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HERMISTON FIRE & EMERGENCY SERVICES

EMS Protocols


i




HERMISTON FIRE
AND EMERGENCY
SERVICES


EMS PROTOCOLS



























HERMISTON FIRE & EMERGENCY SERVICES

EMS Protocols


ii




TABLE OF CONTENTS



TREATMENT

PAGE

General orders

................................
.

1

Allergic Reactions

..........................


2

Altered Mental St
atus

......................

3

Anaphylactic Shock

.......................

31

Asthma

................................
...........

26

Behavioral/Psychiatric

....................


5

Bradycardia

................................
....

10

Burns

................................
..............


6

Burns: Rule of Nines

.......................

8

Cardiac

................................
............


9

Cardiogenic Shock

.........................

33

Cerebrovascular Accidents

............

12

Cincinnati
Stroke Scale

.................

13

Chemical Burns

..............................


7

Chest Pain

................................
.......


9

CHF

................................
...............

28

Coma/Decreased LOC

....................


3

COPD

................................
............

26

Diabetic Emergencie
s

....................

14

Dysrhythmias

................................
.

10

Electrical Burns

..............................


7

Environ. Emergencies

....................

15

Frostbite

................................
.........

15

Glascow Coma Scale

.......................

4

Gynecological Emergencies

..........

17

Heat Emergencies

..........................

16

Intraosseous

Infusion
-

EZ
-
IO

........

18

Nausea

................................
...........

19

Neurological Trauma

.....................

20

OB Emergencies

............................

21

PEA

................................
...............

10

Poisoning

................................
.......

23

Respiratory Emergencies

...............

26

Seizure

................................
...........

29

Shock

................................
.............

31

Tachycardia

................................
...

11

Vent. Fib./Pulseless V
-
Tach.

.........

10

Ventricular Arrhythmias

................

1
1













PROCEDURES

PAGE

Airway
-
E.T. Intubation

....................

34

Airway
-
King
Airway

.......................

35

Airway
-
Cricothyrotomy

................

38

Airway
-
Capnography

....................

39

AED
-

Zoll M
-
Series

......................

40

Blood Draw

................................
...

87

Blood Products Administration

.....

41

Cardiocerebral Resuscitation

.........

44

Childbirth

................................
......

49

Childbirth
-
APGAR

........................

51

Communications

............................

52

CPAP

................................
.............

53

Crime Scene Response

..................

54

Death in the Field

..........................

56

DNR

................................
..............

58

Dopamine In
fusion Chart

..............

6
0

Guidelines
f
or Grieving People

.....

61

HEAR Channel Dial
-
Up

-
Motorola VHF

..............................

64

Helicopter Use
-
Medstar

................

66

Intranasal V
ersed for Seizures

.......

68

Intranasal Pain Management

.........

70

Intraosseous Infusion;
EZ
-
IO

........

72

IV Therapy

................................
....

77

Mass Casualty

...............................

78

Multiple Ambulance Response

......

79

On Scene Physician

.......................

80

Pain Control
................................
...

81

Parkland Formula

............................

7

Patient Refusal

...............................

82

Patient Restraint

............................

86

Pelvic Wrap

................................
...

88

Rapid Sequence Intubation

............

89

RSI Dosages

................................
..

90

Spinal
Immobilization

...................

91

Sports Equipment Removal

...........

92

Staging

................................
...........

94

Taser Barb Removal

......................

95

Thoracentesis

................................
.

96

TCP
-
Zoll M
-
Series

........................

98

Tourniquet Use……………………65

Trauma System Entry

..................

100










MEDICATIONS

PAGE

Medication Classification

.............

103

Medication Inventory

...................

104

Activated Charcoal

.......................

105

Adenosine
................................
.....

106

Albuterol

................................
......

108

Aspirin

................................
..........

109

Atropine

................................
.......

110

Atrovent

................................
.......

112

Dextrose, 50%

..............................

113

Diazepam

................................
.....

114

Diphenhydramine

.........................

116

Dopamine

................................
.....

117

Dopamine Infusion Chart

.............

118

Epinephrine

................................
..

119

Fentanyl

................................
........

121

Furosimide

................................
...

122

Glucagon

................................
......

123

Glucose, Oral

...............................

124

Haldol

................................
...........

125

Hydromorphone

(Dilaudid)

..........

126

Lidocaine

................................
......

127

Magnesium Sulfate
.......................

129

Midazolam

(Versed)………

…..130

Morphine


................................
.....

131

Naloxone

(Narcan)………………133

Nitroglycerin

................................

134

Oxygen

................................
.........

135

Promethazine

(Phenergan)………136

Sodium Bicarb

..............................

137

Succinylcholine

............................

138

Thiamine

................................
......

139

Vecuronium

................................
..

140

Ve
rapamil

................................
.....

141

Zofran(Ondansetron)
…………
.

142


AICD Deactivation………...
……
.143

Scope

of Practice

..........................

146
















HERMISTON FIRE AND EMERG
ENCY SERVICES


EMS Protocols


0

INTRODUCTION TO THE PROTOCOLS



The following protocols are intended to give guidance to the EMTs working under
the auspices of the Hermiston Fire and Emergency Services. They are not intended to
eliminate or discourage consultation with Medical Control,
or

to give authority for
patient

care outside of the State of Oregon EMT scope of practice. Individual EMTs
are expected to know their legal and personal limits. These protocols are also not
intended, nor can they be expected, to cover every conceivable patient condition or
situation t
hat the EMTs may encounter. Individual judgment must be used and if
there is a question the base physician should be contacted before questionable
treatment is instituted.



While the protocols are separated into Basic, Intermediate and Paramedic levels o
f
care, the EMT
-
Intermediate may establish IVs or saline locks as may be outlined in
the Paramedic level care sections.



If treatment is given (or withheld) contrary to these written guidelines, the
exceptions will be documented on the prehospital care re
port.



All patient care and prehospital care reports are subject to review by the
Department’s Supervising Physician, the Hermiston Fire and Emergency Services
EMS Coordinator and others as may be designated by the Supervising Physician. This
review proc
ess is not intended to be punitive, but to insure continuing high
-
quality
patient care.



These protocols will be used in conjunction with the Hermiston Fire and
Emergency Services EMS Policies and Procedures manual and are subject to change
to meet the ne
eds of the department.



As the supervising physician for Hermiston Fire & Emergency Services, I approve
these protocols, pages 1
-
162

dated
February

2011

until
June
2012
and authorize the
EMTs, as members of the Hermiston Fire and Emergency Services Distri
ct, to operate
under them.



________________________ ___________


Bradley Adams, MD




Date


Supervising Physician


HERMISTON FIRE AND EMERGENCY SERVICES



EMS Protocols


0








TREATMENT





























___________________________________________________








HERMISTON FIRE AND EMERGENCY SERVICES



EMS Protocols


1

GENERAL ORDERS FOR ALL PATIENTS


I PRIMARY SURVEY


To
identify and correct life
-
threatening conditions.

A.

Airway
-

Establish level of consciousness. Establish immediate control of the
airway. Identify and correct existing or potential airway obstructions while
protecting C
-
spine in traumatized patients.

B.

Breat
hing
-

Identify and correct existing or potential compromising factors. Begin
artificial or assisted ventilation as indicated. Include a brief chest examination on
trauma patients.

C.

Circulation
-

Begin chest compressions if pulseless. Control active exte
rnal
bleeding.

The order of treatment for bleeding is direct pressure, followed by
tourniquet if needed. Elevation may be helpful. Also consider use of a pressure
point, but evidence has shown collateral circulation will still occur.

D.

Defibrillation
-

Def
ibrillate if appropriate

E.

Disability
-

Determine gross neurological function.

F.

Expose
-

Disrobe patients as necessary to adequately assess and treat. Specifically
examine the head, neck, chest and abdomen for life
-
threatening injuries,
conditions, etc.


II

SECONDARY SURVEY

A.

Perform a head
-
to
-
toe assessment. Obtain and record vital signs including pulse,
blood pressure, respiration, skin color, capillary refill, Glasgow coma scale.

B.

Obtain pertinent medical and event history from patient, family, or bystander
s.

C.

Repeat vital signs as indicated by patient condition. Repeat at least LOC, blood
pressure and pulse after medication administration.


III TREATMENT/RESUSCITATION

A.

Treat all emergent problems in order of priority and according to these protocols.

B.

Reassure the patient and keep him/her informed of treatment.


IV PERSONAL PROTECTIVE EQUIPMENT

A.

Gloves will be worn when there may be contact with the patient's bodily fluids.
See the
Infection Control Pol
icy.

B.

