COOKE COUNTY EMERGENCY MEDICAL SERVICES

Transcription

1 COOKE COUNTY EMERGENCY MEDICAL SERVICES Patient Treatment Protocols For use by Cooke County Emergency Medical Services Douglas T. Lewis, M.D. Medical Director Effective Date: June 1, 2012

2 Table of Contents Geographical and Status Personnel... 5 Protocol Definitions... 6 Trauma Section 5 37 Introduction... 8 Initial Scene Survey... 9 Decision to Attempt Resuscitation Initial Trauma Assessment and Treatment Traumatic Arrest Traumatic Shock Penetrating Injuries: Truncal Wounds Neck wounds Head/Face Wounds Isolated Extremity Wounds Impaled Objects Sucking Chest Wound Traumatic Brain Injury Eye Injuries: Corneal Burns and Abrasions Blunt or Penetrating Eye Injuries Burn Injuries: Chemical Injuries to Eye Thermal Burns Chemical Burns Electrical Burns / Electrocutions Amputation Pregnant Trauma Patient Pediatric Trauma Isolated Musculo-Skeletal Injury Acute Blunt Spinal Cord Injury Domestic Violence These protocols are unique to Cooke County EMS per Medical Director Page 1

3 Medical Section Abdominal Pain Allergic Reaction Mild Allergic Reaction Moderate Allergic Reaction Severe - Anaphylaxis Cardiac Arrest Asystole Pulseless Electrical Activity (PEA) VF / Pulseless VT Post Resuscitation Bradycardia PSVT: Stable PSVT: Unstable VT: Stable VT: Unstable Acute Coronary Syndrome (Chest Pain - Suspect MI) STEMI Induced Hypothermia Cardiogenic Shock Hypotension / Shock unexplained Hypertensive Crisis Stroke Asthma CHF and Pulmonary Edema COPD Pneumonia / Bronchitis Seizures Dehydration Diabetic Emergencies Altered Mental Status Overdose / Poisoning Behavioral/ Emotionally Disturbed Chemical Restraint Carbon Monoxide Poisoning Heat Cramps / Exhaustion Heat Stroke Hypothermia Radiation Exposure Snakebite Sexual Assault These protocols are unique to Cooke County EMS per Medical Director Page 2

4 OB / GYN Section Vaginal Bleeding Pre-Eclampsia / Eclampsia Labor Delivery Breech Presentation Cord Presentation Limb Presentation Pediatric Section Post Delivery Neonatal Resuscitation Meconium Staining Asystole PEA VF / Pulseless VT Post Resuscitation Unstable Narrow Complex Tachycardia Bradycardia Abdominal Pain Allergic Reaction Mild Allergic Reaction Moderate Allergic Reaction Severe- Anaphylaxis Altered Mental Status Hypoglycemia Hyperthermia Hypothermia Near Drowning Overdose / Poisoning Asthma Bronchiolitis Croup Epiglottitis Obstructed Airway / Foreign Body Seizures These protocols are unique to Cooke County EMS per Medical Director Page 3

5 Appendix: Procedure Protocols Pain Management Medication Assisted Intubation (MAI) Rapid Sequence Induction for Intubation (RSI) Continued Sedation / Paralysis Airway Management for the Burn Victim Air Evacuation Protocol Pacing Protocol DNR Protocol Transtracheal Jet Ventilation Surgical Cricothyroidotomy Nasotracheal Intubation Orotracheal Intubation King Airway Needle Chest Decompression Mucosal Atomization device (MAD) Portable Ventilator Tidal Volumes (Pedi & Adult) Blood Administration Continuous Positive Pressure EZ IO Intraosseous Infusion Rule of Nine s Adult Burn Chart Rule of Nine s Child Burn Chart Lund & Browder Burn Chart Classification of Burn Severity Reference Pediatric Drug Chart Drug Calculations Dopamine Drip Chart Levophed Drip Chart Nitroglycerin Drip Dosage Chart Dobutamine Drip Chart Nasogastric Tube Lead Placement Reference Termination of Pre-hospital Resuscitation Spinal Immobilization Clearance Orthostatic BP Measurement Start Triage Guide System Drug Guide Section Pregnancy Category for Drugs Drugs A Z These protocols are unique to Cooke County EMS per Medical Director Page 4

