Dr. Justin Northeim Medical Director ________________________________ Medical Director ________________________________ Chief ________________________________ Protocol Effective Date ________________________________ Department License Expiration Date Table of Contents Section One: General Information!..........................................................7 • Aero-medical Transport Guidelines: 7 • Cessation of Efforts: 7 • Consent/Refusal of Treatment: 8 • Controlled Substances: 11 • Do Not Resuscitate (DNR): 12 • EMS Patient Care Report: 14 • Immobilization Standards: 14 • Infectious Disease: 16 • Inter-Hospital Emergency Transfers: 16 • Mass Casualty Incident: 17 • Medical Control: 21 • Ongoing Skills and Competencies: 21 • Out of City Response: 21 • Restraint Policy: 21 • Resuscitation Guidelines: 23 • Run Review Process: 23 • Scope of Practice: 24 • Standing Orders: 25 • Transportation Guidelines: 25 • Unknown Health Care Professional at Scene: 27 Section Two: Patient Assessment!........................................................29 • Capnography: 29 • Initial Patient Assessment: 30 • History and Physical—Medical Patient: 31 • History and Physical—Trauma Patient: 31 • Intravenous Access/Fluids: 31 • Neurological Assessment: 32 • Patient Movement: 33 • Scene Size-Up: 33 • Triage: 34 • Twelve Lead EKG: 34 *These protocols are not to be copied or distributed without written consent from BEST EMS 1 • Vital Signs: 35 Section Three: Medical Protocols!.........................................................37 • Allergic Reactions (Mild and Moderate): 37 • Allergic Reaction (Severe): 38 • Altered Mental Status: 39 • Carbon Monoxide/Cyanide Poisoning: 40 • Diabetic Emergencies--Hyperglycemia: 42 • Diabetic Emergencies--Hypoglycemia: 43 • Environmental Emergencies--Hyperthermia: 44 • Environmental Emergencies--Hypothermia: 45 • Epistaxis (Nose Bleed): 46 • Hyperkalemia/Renal Dialysis: 47 • Hypertensive Crisis: 48 • Hyperventilation/Anxiety: 49 • Nausea and Vomiting: 50 • Obstetrics: 51 • Obstetrical Delivery: 52 • Obstetrical Complications: 53 • Obstetrics Post Delivery/Neonatal Resuscitation: 54 • Opthalmic Emergencies: 56 • Overdose/Poisoning: 57 • Pain Management: 59 • Pre-eclampsia/Eclampsia: 60 • Psychiatric/Behavioral Emergencies: 61 • Respiratory Distress (Mild and Moderate): 62 • Respiratory Distress (Severe): 63 • Seizures: 64 • Sepsis: 65 • Shock (Non-traumatic): 66 • Snake Bites: 67 • Stroke: 68 • Syncope: 70 • TASER Barb Removal: 71 Section Four: Cardiac Protocols!..........................................................73 • Atrial Fibrillation/Atrial Flutter with Rapid Ventricular Response: 73 • Bradycardia (Symptomatic): 74 • Cardiac Arrest: 75 • Cardiogenic Shock: 77 *These protocols are not to be copied or distributed without written consent from BEST EMS 2 • Chest Pain: 78 • Congestive Heart Failure (CHF): 79 • Hypothermic Protocol after ROSC: 80 • Tachycardia: 81 Section Five: Pediatric Protocols!.........................................................83 • Allergic Reaction (Mild and Moderate) (Pediatric): 84 • Allergic Reaction (Severe) (Pediatric): 85 • Altered Mental Status (Pediatric): 86 • Bradycardia (Pediatric): 87 • Cardiac Arrest (Pediatric): 88 • Diabetic Emergencies--Hyperglycemia (Pediatric): 90 • Diabetic Emergencies--Hypoglycemia (Pediatric): 91 • Environmental Emergencies--Hyperthermia (Pediatric): 92 • Environmental Emergencies--Hypothermia (Pediatric): 93 • Hyperventilation/Anxiety (Pediatric): 94 • Nausea and Vomiting (Pediatric): 95 • Overdose/Poisoning (Pediatric): 96 • Pain Management (Pediatric): 97 • Respiratory Distress (Mild and Moderate) (Pediatric): 98 • Respiratory Distress (Severe) (Pediatric): 99 • Seizures (Pediatric): 100 • Tachycardia (Pediatric): 101 Section Six: Trauma Protocols!...........................................................103 • General Trauma Recommendations: 103 • Amputations: 104 • Burns/Electrical: 105 • Drowning/Near-Drowning: 107 • Head/Spinal Cord Injury: 108 • Musculoskeletal: 109 • Thoracic/Abdominal/Pelvic: 110 • TXA (Tranexamic Acid) Protocol: 111 Section Seven: Skills!...........................................................................113 • AED: 113 • Airway/Breathing: 113 • Bandaging: 114 • Blood Draw: 114 • Bronchodilator Administration: 114 *These protocols are not to be copied or distributed without written consent from BEST EMS 3 • Cardioverson: 114 • Chronic Tracheostomy: 115 • CPAP: 115 • Defibrillation: 116 • Dialysis Catheter Access: 116 • EKG: 117 • Endotracheal Drug Administration: 118 • Endotracheal Intubation: 118 • External Jugular Vein Access: 119 • I-Gel: 119 • Intramuscular Drug Injection: 120 • Intranasal Drug Administration: 120 • Intraosseous Insertion: 121 • Intravenous Drug Administration: 122 • Medi-port