Eye protection will be worn when there is a reasonable possibility of exposure to
airborne fluids.

C.

Respiratory protection will be worn when there is the reasonable possibility of
exposure to airborne contaminants.


IV TRANSPORT


All patients should b
e evaluated, appropriately treated, and prepared for transport without
undue delay. While stabilization of medical emergencies should be attempted if possible
before transport, on
-
scene time for major trauma patients should be kept to a minimum,
preferabl
y less than 10 minutes, unless heavy extrication is required. If extended on
-
scene
time is required, keep medical control informed periodically.

HERMISTON FIRE AND EMERGENCY SERVICES



EMS Protocols


2


ALLERGIC REACTIONS



Allergic reactions may be caused by a variety of agents. The
intensity of the reaction can
range from minimal swelling to anaphylaxis and cardiovascular collapse. Management
should be based upon the rapidity of the appearance and the severity of the reaction.


SIGNS/SYMPTOMS OF ALLERGIC REACTIONS


May include: hive
s, dyspnea, swelling around mouth, face and/or tongue, hypotension,
weak rapid pulse, flushed skin, tightness in the chest and cough.



~~~~~~~~~~~~~~~~~~~~~~~~EMT BASIC CARE~~~~~~~~~~~~~~~~~~~~~~~


A.

Keep patient calm and provide reassurance that appropr
iate care is underway.


B.

Administer high flow
oxygen

for respiratory distress; provide ventilatory assistance
as needed.


C.

In the case of moderate to severe anaphylaxis give:




Epinephrine

1:1,000

SQ, 0.3
-
0.5 mg (0.3
-
0.5 cc);

o

pediatric dose 0.01 mg/kg (0.01 cc/kg). Adult and pediatric dosage
may be repeated after 10 minutes PRN. Contact Medical Control.


D.

Continue appropriate respiratory and cardiac support.



~~~~~~~~~~~~~~EMT INTERMEDIATE
CARE~~~~~~~~~~~~~~

See Respiratory Distress Protocol



~~~~~~~~~~~~~~~~~~~EMT PARAMEDIC CARE~~~~~~~~~~~~~~~~~~~~~


E.

If respiratory distress or stridor is present, consider intubation early.


F.

Start
IV

Lactated Ringers if reaction severe; treat hypotension with fluid bolus
initially.


G.

If the reaction is severe, administer:





Epinephrine

1:10,000 may be administered IV at 5 minute intervals as
needed. The adult dose is 0.5
-
1.0 mg (5.0
-
10.0 cc)

o


pediatric dose is 0.01 mg/kg (0.1 cc/kg). Contact medical control.


H.

Consider
Benadryl

25
-
50 mg IM/IV.



HERMISTON FIRE AND EMERGENCY SERVICES



EMS Protocols


3

ALTERED MENTAL STATUS



This protocol defines the management of the emergency medical patient who has an
altered mental status, i.e., decreased LOC, confusion, disorientation, & coma. Care of the
trauma patient is outlined in the ap
propriate trauma protocol.


I MANAGEMENT


A.

Assessment
-

ABC's. Use
GLASGOW COMA SCALE

to categorize level of
consciousness.
C
HECK FOR
M
EDIC
-
A
LERT TAG
.


B.

Differential diagnosis:

1.

Cardiac event

2.

Hyperglycemia

3.

Hypoglycemia

4.

Hyperthermia

5.

Hypothermia

6.

CVA


7. Trauma


8. Postictal (2
o

to seizure?)


9. Shock

10. Drug overdose

11. Other


C.

Therapy


~~~~~~~~~~~~~~~~~~~~~~~~EMT BASIC CARE~~~~~~~~~~~~~~~~~~~~~~~



1.

Airway management has priority. Insert an
oropharyngeal or nasopharyngeal
airway and provide ventilatory assistance as appropriate. Have suction
immediately available. All patients with altered mental status should receive
supplemental oxygen, preferably via non
-
rebreather mask or assisted venti
lation.



2.

Determine blood glucose levels (BGL) if time and patient condition allows.



3.

If a CVA is not suspected and if the BGL is < 60, give
glucose paste

via the
buccal membranes. See the
CVA
protocol
.



4.

If aggressive airway management is not required, place the unconscious patient
on the side in the recovery position.



~~~~~~~~~~~~~~~~~~~~EMT INTERMEDIATE CARE~~~~~~~~~~~~~~~~~~~~


Per Oregon EMT
-
Intermediate protocols


~~~~~~~~~~~~~~~~~~~~
~~EMT PARAMEDIC CARE~~~~~~~~~~~~~~~~~~~~~



5.

Draw a blood sample if time and patient condition allows.



6.

Establish an
IV

of NS or LR as appropriate to assessment.



7.

Administer 100 mg
thiamin
e

IM/IV if history or presentation indicates either
ETOH abuse or malnutrition (prior to glucose administration).



8.

If a CVA is not suspected and if glucose level < 60:




Administer
D
50

25 gm IV push in securely patent IV. Repeat
once after 10
minutes if needed.




If unable to obtain peripheral IV:

o

Glucagon

1 mg IM. Note precautions in
CVA Protocol
.



9.

If no response to above treatment or if respirations are depressed, administer
Narcan

0.4
-
2.0 mg IV
/IM/IN
. Consider restraining the patient before
administration of
Naloxone
.

10.

If glucose level is >

300 and there is not evidence of pulmonary edema consider a
fluid bolus.

11.

Monitor cardiac rhythm and vital signs.

HERMISTON FIRE AND EMERGENCY SERVICES



EMS Protocols


4

ALTERED MENTAL STATUS: GLASCOW COMA SCALE



ACTIVITY

SCORE



Eye Opening



None

1 = Even to supra
-
orbital
pressure

To pain

2 = Pain from sternum/limb/supra
-
orbital pressure

To speech

3 = Non
-
specific response, not necessarily to command

Spontaneous

4 = Eyes open, not necessarily aware


Motor Response



None

1 = To any pain; limbs remain flaccid

Extension

2 = Shoulder adducted and shoulder and forearm internally
rotated

Flexor response

3 = Withdrawal response or assumption of hemiplegic posture

Withdrawal

4 = Arm withdraws to pain, shoulder abducts

Localizes pain

5 = Arm attempts to remove supra
-
orbi
tal/chest pressure

Obeys commands

6 = Follows simple commands


Verbal Response



None

1 = No verbalization of any type

Incomprehensible

2 = Moans/groans, no speech

Inappropriate

3 = Intelligible, no sustained sentences

Confused

4 = Converses but
confused, disoriented

Oriented

5 = Converses and oriented




TOTAL (3

15):


HERMISTON FIRE AND EMERGENCY SERVICES



EMS Protocols


5

BEHAVIORAL/PSYCHIATRIC



ALWAYS PROTECT YOURSELF AND YOUR CREW

when managing the patient
who is emotionally unstable and/or displays behavior that may

be dangerous to himself
and/or others. Consider
Staging

protocol.



~~~~~~~~~~~~~~~~~~~~~~~~EMT BASIC CARE~~~~~~~~~~~~~~~~~~~~~


A.

Do not spend time attempting an extensive psychiatric evaluation at the scene.


B.

The major
responsibility of EMS personnel is to:



1.

Establish that the patient is a threat to himself or others.



2.

Quickly assess and provide appropriate treatment for any associated illness,
injury, poisoning, or underlying medical conditions.



3.

Transport t
he patient as quickly as possible to the appropriate facility without
causing further emotional or physical harm to the patient.

D.

If the patient refuses to be treated or transported, contact dispatch for law
enforcement and mental health assistance.



The pa
tient that chooses to hurt themselves intentionally or
attempt

suicide is
not a candidate for pt. refusal. Contact medical control for further
instructions.


D.

Always request law enforcement for assistance with any patient who displays violent
or suicidal

behavior.