6 Geographical and Status of Personnel Geographical Responsibility and Status of Personnel Cooke County Emergency Medical Services covers 874 Sq. Miles of Cooke County. We are a rural EMS provider with pockets of dense population. This protocol is to clarify when an EMT, EMT-P, Licensed Paramedic or Critical Care Paramedic may perform his or hers protocols and in what areas they may utilize these protocols. It is intended that these protocols are for on duty personnel. It is understood that there are times the off duty personnel respond to major incidents, and in this case, the off duty personnel may utilize their skills. It is further understood that off duty personnel may come across incidents that may require for them to utilize their skills. Within the operating area of Cooke County, the personnel may utilize their skills, but all must be documented on the Patient Care Report. Off Duty personnel that are traveling outside of Cooke County, that come across an incident, may utilize all their skills within the guidelines of these protocols. An incident report must be completed and turned into the Administrator, and a copy must go to the Medical Director for review. On Duty personnel that are out of Cooke County EMS operating area and come across and incident, may utilize their skills to the certified level. All appropriate patient care documentation must be completed. These protocols are unique to Cooke County EMS per Medical Director Page 5

7 Protocol Definitions Definitions 1. Vital signs For the purposes of these protocols, vital signs will be defined as follows: a. Pulse b. Respirations c. Blood Pressure d. Pulse Oximetry e. Temperature f. Blood Glucose (as Indicated) g. End Tidal Co2 numbers and Charted waveforms on the following types of patients: 1) All intubated patients 2. Multi-Casualty Incident: Any incident that overwhelms local response capabilities 3. Verified intubation tube placement A successful endotracheal intubation will be verified and documented by at least 4 of the following criteria: 4. Pediatric Limits a. Direct Visualization of tube passing through the cords b. Auscultation of six lung fields with positive air return c. Auscultation of an absence of air in the epigastrium d. Fogging of the tube e. Positive initial ETCO2 return f. Continuous ETCO2 return g. Charting of ETCO2 waveform h. Proper use of Bougie Stylet device a. Any patient < 18 years of age and < 40 kg or b. Any patient < 12 years of age. These protocols are unique to Cooke County EMS per Medical Director Page 6

8 Trauma Protocols These protocols are unique to Cooke County EMS per Medical Director Page 7

9 Trauma Introduction The initial assessment and treatment of a trauma patient must be performed in a rapid, systematic, and thorough fashion. Evaluation of the patient according to established priorities will help one to identify serious life-threatening situations quickly, so that intervention can take place, possibly preventing further deterioration in the patient s status. The systematic evaluation of the trauma patient should be performed on all injured patients, even those with minor trauma. The most important priorities in the evaluation and treatment of the trauma patient are found in the primary survey of the patient. Frequently, patient assessment must occur simultaneously with patient treatment during this phase of the patient s evaluation. At times, invasive procedures (e.g., intubation with in-line cervical stabilization) or initiation of rapid transport may be required before the complete, overall patient assessment is achieved. The primary survey in a trauma patient includes assessment and treatment of the following: 1. Airway Evaluation, establishment, and maintenance of an airway using C-spine precautions; determination of the patient s level of consciousness in order to provide additional information concerning the patient s airway status. 2. Breathing Determination of whether or not a trauma patient is adequately breathing and oxygenating. Serious chest injuries may rapidly progress to cardio-respiratory arrest, and certain chest injuries that may require immediate intervention (sucking chest wounds, tension pneumothorax). 3. Circulation Determination if a pulse is present, controlling external bleeding, and identification of injuries that may use significant blood loss. Initiation of rapid transport and intravenous fluids play a role in the treatment of the patient at this stage. 4. Disability Performance of a rapid neurological evaluation to establish a patient s level of consciousness, and pupillary size and reaction. 5. Exposure The clothing is removed to identify all injured areas with special care to avoid hypothermia. These protocols are unique to Cooke County EMS per Medical Director Page 8

10 Trauma - Initial Scene Survey This guideline should be used in the initial assessment of the scene where a trauma patient is located. 1. Survey the scene for possible hazards and resurvey periodically. 2. Protect yourself first, then victims from hazards. 3. Identify mechanism of injury. 4. Identify all potential patients. Notify Medical Control of victim count. 5. Prioritize patients, if more than one, using the same ABC system. 6. If MCI, triage using START. 7. Secure the scene. These protocols are unique to Cooke County EMS per Medical Director Page 9