Access: 122 • Needle Decompression: 123 • Open Crichothyrotomy: 124 • Oral Gastric Tube Placement: 124 • Pelvic Binding: 125 • Percutaneous Trans-tracheal Ventilation: 126 • Peripheral IV Access: 126 • PICC Line/Central Line Access: 127 • Piggyback Drug Administration: 127 • Rapid Sequence Intubation: 128 • Spinal Immobilization-Seated: 130 • Spinal Immobilization-Supine: 130 • Spinal Immobilization-With Protective Clothing/Devices: 130 • Splinting: 130 • Suctioning: 130 • Tourniquet: 131 • Traction Splinting: 131 • Transcutaneous Pacing: 131 • Umbilical Vein Cannulation: 132 • Vagal Maneuvers: 132 Section Eight: Medications!.................................................................134 • Acetaminophen (Tylenol) 134 • Adenosine (Adenocard) 134 • Albuterol (Proventil) (Ventolin) 134 • Alcaine 134 • Amiodarone (Cordarone) 135 *These protocols are not to be copied or distributed without written consent from BEST EMS 4 • Aspirin 135 • Atropine 135 • Calcium Gluconate/Chloride 135 • Cyanokit (Hydroxocobalamin) 136 • Dextrose 136 • Diltiazem (Cardizem) 136 • Diphenhydramine (Benadryl) 136 • Epinephrine 1:1,000 137 • Epinephrine 1:10,000 137 • Epinephrine (Push Dose Pressor) 137 • Etomidate 137 • Fentanyl 138 • Glucagon 138 • Ipatropium (Atrovent) 138 • Ketamine 138 • Labetalol 138 • Lidocaine 139 • Magnesium Sulfate 139 • Methylprednisolone (Solumedrol) 139 • Midazolam (Versed) 139 • Naloxone (Narcan) 139 • Nitroglycerin 140 • Ondansetron (Zofran) 140 • Oxygen (O2) 140 • Promethazine (Phenergan) 140 • Rocuronium (Zemuron) 140 • Sodium Bicarbonate 141 • Succinylcholine 141 • Tranexamic Acid (TXA) 141 • Vecuronium (Norcuron) 141 *These protocols are not to be copied or distributed without written consent from BEST EMS 5 Section One: General Information *These protocols are not to be copied or distributed without written consent from BEST EMS 6 Section One: General Information Aero-medical Transport Guidelines: 1. The ground ambulance crew may request a scene response by a helicopter air ambulance under the criteria listed below 2. Contact Medical Control for proper disposition if the patient falls outside of the criteria listed in this section. 3. Once an air ambulance is en-route to the scene, only the pilot or medical personnel in attendance with the patient at the scene may cancel the air ambulance response 4. Scene response requests will be reviewed by the Medical Director as part of the EMS quality assurance program Criteria for Aero-Medical Transport: 1. Patient located in remote or off-road area not readily accessible to ground ambulance 2. Ground resources exhausted or exceeded 3. Special environmental conditions which affect potential patient outcome or prohibit ground access to hospital 4. Patients with greater than 20 minute extrication time 5. When ground transport times exceed 45 minutes to an appropriate facility 6. The incident commander or lead paramedic feels that the benefits outweigh the risks Cessation of Efforts: When all of the following circumstances exist in addition to the TOR criteria below, resuscitation efforts may be stopped in the field: 1. Patient must be age > 18, not pregnant, not traumatic and not hypothermic 2. Scene must be safe and situation appropriate 3. TWENTY minutes of ACLS must be performed 4. There must have been successful advanced airway placement (ET tube or I-Gel) 5. There has been no return of pulse, spontaneous respirations, eye opening, motor response, or improvement of neurologic activity 6. If all above exist, then the police/medical examiner should be called according to local protocols 7. Either police, EMS personnel, or medical examiner must stay on scene with the deceased until transported from the scene; do not remove anything from the body NOTES: The purpose behind termination of ACLS in the field is to keep paramedic units in-service for emergencies instead of transporting non-salvageable patients under ACLS. This protocol provides a method for terminating ACLS in hopeless cases. If there are any questions on scene, please call Medical Control. *These protocols are not to be copied or distributed without written consent from BEST EMS 7 Consent/Refusal of Treatment: A. Person: Any person that Emergency Medical Care Personnel encounters, who does not demonstrate any known/suspected illness/injury after an evaluation, may be released B. Patient: • Any individual for whom 911 is activated on their behalf and has a chief complaint or injury • Any individual with an injury or illness • Any individual with a medical or traumatic complaint • Any individual with a new altered level of consciousness • Any individual where EMT/Paramedic suspects injury due to mechanism C. “Incapacitated”: Means lacking the ability, determined by reasonable medical judgment, to