~~~~~~~~~~~~~~~~~~~~~~EMT INTERMEDIATE CARE~~~~~~~~~~~~~~~~~~~~~

Per Above EMT
-
Basic care and physical restraint procedures



~~~~~~~~~~~~~~~~~~~~~~EMT PARAMEDIC CARE~~~~~~~~~~~~~~~~~~~~~


E.

Additional paramedic care may be considered:

1.

Adult
patients suffering from emotional
upset or acute anxiety

may be given



Valium
, 2
-
5 mg IV or IM, or



Versed
, 1
-
2.5 mg IV over 2 minutes. (not recommended for pediatric
behavior control)

2.

Adult patients who are exhibiting
uncontrollable behavior

not suspected to be
due to head injury may be given:



Haldol

2.5


5.0 mg IV or IM

NOTE: Haldol can lower the seizure threshold in patients at risk for seizures (ETOH abuse,

epileptics, stimulant use, etc.)
Consider administration of

valium or versed concurrently
with these patients.



Versed

1
-
2.5 mg IV
/IN

slowly over 2 minutes, titrated to desired effect.
Not recommended for pediatric behavior co
ntrol.

OR:



Valium

2
-
5 mg IV or IM

PHYSICAL RESTRAINTS


Physical restraints should be used only as a last resort and only if there is some indication
that transporting/treating the patient without physical restraints would likely be a danger to
the patient or the transporting EMTs.


SEE PATIENT RESTRAINT PROCEDURES

HERMISTON FIRE AND EMERGENCY SERVICES



EMS Protocols


6

BURNS



Defined here is the prehospital evaluation and management of major burns. Remember
that age (infants and the elderly), underlying medical conditions, smoke inhalation and
associated trauma can complicate the condition and care of the acutely burned individ
ual.
Evaluation of all major burns should include using the
"Rule of Nines"

to assess the extent
of the burns.


I GENERAL BURN MANAGEMENT


~~~~~~~~~~~~~~~~~~~~~~~~EMT BASIC CARE~~~~~~~~~~~~~~~~~~~~~~~


A.GENERAL



1.

STO
P THE BURNING!




a.

Remove the patient from the source of the burn if you can do so safely.




b.

Remove smoldering or hot clothing/bedding and restricting jewelry if it can
be done without removing burned skin.




c.

In the case of an acid/chemical burn,

flush with water, NS or L.R. Note:
Alkali burns (cement, anhydrous ammonia, lye) require flushing with large
volumes of water until all the feeling of "soapiness" is gone.



2.

Wrap the disrobed patient in
sterile burn sheets
. Remember to wrap burned
lim
bs and digits separately so that tissue doesn't become adherent.



3.

DO NOT!!!




-
Do not apply ice directly to the skin




-
Do not apply ice if burned Body Surface Area (BSA) > 10%.




-
Do not break blisters




-
Do not remove material that firmly adheres

to burned skin.




-
Do not use ointments, creams or sprays on any burn that will require
further medical treatment.



4.

Conserve patient's body warmth with sheet/blankets





(avoid cold/ice for large area burns).



5.

Elevate burned extremities.



6.

Give nothing by mouth (NPO).



7.

LOOK FOR ADDITIONAL TRAUMA! Injuries should be treated using other
appropriate protocols.


B. AIRWAY MANAGEMENT



1.

Follow respiratory protocol



2.

Administer
oxygen

to any burned patient with
possible respiratory involvement.

3.

Give 100% oxygen to all suspected carbon monoxide poisonings. Continually reassess
the patient for signs of respiratory distress and treat early.




Pulse oximeter readings may be falsely high in CO poisonings.



4.

Evaluate risk factors for airway compromise. ALL PATIENTS IN THIS
CATEGORY RECEIVE HIGH FLOW O
2
.




a)

Closed space fire




b)

Burns to face or singed nasal hairs/blackened rim of nares




c)

Hoarseness/inspiratory stridor




d)

Carbon deposits on tongue/
oropharynx

HERMISTON FIRE AND EMERGENCY SERVICES



EMS Protocols


7

BURNS (continued)



~~~~~~~~~~~~~~~~~~~~~~EMT PARAMEDIC CARE~~~~~~~~~~~~~~~~~~~~~


C.

AIRWAY MANAGEMENT


Consider
intubation

early in the high risk patients.


D.

FLUID RESUSCITATION



Start a minimum of one large bore
IV

line. Start the line as far from the burn as
possible, but if necessary, the IV may be started through the burned tissue. IV fluid of
choice is
Lactated Ringers
. Run the IV wide open if pul
monary edema is not
present; monitor lung sounds.

PARKLAND FORMULA:




The Parkland formula is used during the first 24 hours of fluid
resuscitation and is as follows:

Amount of IV fluid in first 24 hours = weight in kg X 4
ml

X %
BSA burned



Administer one half of the calculated fluid during the first 8 hours

and one half of the calculated fluid in the subsequent 16 hours. The
starting time is considered to be the time at which the burn occurred
and not the time at which medica
l care is initiated.


E.

Cardiac monitoring


F.

ADDITIONAL CARE
--



If there is no respiratory compromise, pain relief may be managed with:




Morphine

Sulfate

2
-
5 mg IV given every 3
-
5 minutes or




Hydromorphone

(Dilaudid) 2
-
4 mg IM or IV over 3
-
5 minutes every 3
-
4
hours titrated to pain relief. Not recommended for prehospital use in
pediatrics.


*** MONITOR RESPIRATORY STATUS CLOSELY ***


II
ELECTRI
CAL BURNS
--
USE CAUTION, PROTECT YOURSELF


A.

Electrical burns are frequently more severe than they appear; remember that deep
injury is predominant.


B.

Patients with electrical burns have a high risk for spinal injury; manage accordingly.


C.

ALL electric
al burn patients should have cardiac monitoring and IV, NS for drug
route.


III
CHEMICAL BURNS
--
USE CAUTION, PROTECT YOURSELF


A.

Unless specifically advised otherwise by medical control or poison control, all
chemicals should be w
ashed off with copious amounts of water.


B.

Dry powder chemicals should be brushed off first, then flushed.


C.

Caustic burns of the eye should be IMMEDIATELY rinsed WITH THE CLEANEST
WATER AVAILABLE. Rinsing with normal saline should continue for at
least 15
minutes prior to and during transport.


D.

If available, get MSDS for industrial chemicals; follow MSDS recommended
procedure.



E.

Contact poison control at
1
-
800
-
222
-
1222

HERMISTON FIRE AND EMERGENCY SERVICES



EMS Protocols


8

BURNS: RULE OF NINES

Adult



















Adolescent Pediatric








Adolescent



Adolescent




Infant













HERMISTON FIRE AND EMERGENCY SERVICES



EMS Protocols


9

CARDIAC


I CHEST PAIN



Non
-
traumatic chest pain should be treated as cardiac in origin until proven otherwise.
Chest pain associated with shortness of breath, diaphoresis, vomiting, previous cardiac
disease, and/or hypotension ha
s a frequent association with myocardial ischemia.


Myocardial infarction should be considered in any patient exhibiting signs/symptoms
(chest pain associated with shortness of breath, diaphoresis, vomiting, previous cardiac
disease, and/or hypotension) an
d history consistent with myocardial infarction.

~~~~~~~~~~~~~~~~~~~~~~~~EMT BASIC CARE~~~~~~~~~~~~~~~~~~~~~~~

G.

Position of comfort depending on the patient's status

H.

Oxygen; beginning with 2
-
4 l/m via nasal cannula and increasing flow and delivery
system a
s appropriate. Consider additional oxygen by NRB if the patient is in
respiratory distress, has an irregular pulse, a decreased level of consciousness or
oxygen saturation < 90.

I.

Oral administration (chewing) of 2
-
4 (81 mg each) chewable baby aspirin (ASA)

(162
-
324 mg) if the patient has no allergies to ASA or NSAIDS.
This is
recommended even if the pt. takes daily aspirin.

J.

May complete a TPA checklist provided by GSMC for suspected MI patients.

K.

EMT
-
Basics may assist a patient with his/her own Nitroglyceri
n under the following
circumstances:

L.

The Nitroglycerin is prescribed to the patient by his/her own doctor. The Basic
can
not

give a patient Nitroglycerin from the ambulance or another person’s supply.

M.

The patient has taken less than 3 Nitroglycerin with t
his episode of chest pain.

N.

The patient is conscious and alert

O.

Blood pressure must be >/= 90 systolic


If the chest pain persists and the above circumstances do not change, the EMT may
assist the patient with up to a total of 3
Nitroglycerin

at 5 minute intervals counting
any the patient took prior to EMS arrival.



~~~~~~~~~~~~~~~~~~EMT INTERMEDIATE CARE~~~~~~~~~~~~~~~~~~~~

Above EMT
-
Basic care and Oregon EMT
-
Intermediate protocols

^^^Analgesics only with individual written

authorization from HFES^^^



~~~~~~~~~~~~~~~~~~~~EMT PARAMEDIC CARE~~~~~~~~~~~~~~~~~~~~~

G.

Cardiac monitor. Perform 12
-
Lead ECG before treatment to record baseline ECG.

H.

IV NS TKO or saline lock



Nitroglycerin

0.4 mg SL every 3
-
5 minutes as needed for pain relief as long as
systolic BP >/= 9
0, and
systolic blood pressure has not drop
p
ed more than 30
mmHg from baseline
.