11 Trauma Decision to Attempt Resuscitation The following are guidelines regarding the decision to attempt resuscitation in the field. Good judgment and common sense shall be used in the application of these guidelines. 1. In all situations where there is any possibility that life exists, every effort should be made to resuscitate the patient and transport to the hospital. 2. The paramedic should be aware of the following facts: a. Those persons in VF, PEA, and Asystole can potentially be resuscitated. b. That time down is an inaccurate parameter of resuscitation, as the patient could have been in bradycardia or simply unconscious for all of that time, yet still perfusing blood to the brain. Additionally, information received from bystanders in regard to time is often inaccurate. c. That pupil size and response to light can be inaccurate as medications taken orally or intraocular can affect them. Additionally, children and hypothermic patients may have fixed and dilated pupils from anoxia and yet be resuscitated without neurological deficit. 3. Resuscitation need not be attempted in the field in cases of: a. Decapitation b. Decomposition c. Rigor mortis d. Dependent lividity e. Visual massive trauma to the brain or heart conclusively incompatible with life f. Blunt mechanism of injury in cardiac arrest 4. Mass Casualty Incidents - In these situations, the acceptable triage protocol will apply. 5. Living Wills - The paramedic s actions should not be changed by a Living Will described or produced by the family or bystanders. 6. NO TRANSPORT Decisions to not transport must be approved through MEDICAL CONTROL. Note: Since it is usually not possible to predict no recoverability of a brain acutely insulted by cardiac arrest and attempts to do so increase anoxia time with the likelihood of further permanent brain damage, the responsible paramedic is usually obligated to start CPR. Paramedics should keep in mind that they may be held liable if they elect not to do so, on an arbitrary basis. These protocols are unique to Cooke County EMS per Medical Director Page 10

12 Trauma - Initial Assessment and Treatment Clinical Definition: This guideline establishes priorities in the initial assessment and treatment of trauma patients. The trauma patient must be evaluated and treated in a rapid and orderly fashion in order to achieve the best patient outcome. When a treatable problem is identified, treatment is initiated for that problem before proceeding with the next step in the guideline. Using this approach, life-threatening injuries are identified and treated in a stepwise manner. NOTE: Assume the following in ALL severely injured patients: a. The patient has a spinal injury until proven otherwise b. The patient has an immediate threat to life that has not yet been found. c. The patient is going to decompensate at any moment. The only aspects of patient care that, in most cases, would be performed prior to the initiation of patient transport include: a. Establish and maintain an adequate and appropriate airway with oxygenation and ventilation as required. b. Immobilize and protect the spine as indicated and required c. Initial attempts to control significant external hemorrhage AIRWAY: Basic Life Support: 1. Assess level of consciousness 2. Assess, establish, and/or maintain an adequate airway, while also observing C-spine precautions. Apply cervical collar if indicated and while doing so, note: a. Is trachea midline? b. Any bruising, swelling, or crepitus in the neck? c. Is carotid pulse present? If no pulse present, begin CPR and immediately refer to Traumatic Arrest Protocol. (pg. 15) 3. Insert oral or nasopharyngeal airway as indicated. 4. Administer high flow oxygen (100% by face mask or BVM) and assist patient s ventilation as needed. If the patient has a decreased level of consciousness, ventilate: a. 13 y/o breaths/mi b y/o breaths/min c. 0 4 y/o breaths/min If the patient has a decreased LOC or other signs of a traumatic brain injury: refer to Traumatic Brain Injury Protocol (pg. 23), after completion of the Initial Trauma Assessment and Treatment Protocol. (pg ) 5. Reassess patient frequently including adequacy of ventilations. Intermediate and Paramedic: 6. Establish need for in-line endotracheal intubation. Observe C-spine precautions. 7. If intubation is necessary, it should be performed using the two-man technique with one person stabilizing the cervical spine while the other person performs the intubation. Extreme care must be taken to avoid flexion or extension of the neck. These protocols are unique to Cooke County EMS per Medical Director Page 11

