediatric Failed 7. Back Pain 8. Behavioral 9. Fever / Infection Control 10. IV Access 11. Pain Control Adult 12. Pain Control Pediatric 13. Spinal Immobilization Clearance 14. Police Custody 15. Abdominal Pain 16. Allergic Reaction 17. Altered Mental Status 18. Asystole 19. Bradycardia 20. Cardiac Arrest 21. Chest Pain 21b. STEMI 22. Dental Problems 23. Epistaxis 24. Hypertension 25. Hypotension 26. Hypothermia – Induced 27. Overdose Toxic Ingestion 28. Post Resuscitation 29. Pulmonary Edema 30. Pulseless Electrical Activity 31. Respiratory Distress 32. Seizure 33. Supraventricular Tachycardia 34. Suspected Stroke 34b. Stroke Destination Determination 35. Syncope 36. Ventricular Fibrillation Pulseless Ventricular Tachycardia 37. Ventricular Tachycardia 38. Vomiting and Diarrhea 39. Childbirth / Labor 40. Newly Born 41. Obstetrical Emergencies 42. Pediatric Bradycardia 43. Pediatric Head Trauma 44. Pediatric Hypotension 45. Pediatric Multiple Trauma 46. Pediatric Pulseless Arrest 47. Pediatric Respiratory Distress 48. Pediatric Seizure 49. Pediatric Supraventricular Tachycardia 50. Bites and Envenomations 51. Burns – Thermal 52. Burns – Chemical and Electrical 53. Drowning 54. Extremity Trauma 55. Adult Head Trauma 56. Hyperthermia 57. Hypothermia 58. Multiple Trauma 59. WMD Nerve Agent 60. Field Triage and Bypass Protocols 2010 LEGEND Indicates a Protocol Indicates a Medication / L E G Treatment E N D Indicates an Intervention Legend Indicates the Minimum Level of F First Responder F B EMT B Provider authorized to perform A Advanced EMT A this task. P Paramedic P The P/M symbol indicates that M Medical Control M the Paramedic may perform the P Paramedic with P intervention only with OnLine Online Medical M Control M Medical Direction. LEGEND Universal Patient Care Protocol Legend Scene Safety F First Responder F Bring all necessary equipment to patient's side B EMT B Demonstrate Professionalism and Courtesy A Advanced EMT A P Paramedic P PPE (Consider Airborne or Droplet if indicated) M Medical Control M Initial assessment Pediatric Assessment Procedure Cardiac Arrest Cardiac Arrest Protocol G Adult Assessment Procedure e n Consider Spinal Immobilization e r (< 12 years old or < 55 Kg defines the pediatric patient) a l P r o t Airway Protocol (Adult or Pediatric) o c o l Vital Signs s F F (Temperature if appropriate) If available, consider Oral Glucose, B Pulse Oximetry B < 60 F 1 to 2 tubes if awake and no risk for F Consider Glucose Measurement aspiration F Consider Supplemental Oxygen F · 50% Dextrose Adult A · 25% Dextrose Pediatric A B Consider 12 Lead ECG B Glucagon if no IV access P Consider Cardiac Monitor P Go to Appropriate Protocol Patient does not fit a protocol? M M Contact Medical Control Pearls · Recommended Exam: Minimal exam if not noted on the specific protocol is vital signs, mental status with GCS, and location of injury or complaint. · Any patient contact which does not result in an EMS transport must have a completed disposition form. · Required vital signs on every patient include blood pressure, pulse, respirations, pain / severity. · Pulse oximetry and temperature documentation is dependent on the specific complaint. · A pediatric patient is defined by <12 years old or <55 Kg. · Timing of transport should be based on patient's clinical condition and the transport policy. · Never hesitate to contact medical control for patient who refuses transport. · Orthostatic vital sign procedure should be performed in situations where volume status is in question. Protocol 1 2010 Airway, Adult Assess ABC's Legend -Respiratory Rate Supplemental F First Responder F Adequate -Effort Oxygen -Adequacy B EMT B Pulse Oximetry A Advanced EMT A P Paramedic P Inadequate M Medical Control M Basic Maneuvers First Obstruction -open airway Unsuccessful -nasal or oral airway Airway: -Bag-valve mask (BVM) Obstruction Procedure G Becomes Successful Direct e Unsuccessful P P n Laryngoscopy e r Long Transport a l or Need to Protect B Continue BVM B P Airway r o t Blind Insertion o B B c Airway Device o l Oral-Tracheal s Intubation 3 Attempts Nasal-Tracheal Failed airway protocol P Intubation P Unsuccessful Post-Intubation, Consider Diazepam, Lorazepam, or Midazolam for sedation If Available, Notify Destination Successful P Consider P M M or Contact MC Gastric Tube Pearls · This protocol is only for use in patients with an Age >12 or >55 Kg. · Capnometry (Color) or capnography is mandatory with all methods of intubation. Document results. · Continuous capnography (EtCO2) should be utilized for the monitoring of all patients with a BIAD or endotracheal tube. · If an effective airway is being maintained by BVM with continuous pulse oximetry