Pediatric use in the field is not recommended. Observe the
patient closely for hypotension.

If the pain is not relieved with 2
-
3 nitroglycerine
doses, consider additional measu
r
es below.

J.

Additional treatment for adults may include:




-
Morphine
; 2
-
5 mg IV bolus for pain relief and/or pulmonary edema




-
Lasix
; 40
-
80 mg IV bolus for pulmonary edema




-
Dopamine
; 2
-
10 mcg/kg/min IV infusion for hypotension
per shock protocol
.

HERMISTON FIRE AND EMERGENCY SERVICES



EMS Protocols


10

CARDIAC (Continued)


III
CARDIAC DYSRHYTHMIAS


Treatment of cardiac dysrhythmias should be based on the patient's condition, not the
monitor. A stable patient does not necessarily need immediate treatment. Treat per current
AHA Advanced Cardiac Life Support (ACLS)
and CCR
protoco
ls. In addition to the Chest
Pain protocol above as indicated, treatment of patients with suspected/documented
dysrhythmias should include:


A.

GENERAL MANAGEMENT


~~~~~~~~~~~~~~~~~~~~~~~~EMT BASIC CARE~~~~~~~~~~~~~~~~~~~~~~~

1.

Administer supplemental oxygen

per nasal cannula at 2
-
4 liters/minute. Consider
additional oxygen by mask if the patient is in respiratory distress, has an irregular
pulse, a decreased level of consciousness or oxygen saturation < 90%.



2.

EMT
-
Basics may place the
AED/SAED

using defibrillation leads on the patient
who is unconscious or pulseless. Specific treatment will follow the AED/SAED
protocols.


~~~~~~~~~~~~~~~~~EMT INTERMEDIATE CARE~~~~~~~~~~~~~~~~~~~~


EMT
-
Intermediates may treat cardia
c dysrhythmias as outlined in the Oregon State EMT
-
Intermediate protocols.

~~~~~~~~~~~~~~~~~~~EMT PARAMEDIC CARE~~~~~~~~~~~~~~~~~~~~~



1.

Cardiac monitor



2.

IV NS TKO or saline lock

B.

VENTRICULAR FIBRILLATION/PULSELESS VENTRICLAR
TACHYCARDIA

1.

Follow CCR guidelines for cardiac origin arrest in patients 17 years and older.

2.

All other arrest cases follow current AHA guidelines.


C.

PULSELESS ELECTRICAL ACTIVITY (PEA)



1.

CPR as indicated with intubation



2.

Intubate and confirm placement visually and by auscultation and ETCO2
monitor.



3.

Attempt to identify and treat the cause



4.

Follow CCR guidelines for cardiac origin arrest in patients 17 years and older.



5.

All other arrest cases follow current AHA

guidelines.


D.

BRADYCARDIA (Symptomatic)



1.

Atropine

0.5mg, IV bolus; may be repeated q 5 minute intervals to a maximum
of 0.04 mg/kg (about 3.0 mg total)

o

Pediatric dose is 0.02 mg/kg bolus.



2.

Con
tinue to follow the ACLS Bradycardia algorithm; consider TCP early.



E.

VENTRICULAR ECTOPY

-

in setting of MI



1.

Consider
Atropine

if bradycardia is present



2.

Consider
Lidocaine

(0.5 mg/kg) in case of 'high risk' PVCs (R on T, PVCs >
6/min, couplets, runs of V. Tach, multi
-
formed). Treat bradycardia first if
present.

HERMISTON FIRE AND EMERGENCY SERVICES



EMS Protocols


11

CARDIAC (Continued)



F.

TACHYCARDIA
--
A patient wit
h tachycardia (rate greater than 100) will be
considered unstable if showing signs/symptoms of chest pain, shortness of breath,
decreased level of consciousness, hypotension, shock, pulmonary congestion, CHF or
AMI if the signs/symptoms are related to the
tachycardia.




Stable
--
(Symptomatic)



1.

Establish a normal saline IV before proceeding.



2.

Have patient attempt valsalva maneuver





3.

Continue to follow the ACLS Tachycardia Algorithm as applicable.




Unstable
--
(symptoms must be related to the
tachycardia)



1.

If the heart rate is > 150, prepare for immediate cardioversion. See the ACLS
Electrical Cardioversion Algorithm. (Immediate cardioversion rarely needed for
rates < 150.)



2.

A brief trial of medication based on the dysrhythmia may be
attempted.



3.

Continue to follow the ACLS Tachycardia Algorithm as applicable.



AFib/SVT:
Follow narrow complex tachycardia algorithm.



Adenosine 6 mg IVP



Adenosine 12 mg IVP; repeat once if unsuccessful



Verapamil



Initial dose: 2.5
-

5 mg slow IVP over
1
-
2 minutes.



Consider 1
-
3 mg in elderly patients)



Repeat dose: 5
-
10 mg in 30 minutes or 5 mg q 15 minutes until
desired response; max. 30 mg dose.



NOTE:

-
Adenosine must be immediately flushed with 20cc or more IV fluid
via close proximity syringe due to
its short half
-
life.

-
Adenosine administration may slow the rate enough to reveal an
underlying rhythm such as A
-
Flutter.




IV
CARDIAC ARREST
--
Begin CPR and follow the appropriate AHA
or CCR
guidelines
for available level of care. EMT
-
Intermediates may
follow the appropriate Oregon State
EMT
-
Intermediate

protocol; Cardiac Arrest, Shockable Rhythm or Cardiac Arrest, Non
-
shockable Rhythm.


V
EMT
-
INTERMEDIATE PROTOCOL
--
As well as other EMT
-
Intermediate level
interventions, EMT
-
Intermediates may place the EK
G monitoring electrodes and leads as
directed in EMT
-
Intermediate protocols.

HERMISTON FIRE AND EMERGENCY SERVICES



EMS Protocols


12

CEREBROVASCULAR ACCIDENT (CVA)



Cerebrovascular accidents (CVA or stroke) are relatively common neurovascular events
that can present with a range of ne
urological signs and symptoms. Time of onset is a critical
piece of information to obtain.


~~~~~~~~~~~~~~~~~~~~~~~~EMT BASIC CARE~~~~~~~~~~~~~~~~~~~~~~~


A.

Perform primary survey.


B.

Protect airway as loss of gag reflex is common. If the LOC is decreased and injuries
don't contraindicate it, place patient on his/her side in the recovery position. Suction
as required.


C.

Administer oxygen per nasal cannula 2
-
4 L/min. Increase oxygen
delivery as
indicated by patient condition.


D.

Assist ventilation as necessary


E.

Maintain verbal contact and be reassuring. Although the patient may not be
answering, or may appear confused, he/she may comprehend what is happening.


F.

Protect affected
limbs from injury.


G.

Allow patient to seek position of comfort if able.


H.

Check blood glucose via finger stick. If BG level is < 60, consult with Medical
Control for permission to administer oral glucose in the CVA patient.


I.

Note and document chang
es in the patient's level of conscious and vital signs.


J.

Try to ascertain the time of acute change in neurologic changes.


~~~~~~~~~~~~~~~~~~~~EMT INTERMEDIATE CARE~~~~~~~~~~~~~~~~~~~~

K.

Consider drawing a blood sample while starting an IV.



See Altere
d Mental Status Protocol


~~~~~~~~~~~~~~~~~~~~~~EMT PARAMEDIC CARE~~~~~~~~~~~~~~~~~~~~~


M.

Monitor cardiac rhythm.


N.

Consider drawing a blood sample.


O.

Start an IV of LR, TKO or a saline lock.


P. Perform blood glucose check if time and patient
condition allows



If the blood glucose is < 60, Consider:



a.

Administration of 25 gm


Dextrose
, (D
50
W)

IV bolus but only if blood glucose
check can be done.
It is not appropriate to administer glucose to a possible
CVA patient wi
thout confirming significantly low blood glucose
. Contact
medical control if CVA is suspected.



b.

Administration of 100 mg
Thiamine

IM/IV if history or presentation indicates
either a history of ETOH abuse or malnutrition.


Q.

If the patient's condition does not improve, or improves but he/she does not become
fully conscious, the dextrose may be repeated after 10 minutes if a second glucose
level test still shows the patient to be hypoglycemic. Contact medical control.


R.

Orally intubate as needed to protect airway. No nasal intubation if patient is candidate
for thrombolytic therapy.


S.

If decreased LOC, consider Altered Mental Status protocol.