13 8. If intubation is performed, endotracheal tube placement should be assessed and documented using three or more of the following techniques: a. Visualization of endotracheal tube passing through vocal cords. b. Equal breath sounds. c. Absence of ventilated air in the epigastrium d. Rise and fall of chest wall. e. Use of a Bougie f. Fogging of the Endotracheal Tube g. Positive Initial Co2 return with EtCo2 (if available) h. Charting of ETCO2 waveform 9. End-tidal CO2 monitor. If the patient has a decreased level of consciousness, ventilate to maintain an EtCo2 of mmhg, otherwise ventilate at a rate of breaths/minute for adults and children at a rate of breaths/min for children less than 4 years of age. If the tube cannot be confirmed in the proper position, it should be removed and the patient re-intubated. When proper placement is confirmed, the tube should be properly secured with tube holder and c-collar and CID to minimize the chances of dislodgment. (If unable to fit patient with c-collar, secure head with CID). 10. Reassess patient s airway/ventilation frequently. NOTE: Failure to provide and maintain an adequate airway is the most common cause of preventable pre-hospital morbidity and mortality. The airway should be carefully assessed initially and frequently reassessed to assure a competent airway is maintained during the pre-hospital phase of treatment. BREATHING: Basic Life Support: 1. Observe chest wall movement for symmetry and auscultate breath sounds on both sides of the chest. Rate, depth, and pattern of breathing as well as the integrity of the chest wall should be assessed. 2. Assist or deliver ventilations as required. All patients with a decreased level of consciousness ventilate: a. 13 y/o breaths/min b breaths/min c. 0 4 y/o breaths/min 3. All patients with more than minor injuries (e.g., isolated extremity fractures, minor lacerations, etc.) should receive supplemental 100% oxygen by non-rebreather mask or BVM. 4. If sucking chest wound has been identified, apply dressing as described in Sucking Chest Wound Protocol. (pg. 22) Intermediate: 5. If patient is breathing inadequately, assist ventilations with 100% oxygen through mask or endotracheal tube to maintain a EtCo2 of mmhg. Paramedic: 6. If signs of tension pneumothorax are present, refer to the Needle Chest Decompression Protocol (pg. 132) and contact MEDICAL CONTROL These protocols are unique to Cooke County EMS per Medical Director Page 12

14 CIRCULATION/ BLEEDING: Basic Life Support: 1. Control serious external bleeding by direct pressure or pressure dressings. 2. If not already done, palpate for a pulse. If not present, initiate CPR and proceed to the Traumatic Arrest Protocol (pg. 15) 3. If pulse is present, then obtain pulse rate and BP. If systolic BP < 90, Heart Rate > 120, and/or clinical evidence of shock is present, refer to Traumatic Shock Protocol. (pg. 16) 4. Palpate abdomen for rigidity or tenderness and pelvis for pain or crepitus (identifying potential sources for significant blood loss). 5. Examine the patient s back, if possible, for gross deformities or penetrating injuries prior to placing the patient on the backboard. 6. For penetrating injuries, also see Penetrating Injuries Protocol. (pg. 17) Intermediate and Paramedic: 7. If there is evidence of a significant mechanism of injury, external blood loss, or evidence of possible pelvic or femur fracture or other significant injuries, attempt to establish 2 large bore IVs with NS and run wide open if the patient s SBP is less than 90 mmhg systolic. Run IV at TKO rates or at the direction of MEDICAL CONTROL. Attempts to establish IV access are usually made en route but may be made at the scene if long transports are anticipated after consulting MEDICAL CONTROL. Transport should not be delayed for multiple attempts at initiation of an IV. If long transports are necessary, maximum volumes and flow rates should be determined by MEDICAL CONTROL. Pressurized infusion devices may be used. If the patient has a SBP < 90 or heart rate > 120, see the Traumatic Shock Protocol. (pg. 16) DISABILITY (Neurological Exam): All Levels: 1. Evaluate neurological status by noting the following: a. Mental status/level of consciousness. b. Presence/absence of movement in extremities, either spontaneously or in response to pain c. Pupillary size and reactivity. d. Evidence of trauma to the head or neck. 2. If evidence of head trauma, have suction ready and observe for any seizure activity. 3. If altered level of consciousness, assist or ventilate patient (if patient will allow). a. 13 y/o breaths/min b y/o breaths/min c. 0 4 y/o breaths/min End-tidal CO2 monitor, ventilate to maintain an EtCo2 of mmhg. 4. If evidence of closed head injury, see Traumatic Brain Injury Protocol. (pg ) NOTE: The patient s status must be reassessed at frequent intervals to detect changes and these changes should be immediately reported to Medical Control. The ABC s including vital signs should be repeated every 15 minutes in potentially stable patients and every 5 minutes in unstable patients. These protocols are unique to Cooke County EMS per Medical Director Page 13