values of > 90, it is acceptable to continue with basic airway measures instead of using a BIAD or Intubation. · For the purposes of this protocol a secure airway is when the patient is receiving appropriate oxygenation and ventilation. · An Intubation Attempt is defined as passing the laryngoscope blade or endotracheal tube past the teeth or inserted into the nasal passage. · Ventilatory rate should be 6-10 per minute to maintain a EtCO2 of 35-45. Avoid hyperventilation. · It is strongly encouraged to complete an Airway Evaluation Form with any BIAD or Intubation procedure. · Paramedics should consider using a BIAD if oral-tracheal intubation is unsuccessful. · Maintain C-spine immobilization for patients with suspected spinal injury. · Do not assume hyperventilation is psychogenic - use oxygen, not a paper bag. · Sellick’s and or BURP maneuver should be used to assist with difficult intubations. · Hyperventilation in deteriorating head trauma should only be done to maintain a EtCO2 of 30-35. · Gastric tube placement should be considered in all intubated patients if available. · It is important to secure the endotracheal tube well and consider c-collar to better maintain ETT placement. Protocol 2 2010 Airway, Adult - Failed Legend F First Responder F Two (2) failed intubation attempts by most proficient B EMT B technician on scene or anatomy inconsistent with A Advanced EMT A intubation attempts. NO MORE THAN THREE (3) ATTEMPTS TOTAL P Paramedic P M Medical Control M SPO2 > 90% with B Continue BVM B Yes BVM Ventilation ? No If SPO2 drops < 90% G Facial trauma or or it becomes difficult e swelling ? n to ventilate with BVM e r a l P No Yes r o t o c B Continue BVM B o l s SPO2 > 90% ? No P Surgical Airway P Yes Ventilate at <12 BPM Continue Ventilation with Maintain ETCO2 BIAD between 35 and 45 and SPO2 above 90% Notify Destination M M or Contact MC Pearls · If first intubation attempt fails, make an adjustment and then consider: · Different laryngoscope blade · Gum Elastic Bougie · Different ETT size · Change cricoid pressure · Apply BURP maneuver (Push trachea Back [posterior], Up, and to patient's Right) · Change head positioning · Continuous pulse oximetry should be utilized in all patients with an inadequate respiratory function. · Continuous EtCO2 should be applied to all patients with respiratory failure or to all patients with advanced airways. · Notify Medical Control AS EARLY AS POSSIBLE about the patient's difficult / failed airway. Protocol 3 2010 Airway, Drug Assisted Intubation B Preoxygenate 100% O2 B Legend F First Responder F Ensure adequate IV B B B EMT B Suction equipment A Advanced EMT A P Paramedic P Yes Evidence of Head Injury or Stroke? M Medical Control M P Lidocaine P No P Etomidate P B Cricoid Pressure B G P Succinylcholine P e n e r a P Intubate P l P r o Placement Verified with May Repeat One t P P No M M o Capnography Time c o l s P Restraint Procedure P Consider Diazepam, Lorazepam P P or Midazolam for sedation After 2nd Cycle If Available Consider P P Gastric Tube Consider Long Acting Paralytic P P (e.g. Norcuron) Failed airway protocol M Notify Destination or Contact MC M Pearls · This protocol is only for use in patients with an Age > 12 or > 55 Kg. · Once a patient has been given a paralytic drug, YOU ARE RESPONSIBLE FOR VENTILATIONS! · Items in Red Text are the key performance indicators used to evaluate protocol compliance. An Airway Evaluation Form must be completed on every patient who receives Drug Assisted Intubation. · This procedure will take away the patient’s airway away so you must be sure of your ability to intubate before giving drugs. · Continuous Waveform Capnography and Pulse Oximetry and are required for intubation verification and ongoing patient monitoring · Before administering any paralytic drug, screen for contraindications with a thorough neurologic exam. · If First intubation attempt fails, make an adjustment and try again: · Different laryngoscope blade ● Change head positioning · Different ETT size ● Continuous pulse oximetry should be utilized in all patients. · Change cricoid pressure ● Consider applying BURP maneuver (Back [posterior], Up, and to pt’s Right Pressure) · Divide the workload - ventilate, suction, cricoid pressure, drugs, intubation. · All equipment must be in place and ready for use prior to administering any RSI drugs. · Protect the patient from self extubation when the drugs wear off. Longer acting paralytics may be needed post-intubation. Protocol 4 2010 Airway, Pediatric Assess ABC's Legend -Respiratory Rate Supplemental F First Responder F Adequate Oxygen -Effort B EMT B -Adequacy A Advanced EMT A Pulse Oximetry P Paramedic P Inadequate M Medical Control