NOTE: Assessment shall include the Cincinnati Pre
-
hospital Stroke Assessment S
cale

HERMISTON FIRE AND EMERGENCY SERVICES



EMS Protocols


13

CINCINNATI PREHOSPITAL STROKE SCALE


Facial Droop:
Have the Pt. show teeth or smile

Normal: Both sides of face move equally

Abnormal: One side of face does not move at all

Arm Drift:
Pt. closes eyes and holds both arms out

Normal: Both arms move equally or not at all

Abnormal: One arm drifts compared to the other

Speech:
Have the pt. say "you can

t teach an old dog new tricks"


Normal: Patient uses correct words with no slurring

Abnormal: Slurred or inappropriate words or

mute

NOTES:



Patients with one of the three abnormalities, as a
new

event, has a 72%
probability of an ischemic stroke




If all three abnormalities is present, there is an 85% or more probability of
an acute stroke



Other findings such as grips may be
useful


HERMISTON FIRE & EMERGENCY SERVICES


EMS Protocols
14

DIABETIC EMERGENCIES



The EMT should do a blood glucose level (BGL) analysis before beginning treatment if time and
patient condition allows.
In general, the "home" normal

range for most people is about 80 to 120
mg/dL.


I GENERAL
--

ALL EMT LEVELS


A.

Administer oxygen: 2
-
4 l/m via nasal cannula, increasing delivery as appropriate.


B.

If the patient is unconscious but does not require aggressive airway care or ventilati
on during
transport, place him/her in the coma position; left side, knees drawn up, left arm under head.
If the patient is conscious, transport in position of comfort.


C.

Check the patient's blood glucose level via finger stick.


II
HYPERGLYCEMIA
--
TREATMENT (BGL > 120 AND SYMPTOMATIC)


~~~~~~~~~~~~~~~~~~~~~~EMT INTERMEDIATE CARE~~~~~~~~~~~~~~~~~~~~~


A.

Draw a blood sample and start a large bore IV, normal saline; run wide open unless
contraindicated by CHF, etc.


B.

Treat other medic
al/trauma conditions per protocol.


III HYPOGLYCEMIA
--
TREATMENT (BGL < 60)


~~~~~~~~~~~~~~~~~~~~~~~~EMT BASIC CARE~~~~~~~~~~~~~~~~~~~~~~


A.

If the patient is fully conscious, give sugar, milk or oral glucose by mouth. If the patient is
not fully conscio
us, place him/her in the coma position and, being careful not to obstruct the
patient's airway, place table sugar or oral glucose (15gms) in the patient’s cheek to be
absorbed via the buccal membranes.


~~~~~~~~~~~~~~~~~~~~EMT INTERMEDIATE
CARE~~~~~~~~~~~~~~~~~~~~


Per Oregon EMT Intermediate protocols


~~~~~~~~~~~~~~~~~~~~~~EMT PARAMEDIC CARE~~~~~~~~~~~~~~~~~~~~~


B.

Consider drawing a blood sample and start an IV, normal saline, TKO.


C.

Administer 100 mg
Thiamine

IM/IV if history or presentation indicates either ETOH abuse
or malnutrition.


D.

Administer
Dextrose




Adults; 25 gm (D
50
W), IV



Pediatric; dilute
(D
50
W)
1:1 with normal saline to make a 25% solution and give 0.5
-
1.0
gm/kg (
1
-
2 ml/kg) slow IV bolus




If the patient's condition does not improve, or improves but he/she does not become fully
conscious, the dextrose may be repeated after 10 minutes if a second glucose level test still shows
the patient to be hypoglycemic. Cont
act medical control.

NOTE
:
Concentrated glucose is to be
administered in a patent, free
-
flowing IV
.

It is not appropriate to administer glucose to a
possible CVA patient without confirming significantly low blood glucose
.
Contact medical
control if CVA i
s suspected.

E.

If an IV cannot be established



Administer 1 mg
Glucagon

IM (not for pediatric use).

NOTES:


A.

If the EMT is unable to determine whether or not the patient is hypo
-

or hyperglycemic, the
hypoglycemia protocol
should be followed.

HERMISTON FIRE & EMERGENCY SERVICES


EMS Protocols
15


B.

If pt. becomes alert and refuses transport, advise them to see a physician & document well.

HERMISTON FIRE & EMERGENCY SERVICES


EMS Protocols
16

ENVIRONMENTAL EMERGENCIES


I
COLD INJURIES


A.

Frostbite



1.

Do not rub affected areas



2.

Protect frostbitten areas from further damage.



3.

Do not allow re
-
warming of affected tissue if there is any chance for re
-
freezing. Major
extremity frostbite should be re
-
warmed only at the hospital.


B.

Hypothermia

**THE SEVERE HYPOTHERMIA PATIENT

MUST BE HANDLED VERY GENTLY**



~~~~~~~~~~~~~~~~~~~~~~~~EMT BASIC CARE~~~~~~~~~~~~~~~~~~~~~~~



1.

Perform primary survey and include temperature assessment using hypothermic
thermometer if possible.



2.

Provide supplemental oxygen via non
-
rebreather mas
k or assisted ventilations.



3.

Patient may appear to be lifeless and a pulse may not be felt. If ALS CARE personnel
are immediately available, establish EKG monitoring before beginning chest
compressions. Support ventilation as necessary.



4.

Begin pa
ssive external re
-
warming.




-

remove wet clothing




-

dry the patient well




-

wrap patient in warm, dry blankets




-

give warmed, humidified oxygen by mask if available



~~~~~~~~~~~~~~~~~~~~~~EMT INTERMEDIATE CARE~~~~~~~~~~~~~~~~~~~~~



5.

Start IV

of Normal Saline (no Lactated Ringers on Hypothermia) and run wide open
unless pulmonary edema is present.



~~~~~~~~~~~~~~~~~~~~~~EMT PARAMEDIC CARE~~~~~~~~~~~~~~~~~~~~~



6.

Intubate only if LOC is decreased with GCS < 8
AND

the patient can not be adequately
ventilated by other means. Intubation of the severely hypothermic patient may
precipitate ventricular fibrillation.



7.

Apply cardiac monitor.




a.

DO NOT INITIATE CHEST COMPRESSIONS IF THE EKG RHYTHM IS
LIFE
-
SUSTAIN
ING EVEN IF THERE IS NO PULSE.




b.

DEFIBRILLATION MAY BE CONTRAINDICATED IN THE SEVERELY
HYPO
-
THERMIC PATIENT. CONTACT MEDICAL CONTROL.



8.

Start IV of NS and run wide open unless pulmonary edema is present.

HERMISTON FIRE & EMERGENCY SERVICES


EMS Protocols
17

ENVIRONMENTAL EMERGENCIES (Continued)


II

HEAT INJURIES


A.

Heat Exhaustion/Heat Cramps


~~~~~~~~~~~~~~~~~~~~~~~~EMT BASIC CARE~~~~~~~~~~~~~~~~~~~~~~~



1.

Perform primary survey and include temperature assessment if possible.



2.

Move patient to cool environment. Remove
excess clothing and apply cool compresses
to extremities and forehead. Open windows, fan patient, etc. Do not cool the patient to
the point of shivering.



3.

Give cool liquids orally if the patient is fully conscious and alert.



~~~~~~~~~~~~~~~~~~~~~~E
MT INTERMEDIATE CARE~~~~~~~~~~~~~~~~~~~~~



4.

If patient is unable to take liquids orally or if signs of shock are present, start IV of
Lactated Ringers and run wide open. Monitor the patient for signs of pulmonary edema.



~~~~~~~~~~~~~~~~~~~~~~EMT PARA
MEDIC CARE~~~~~~~~~~~~~~~~~~~~~



5.

Apply cardiac monitor.



6.

If patient is unable to take liquids orally or if signs of shock are present, start IV of
Lactated Ringers and run wide open. Monitor the patient for signs of pulmonary edema.



B.

Heat Stro
ke


~~~~~~~~~~~~~~~~~~~~~~~~EMT BASIC CARE~~~~~~~~~~~~~~~~~~~~~~~



1.

Perform primary survey and include a temperature assessment if possible.



2.

Manage airway as needed. Give
oxygen

at 10
-
15 l/m by NRB mask. Consider manual
ventilation and intubation if indicated by patient’s condition.



3.

Move patient to cool environment. Remove excess clothing. Begin aggressive cooling
measures including covering the patient with wet sheets, uti
lizing fans or open windows
to circulate air and applying wrapped cold packs to axilla and groin.



4.

If unconscious, treat per
Coma Protocol
.



~~~~~~~~~~~~~~~~~~~~~~EMT INTERMEDIATE CARE~~~~~~~~~~~~~~~~~~~~~



5.