15 EXPOSE AND EXAMINE: All Levels: 1. Examine for specific injuries burns, chemicals, drowning, eye, etc. If present, see specific protocol. 2. Assess extremities by inspection and palpation for present of tenderness, gross deformity, soft tissue swelling, lacerations, or abrasions. Also, note motor, sensory, and vascular integrity in each extremity. Appropriately dress and splint extremity injuries as required and as time will allow. Elevate injured extremities when possible. 3. If possible, when patient is log rolled onto backboard, palpate and inspect back for evidence of trauma. 4. Calculate Glasgow Coma Score and Revised Trauma Score. GLASGOW COMA SCORE REVISED TRAUMA SCORE Eye Opening Spontaneously To verbal Command To Pain No Response Score: Score Respiratory Rate = > 29 = 6 9 = 1 5 = 0 = Score: Score Best Verbal Response Oriented Confused Inappropriate words Incomprehensible sounds No Response Score: Systolic Blood Pressure > 89 = = = 1 49 = 0 = Score: Best Motor Response Obeys Localized Pain Withdraws to pain Abnormal Flexion to pain Extension to pain No Response Glasgow Coma Score = 9 12 = 6 8 = 4 5 = 3 = Score: Score: Total Total These protocols are unique to Cooke County EMS per Medical Director Page 14

16 Traumatic Arrest Clinical Definition: This protocol should be used for the treatment of a patient who has suffered a traumatic cardiac arrest. Patients with a blunt mechanism of injury and who have a cardiac arrest have minimal, if any, chance of survival, and many pre-hospital providers do not attempt resuscitation. For those providers who attempt resuscitation, the following protocol should be used. Resuscitation should be attempted in all patients with a penetrating mechanism of injury. Basic Life Support: 1. If not already done, evaluate/treat ABC s according to Trauma assessment and Treatment Protocol. (pg ) 2. Initiate CPR and prepare for rapid transport. Immobilize spine, if appropriate. Intermediate: 3. Intubate using in-line cervical spine stabilization, if appropriate. 4. Identify correctable causes of hypoxia and initiate treatment: a. Administer 100% oxygen. b. For sucking chest wounds, treat according to Sucking Chest Wound Protocol. (pg. 22) 5. End-tidal CO2 monitor. If the patient has a decreased level of consciousness, ventilate to maintain an EtCo2 of mmhg, otherwise ventilate at breaths/minute for adults and children at breaths/min for children less than 4 years of age. 6. Attempt to establish 2 large bore IVs with Normal Saline and run wide open. Attempts at IV access should be made en-route, but can be attempted at the scene if approved by MEDICAL CONTROL. Transport should not be delayed for multiple attempts at initiation of an IV. If long transports are necessary, maximum volumes and flow rates should be determined by MEDICAL CONTROL. Pressurized infusion devices may be used. If unable to obtain IV, IO may be used. Paramedic: 7. Apply ECG electrodes and determine cardiac rhythm. 8. If rhythm other than PEA, treat cardiac arrhythmia per protocol during transport. 9. Continue evaluation as per Initial Trauma Assessment and Treatment Protocol. (pg ) 10. Evaluate for tension pneumothorax, Contact Medical Control and refer to the Needle Chest Decompression Protocol. (pg. 132) Note: PEA in a trauma patient is most likely due to hypovolemia from blood loss. Definitive therapy is usually required to stop the source of hemorrhage and blood transfusions are needed usually ASAP. Hence rapid extrication and transport is essential. Remember that Normal Saline helps expand the circulating blood volume BUT DOES NOT CARRY OXYGEN. These protocols are unique to Cooke County EMS per Medical Director Page 15