Start IV
of Lactated Ringers or Normal Saline.



~~~~~~~~~~~~~~~~~~~~~~EMT PARAMEDIC CARE~~~~~~~~~~~~~~~~~~~~~



6.

Apply cardiac monitor.



7.

Start IV of Lactated Ringers or Normal Saline.



8.

Treat seizures with
Valium

or
Versed

HERMISTON FIRE & EMERGENCY SERVICES


EMS Protocols
18

GYNECOLOGICAL EMERGENCIES



Gynecological emergencies are limited to those involving the genital tract in women and may
include: abdominal pain during childbearing years; pelvic inflammatory disease (PID);

trauma;
unusual vaginal bleeding other than during pregnancy/childbirth. Other situations are covered
elsewhere in these protocols. Except as noted below or in other protocols, these conditions are
generally not life threatening and can be adequately tre
ated with supportive measures.


I

Rape: Confine your examination to injuries other than the rape; specifically, there is no need to
examine the vaginal area of a rape victim. Be sensitive to patients fears; have female present if
possible during treatment

and transport; don't allow the patient to wash, douche or go to the
bathroom; transport gently and quietly unless patient injuries indicate the need for more
aggressive care. The EMT doesn’t need to investigate the incident; limit questioning to that
nee
ded to determine your course of treatment. DOCUMENT WELL WHAT IS SAID AND
SEEN.


II

Vaginal bleeding: (other than during pregnancy/childbirth) Treat for shock/potential shock if
indicated. Treatment may include oxygen and
IV

therapy. See
shock protocol
. Do not insert
anything into the vagina; pads may be applied to the vaginal opening to absorb blood. Be sure
and ask the patient about possibility of being pregnant.

HERMISTON FIRE & EMERGENCY SERVICES


EMS Protocols
19

INTRAOSSEOUS INFUSION
-

EZ
-
IO

Definition:

An alternative technique for establishing IV access in critical adult and pediatric patients
when peripheral IV access is difficult or time
-
sensitive.

Indications:

A.
Intraosseous infusion is indicated in emergency situations when life
-
saving f
luids or drugs
should be administered and IV cannulation is difficult, impossible or too time
-

consuming to
perform.

B.
If a peripheral IV cannot be established after two attempts or within 60

90 seconds of
elapsed time
and
in:

C.
Adult and pediatric patie
nts, within the proper weight range, who present with one or
more of the following clinical conditions:

1.
Cardiac arrest.

2.
Hemodynamic instability (BP <90 mmHg and clinical signs of shock).

3.
Imminent respiratory failure.

4.
Status epilepticus with prolonged seizure activity greater than 10 minutes, and refractory
to IM anticonvulsants.

5.
Toxic conditions requiring immediate IV access for antidote.

D.
IO placement may be considered prior to peripheral IV attempts in cases
of
cardiopulmonary or traumatic arrest, in which it may be obvious that attempts at placing an
IV would likely be unsuccessful and or too time consuming, resulting in a delay of life
-
saving fluids or drugs.

HERMISTON FIRE & EMERGENCY SERVICES


EMS Protocols
20

NAUSEA


Indications:
Nausea associated with motion sickness, flu symptoms, administration of other
medications, especially narcotics


Assessment:

Vital Signs (Record before AND after administration of medication)

Abdominal exam

Consider nausea with vertigo to be ear problems.



~~~~~~~~~~~~~~~~~~~~~~~~EMT BASIC CARE~~~~~~~~~~~~~~~~~~~~~~~

A.

Administer oxygen via nasal cannula at 2
-
4 liters/minute; increase oxygen delivery if in the
presence of respiratory distress, decreased level of consc
iousness, irregular pulse or
SaO
2

< 90.

B.

Transport patient with the head elevated.



~~~~~~~~~~~~~~~~~~~~~~EMT INTERMEDIATE CARE~~~~~~~~~~~~~~~~~~~~~

C.

Cardiac monitor

D.

IV NS TKO or saline lock



Zofran (Ondansetron)

Adults
-

IM 4 mg

Adults
-

IV/IO 4

mg over 2
-
5 minutes.
May repeat once.

Child
-

>40kg
4 mg IV over 2
-
5 minutes
,

single dose.

Child
-

<40kg 0.1mg/kg
IV
over 2
-
5 minutes
,

single dose.



~~~~~~~~~~~~~~~~~~~~~~EMT PARAMEDIC CARE~~~~~~~~~~~~~~~~~~~~~

E.

Cardiac monitor

F.

IV NS TKO or saline lock



Zofran (Ondansetron)

Adults
-

IM 4 mg

Adults
-

IV/IO 4

mg over 2
-
5 minutes.
May repeat once.

Child
-

>40kg 4 mg IV over 2
-
5 minutes
,

single dose.

Child
-

<40kg 0.1mg/kg
IV
over 2
-
5 minutes
,

single dose.




Promethazine

(Phenergan) 12.5
-
25

mg IV slow or IM q 3 hrs. as needed.

o

Dilute with a minimum of 10 ml NS to prevent pain, vein damage and
phlebitis.


G.

If patient continues to vomit, administer fluid challenge per protocol.

H.

If patient becomes restless or develops extra pyramidal symptoms after administration of
P
romethazine:



Diphenhydramine

(Benadryl)

25 mg IV.


HERMISTON FIRE & EMERGENCY SERVICES


EMS Protocols
21

NEUROLOGICAL TRAUMA



This protocol covers the usual considerations in management of the known or suspected head or
spinal injury patient and is to be used in

conjunction with other applicable Trauma Protocols.


NOTE:



Most neurologic trauma is associated with other system trauma and should be assessed and
managed in light of all known or suspected injuries.



Assume that all head injuries have associated spinal i
njuries and stabilize appropriately prior to
transport.



Hypotension in a closed head injury should be assumed to be caused by other injuries.
Remember that spinal injuries can result in hypotension when no obvious source of bleeding is
found.



MANAGEMENT

STRATEGY:



ABC's WITH SPINAL STABILIZATION



NEUROLOGIC ASSESSMENT (Glasgow Coma Scale/Disability Assessment)



PREVENT OR REDUCE INCREASING INTRACRANIAL PRESSURE



~~~~~~~~~~~~~~~~~~~~~~~~EMT BASIC CARE~~~~~~~~~~~~~~~~~~~~~~~


A.

Follow Respiratory and Trauma

Protocols as indicated.


B.

Transport using a backboard along with an extrication collar, head stabilizers and tape, ties or
straps to maintain axial control of spinal column. Maintain manual stabilization of the neck
while the body is secured to the boa
rd and then secure the head and extremities to the board.
The torso is to be secured to the board BEFORE securing the head.


C.

All neurological trauma patients should be evaluated using the
Glasgow Coma Scale

at 5
minute intervals.



D.

All neurological trauma patients requiring ventilatory assistance should be moderately
hyperventilated at a rate of 30
-
35 breaths per minute to decrease the pCO
2
, thereby
decreasing intracranial pressure (ICP). Follow
Capnography protocol
.


E.

Elevate the head of the backboard slightly if shock IS NOT present and the airway is
controlled.



~~~~~~~~~~~~~~~~~~~~EMT INTERMEDIATE CARE~~~~~~~~~~~~~~~~~~~~


Per Oregon EMT
-
Intermediate protocols



~~~~~~~~~~~~
~~~~~~~~~~EMT PARAMEDIC CARE~~~~~~~~~~~~~~~~~~~~~


F.

Consider intubation of the patient with a GCS of < 8. If the head injured patient is hypoxic
and can not be intubated due to combativeness or trismus, consider
RSI
.


G.

All traum
a patients should have at least one (1) large bore
IV

of Lactated Ringers, the flow
rate to be determined by circulatory status. Two IVs are preferred.


H.

DO NOT USE ANY DEXTROSE CONTAINING IV SOLUTIONS ON NEUROLOGIC
OR HEAD

INJURY PATIENTS.


I.

Medications on physician order.

Generally, pain control is withheld in the multi
-
system
trauma pt. or patients with more than 1 injury (distracting).

HERMISTON FIRE & EMERGENCY SERVICES


EMS Protocols
22


OBSTETRIC EMERGENCIES



Obstetric emergencies are those wh
ich are directly related to pregnancy, labor and immediate
postpartum care. Emergency childbirth is covered under a separate protocol.

I SPECIFIC QUESTIONS TO ASK:

a)

If under medical care and by whom;

b)

When did she last see her physician;

c)

Last Menstrual Per
iod (LMP);

d)

Estimated due date;

e)

Previous pregnancies
(Gravida)
;

f)

Number of births, includes any fetus carried longer than 20 weeks, even if "born dead"
(Para, includes each of twins, triplets, etc.)
;

g)

If previous births, were they natural births or C
-
sect
ions;

h)

Were there any complications with previous pregnancies or deliveries;

i)

Any known problems with this pregnancy;

j)

Any recent trauma


II PLACENTA PREVIA; the placenta is implanted on the uterine wall near or covering the opening
(os) of the uterus; may not be painful; may cause severe bleeding, but the blood may be contained
inside the uterus.


TX:

treat for shock as needed, transport patient in a position of comfort if treatment needs don't
contraindicate, usually on her side with her knees bent; use trauma pads to absorb bleeding, but
do not place anything inside the vagina.


III ABRUPTIO PLACENT
A; the placenta tears away from the wall of the uterus; painful; probably
presents with severe bleeding.


TX:

treat for shock as needed, transport patient in a position of comfort if treatment needs don't
contraindicate, usually on her side with her kne
es bent; use trauma pads to absorb bleeding, but
do not place anything inside the vagina.


IV VAGINAL BLEEDING DURING PREGNANCY;


TX:

treat for shock as needed; place patient on her left side, or tilt backboard to left slightly.
Evaluate for potential em
ergency delivery.


V TRAUMA; Treat mother first, best way to keep fetus viable is to keep mother viable.


TX:

Standard trauma care including oxygen, IV and cardiac monitor.


VI ECTOPIC PREGNANCY; Attachment of the fertilized egg outside of the uterus; may be in the
fallopian tubes, the ovaries or the pelvic cavity.


TX:

IV, O
2
, Cardiac monitor,
emergency transport


VII ABORTION; Expulsion if the products of conception from t
he uterus before the fetus is viable;
TX:

Monitor and treat mother as indicated; start IVs if there is moderate to severe bleeding.
Transport the fetus (expelled tissue) to the hospital with mother.



HERMISTON FIRE & EMERGENCY SERVICES


EMS Protocols
23

OBSTETRICAL EMERGENCIES (Continued)


VIII HYPERTENSIO
N/SEIZURES; Toxemia of pregnancy;


TX:

IV, Oxygen, Monitor **
Magnesium

on physician order. Treat seizures with
Valium

or
Versed

per
seizure protocol
.


IX PROLAPSED CORD: If the cord presents first during delivery:


1.

Elevate the
mother’s

hips and place her in a knee
-
chest position;


2.

Administer high flow oxygen to the mother;


3.

With a gloved hand, gently push the baby up the
vagina enough to relieve the pressure the
baby's head exerts on the cord.


4.

DO NOT ATTEMPT TO PUSH THE CORD BACK;


5.

Cover the exposed cord with a moist dressing;


6.

Transport to the hospital immediately, maintaining pressure on the baby's head.


X BRE
ECH PRESENTATION: A breech presentation is one in which the baby presents buttocks
or legs first rather than head first. As the body delivers, the head may become lodged in the
cervical opening. If the head doesn't deliver within 1
-
2 minutes of the body be
ing delivered, the
EMT should insert two fingers of a gloved hand into the vaginal opening, forming a 'V' and
pushing the vaginal wall away from the baby's face, providing an airway for the baby. Transport
immediately and notify the hospital as early as p
ossible.


XI LIMB PRESENTATION: A limb presentation is an indication for immediate transport to the
hospital. Delivery should not be attempted in the field.


See
Childbirth procedures

HERMISTON FIRE & EMERGENCY SERVICES


EMS Protocols
24


POISONING



A
lso see other appropriate protocol, i.e., coma, respiratory, decontamination, etc.
If the
airway/ventilation status of the overdose patient is compromised, consider intubation early.
See Succinylcholine protocol if appropriate. Consider your personal sa
fety! Consider patient
decontamination.


I ASSESSMENT


A.

ABCs


B.

Determine product and route of exposure (topical, inhalation, ingestion, injection, etc). Bring
containers and/or product with patient to the hospital if possible.


C.

Establish time of
incident or exposure.


D.

Determine or estimate amount of exposure or ingestion.


E.

Establish patient's medical history.


F.

Evaluate severity of patient condition and estimate potential changes.


II MANAGEMENT


A.

GENERAL



1.

After brief assessment, tr
eat according to appropriate protocol (Coma, Respiratory,
Shock).



2.

Contact Medical control



3.

If requested to do so by Medical Control and, if agent is known, contact Poison Control
at
1
-
800
-
222
-
1222

for additional treatment information.


B.

TOPI
CAL EXPOSURE (e.g., alkalis, acids, cyanides, hydrocarbons, caustics, pesticides)



~~~~~~~~~~~~~~~~~~~~~~~~EMT BASIC CARE~~~~~~~~~~~~~~~~~~~~~~~



PROTECT YOURSELF, WEAR PERSONAL PROTECTIVE EQUIPMENT



1.

Wash the contaminated area with large amounts of
water. Dry powder agents must be
brushed off before washing (see Burn Protocol).



2.

Remove patient's clothing as appropriate while washing. Clean patient thoroughly
--

hair, ears, groin, umbilical area, fingernails, toenails
--

but do not abrade skin. C
ontinue
flushing for at least 10 minutes.



3.

Eyes: Flush continuously and gently with saline or water using a large pouring vessel or
an IV bag and administration set for a minimum of 15 minutes. Flushing may continue
during transport



4.

Persons handl
ing contaminated patients should take appropriate precautions to protect
self, such as disposable gloves, apron or turnouts.



5.

Put all contaminated clothes, sheets etc., in a plastic bag, label and transport with
patient.



6.

Notify the receiving hospi
tal that you are transporting a decontaminated patient. Give
them as much pertinent information about the contaminant and exposure as possible.



~~~~~~~~~~~~~~~~~EMT INTERMEDIATE/PARAMEDIC CARE~~~~~~~~~~~~~~



7.

If large area of is skin affected, start
IV as per burn protocol



8.

If organophosphates are involved, start an IV and EKG monitoring. See "Specific
Antidotes" below.

HERMISTON FIRE & EMERGENCY SERVICES


EMS Protocols
25

POISONING (Continued)



C.

INGESTION



Dilute strong acids or bases with milk or water if patient is fully conscious and transport.




ACTIVATED CHARCOAL
, consider contacting medical control and/or Poison Control
before administration.



1.

Dose: Adults

25
-
50

gm PO, with at least 8 oz. of water.






Children (1
-
12 years)

15
-
30 gm PO, with at least 8 oz. of water.






Pediatric


1 gm/kg , PO



2.

Activated charcoal is not effective in the treatment of poisoning from cyanide, mineral
acids, strong

bases, methanol, or ethanol.



3.

If activated charcoal is used, do not dilute with milk products.






~~~~~~~~~~~~~~~~~~~~EMT INTERMEDIATE CARE~~~~~~~~~~~~~~~~~~~~


Per Oregon EMT
-
Intermediate protocols



~~~~~~~~~~~~~~~~~~~~~~EMT PARAMEDIC
CARE~~~~~~~~~~~~~~~~~~~~~


D.

SPECIFIC ANTIDOTES:



1.

Organophosphates/Insecticides




Atropine

IM/IV; Adult 2 mg; Children 0.01
-
0.02 mg/kg (0.1
-
0.2 ml/kg). Repeat every
3
-
5 minutes until symptoms subside. Contact Medical Con
trol.



Opiates
:

a.

Narcan

2.0 mg IV/IM
/IN

for suspected
recreational use OD
. repeat as needed

b.

Narcan

0.4 mg titrated IV/IM
/IN

for respiratory and LOC response

in the chronic
pain Rx user.

c.

See
Altered Mental Status protocol.

d.

Opiate overdose can be from recreational opiate drug use of any kind (heroin,
Hydrocodone, etc.) or chronic over
-
use for pain mgt.

e.

Recreational use OD reversal ALSO requires professional pt./provider int
eraction
to minimize pt. agitation.

f.

Caution must be taken with Narcan use on patients using opiates for chronic pain
relief. i.e. cancer pts.

2.

Tricyclic Antidepressants
:
Sodium bicarbonate

-

1 mEq/kg IV and aggressive fluids for
hypotension.

3.

Signs & symptoms include
:

i.

Anticholingergic
mnemonic
:

i.

Mad as a hatter
-
agitation then coma

ii.

Red as a beet
-

flushed skin

iii.

Dry as a bone
-
dry mouth

iv.

Eyes like saucers
-
dilated pupils

ii.

Tachycardia with
OR
without
widening QRS. Tachycardia is earliest
sign.

iii.

Hypotension


HERMISTON FIRE & EMERGENCY SERVICES


EMS Protocols
26

iv.

Seizures

v.

Coma/Death



4.

Nerve Agents
: See "Poisoning
--
Military Agents"


POISONING (Continued)



F.

TOXIC INHALATION

D
O
N
OT
E
NTER
T
OXIC
A
TMOSPHERE
W
ITHOUT
P
ROPER
P
ROTECTIVE
E
QUIPMENT

C
ONSIDER
P
ATIENT
D
ECONTAMINATION
I
F
I
NDICATED


~~~~~~~~~~~~~~~~EMT BASIC/ INTERMEDIATE CARE~~~~~~~~~~~~~~~~~



1.

Remove patient from toxic atmosphere and optimize ventilation





2. If CO suspected, attach CO monitor. Monitor may need to be brough
t to scene.




a. If CO levels at 5
-
10%,

consider transport




b. If CO levels above 10%,

immediate transport




3. Administer high flow oxygen, preferably non
-
rebreather mask or assisted ventilation




~~~~~~~~~~~~~~~~~~~~~~EMT PARAMEDIC
CARE~~~~~~~~~~~~~~~~~~~~~



4
.

Support respirations and
intubate

as necessary.



5
.

Treat for coma per protocol if indicated.



G.

SNAKE BITE/INSECT BITE


~~~~~~~~~~~~~~~~~~~~~~~~EMT BASIC CARE~~~~~~~~~~~~~~
~~~~~~~~~



1.

Be prepared to manage shock, coma, seizures.



2.

Keep patient quiet.



3.

Remove all rings, bracelets, watches, etc. from affected extremity.



4.

If it can be done within 1
\
2 hour of the bite, apply a soft constricting band two inches
abov
e the bite site to occlude lymphatic flow. Release for 90 seconds every 10 minutes.



5.

May wash the site gently with soap and water.



6.

Cover the wound with a sterile dressing.



7.

Splint the extremity, keeping it at or below the patient's heart
level.



8.

DO NOT!!!




-

Do not cut and suck




-

Do not apply ice.




-

Do not apply an arterial tourniquet.



9.

Identify snake or insect if possible and safe to do so.



~~~~~~~~~~~~~~~~~~~~~~EMT PARAMEDIC CARE~~~~~~~~~~~~~~~~~~~~~



10.

Begin an IV L
actated Ringers.



11.

Treat hypotension per Shock Protocol.



12.

Be prepared to handle coma and seizures per protocol.



HERMISTON FIRE & EMERGENCY SERVICES


EMS Protocols
27

RESPIRATORY EMERGENCIES



Recognition and treatment of airway and respiratory dysfunction assumes priority
over all other
conditions in the initial evaluation and treatment of the patient in the field.


I GENERAL


A.

Support the head and neck as appropriate to patient's condition. Perform head and/or jaw
maneuvers as required and appropriate to patient
condition to secure and maintain a patent
airway.


B.

Supply supplemental oxygen at concentrations appropriate to the patient's condition. Use
mouth
-
to
-
mask or bag
-
valve
-
mask with supplemental oxygen to ventilate patients who are
apneic or have inadequate

respirations.


C.

Use oral or nasal airways to facilitate airway maintenance. Soft nasal airways may be
lubricated with
Lidocaine gel

to anesthetize the nasal passages and ease placement.


D.

Suction the oropharynx as
needed to remove secretions, blood and/or vomitus.


E.

See the
Allergic Reaction

protocol if anaphylaxis is suspected.


II UPPER AIRWAY OBSTRUCTION (FOREIGN BODY)


~~~~~~~~~~~~~~~~~~~~~~~~EMT BASIC CARE~~~~~~~~~~~~~~
~~~~~~~~~


A.

Follow current AHA
-
BLS guidelines for foreign body airway obstruction.



~~~~~~~~~~~~~~~~~~~~~~EMT PARAMEDIC CARE~~~~~~~~~~~~~~~~~~~~~


B.

If BLS procedures are unsuccessful and the airway remains obstructed, visualize the airway
with the lar
yngoscope and attempt to remove the obstruction using suction and/or Magill
forceps.


C.

If all other methods fail, the obstruction is in the upper airway and the patient’s condition is
deteriorating, perform
needle cricothyrotomy
. Contact Medical Control.


III
ASTHMA/BRONCHOSPASM/COPD


~~~~~~~~~~~~~~~~~~~~~~~~EMT BASIC CARE~~~~~~~~~~~~~~~~~~~~~~~

A.

Transport in most comfortable position; typically with the head elevated.

B.

Supplementa
l
oxygen

via nasal cannula or NRB.

C.

Basic may assist the patient in self
-
administering the patient’s own metered inhaler as long
as:

1.

The inhaler is prescribed to the patient

2.

The patient is conscious enough to assist in the
administration



~~~~~~~~~~~~~~~~~~~~EMT INTERMEDIATE CARE~~~~~~~~~~~~~~~~~~~~



D.

Medications may include:



Albuterol

2.5 mg in 3.0 ml saline via nebulizer for patients > 12 y/o. For use in children
under 12, use the same dosage

and administer via blow by.



Atrovent Duo
-
neb per Section F under Paramedic care.

HERMISTON FIRE & EMERGENCY SERVICES


EMS Protocols
28

RESPIRATORY EMERGENCIES (Continued)


~~~~~~~~~~~~~~~~~~~~~~EMT PARAMEDIC CARE~~~~~~~~~~~~~~~~~~~~~


E.



After first
-
line actions
(O2 &
DuoNeb
)

re
-
evaluate.

F.

If no or poor response to the initial
DuoNeb (Albuterol 3 mg/ Atrovent .5 mg).
nebulizer,
consider
continuous Albuterol nebulizers per patient condition.

G.

IV NS TKO or saline lock.

H.

Draw a blood sample if time and patient condition allow.


I.


Cardiac monitor

FOR PATIENTS PRESENTING WITH SEVERE, LIFE
-
THREATENING ASTHMA:

J.

O2 and
Albuterol

2.5 mg via nebulizer
if able to move adequate air.

K.


NIPPV (BVM assist. Use caution to avoid Auto
-
PEEP)




Epinephrine SQ or IVP if pt. is unable to move adequate air for inhaled Albuterol or
“silent chest” asthmatic.

L.

Re
-
evaluate after 10 minutes. Significant improvement should be noted



If no improvement, consider
RSI








Special considerations with Asthma patients




Immediately determine

if the pt. is able to adequately move air for inhaled Albuterol to be
effective.



Atrovent

has been shown to be beneficial in children with moderate to severe asthma, is
probably beneficial in adults and may be better tolerated than beta agonists in the el
derly.



Use extreme caution with NIPPV to avoid left/right shunt hypoxia from auto
-
PEEP.



A major Tx goal of asthma is improvement without intubation.



Epinephrine
: Patients over 50 years or with cardiac disease; OLMC required for
**Epinephrine



--
with mild to moderate symptoms (SPO2 91%
-

95%);




Adults: 1:1000 SQ; 0.3
-
0.5 mg for adults




Pediatrics: 1:1000 SQ; 0.01 mg/kg



--
with severe distress (SPO2 < 90%)and

decreased LOC




Adults: 1:10,000 IV, 0.3
-
0.5 mg




Pediatrics: 1:10,000 IV, 0.01 mg/kg




Attempt to administer
Lidocaine

3 minutes prior to laryngoscopy.



Use extreme caution with laryngoscopy. Laryngospasm obstruction may
occur.



Immediately after intubation, administer Albuterol 2.5 mg in 3 ml solution via ET tube.

HERMISTON FIRE & EMERGENCY SERVICES


EMS Protocols
29

RESPIRATORY EMERGENCIES (Continued)


IV CONGESTIVE HEART

FAILURE/PULMONARY EDEMA


~~~~~~~~~~~~~~~~~~~~~~~~EMT BASIC CARE~~~~~~~~~~~~~~~~~~~~~~~



A.

Transport in most comfortable position that allows appropriate treatment, typically sitting
upright, possibly with feet dangling.


B.

Supplemental oxygen via na
sal cannula or mask. Administer high
-
flow oxygen via non
-
rebreather mask if pulmonary edema is present.



~~~~~~~~~~~~~~~~~~~~EMT INTERMEDIATE CARE~~~~~~~~~~~~~~~~~~~~


Per Oregon EMT
-
Intermediate protocols



~~~~~~~~~~~~~~~~~~~~~~EMT PARAMEDIC CARE~~~~~~
~~~~~~~~~~~~~~~


C.

Saline Lock


D.

Cardiac monitor


E.

Albuterol

2.5 mg in 3.0 ml solution via nebulizer in conjunction with the medications in
section F.


F.

Medications for vasodilation and reducing cardiac work load may inc
lude:



1.

Nitroglycerin

0.4 mg SL