17 Trauma - Traumatic Shock Clinical Definition: This protocol should be used for the treatment of patients with traumatic shock SBP < 90 & HR > 120, but with a palpable pulse. If no pulse is palpable, proceed to (Traumatic Arrest Protocol) (pg. 15). Frequently, shock in a trauma patient is due to internal or external bleeding. Hemorrhagic shock can be recognized by hypotension, tachycardia, diaphoresis, pallor, cyanosis, tachypnea, and other clinical signs of shock. Fluid resuscitation should be aimed at maintaining a SBP mm/hg and no higher. Basic Life Support: 1. If not already done, evaluate/treat ABC s according to the Initial Trauma Assessment and Treatment Protocol. (pg. 11) 2. Prepare for rapid transport. Intermediate: 3. If indicated, intubate the patient using C-spine precautions. If intubation is used, End-tidal CO2 monitor ventilate to maintain an EtCo2 of mmhg, otherwise ventilate at breaths/minute for adults and larger children and at breaths/min for children less than 4 years of age. 4. Attempt to establish 2 large bore IVs with Normal Saline and run wide open. Attempts at IV access should be made en route but may be attempted at the scene if approved by MEDICAL CONTROL. Transport should not be delayed for multiple attempts at initiation of an IV. If long transports are necessary, maximum volumes and flow rates should be determined by MEDICAL CONTROL. Pressurized infusion devices may be used. If unable to obtain IV, IO may be used. 5. Continue evaluation as per Initial Trauma Assessment and Treatment Protocol. (pg ) Paramedic: 6. Evaluate as to need for Blood Therapy. (Blood Administration Protocol (pg. 136) 7. Apply ECG electrodes and determine cardiac rhythm. Note: Fluid resuscitation in children is performed according to weight. Definitive therapy is usually required to stop the source of hemorrhage and blood transfusions are needed usually ASAP. Rapid extrication and transport is essential. Remember that Normal Saline helps expand the circulating blood volume; BUT DOES NOT CARRY OXYGEN. MINIMIZE ON - SCENE TIME These protocols are unique to Cooke County EMS per Medical Director Page 16

18 Trauma Penetrating Injuries (Truncal Wounds) Clinical Definition: Any injury in which there is evidence for penetration of the skin by an object that could result in injury to underlying structures. Examples include gunshot wounds, stab wounds, ice pick wounds, impaled objects, sucking chest wounds, etc. Other protocols may apply in cases of penetrating injuries, such as traumatic shock and traumatic arrest. Refer to all of the appropriate protocols that apply. General Guidelines: Truncal Wounds Chest / Abdomen / Back / Proximal Extremities Basic Life Support: 1. Evaluate patient according to Initial Trauma Assessment and Treatment Protocol. (pg ) 2. Prepare for rapid transport, even if vital signs are stable. 3. If impaled object - do not remove; refer to Impaled Object Protocol. (pg. 21) 4. Treat open chest wounds according to guidelines for sucking chest wounds; refer to Sucking Chest Wounds Protocol (pg. 22) 5. Treat evisceration of abdominal contents by covering tissue with saline-moistened gauze sponges or sterile towels. DO NOT attempt to replace abdominal contents through the wound. Intermediate: 6. Attempt to establish 2 large bore IV s with Normal Saline and run at appropriate rate to be aimed at maintaining a SBP between mm/hg and no higher. Attempts at IV access should be made en route but may be attempted at the scene if approved by MEDICAL CONTROL. Transport should not be delayed for multiple attempts at initiation of an IV. Paramedic: 7. Apply ECG electrodes and determine cardiac rhythm. MINIMIZE ON - SCENE TIME These protocols are unique to Cooke County EMS per Medical Director Page 17

19 Trauma Penetrating Injuries (Neck Wounds) General Guidelines: Head / Neck / Face Wounds Basic Life Support: 1. Evaluate patient according to the Initial Trauma Assessment and Treatment Protocol. (pg ) Maintain high index of suspicion for C-spine injury, tracheal injury, blood vessel injury, and lung injury. 2. Prepare for rapid transport, even if vital signs are stable. 3. If impaled object - do not remove; refer to Impaled Object Protocol. (pg. 21) 4. Monitor closely for signs of soft tissue swelling in the neck that could lead to airway obstruction. 5. Have suction set up and ready to clear airway of blood or secretions. 6. Observe closely for signs of a tension pneumothorax. Intermediate: 7. Attempt to establish 2 large bore IV s and Normal Saline and run at appropriate rate to be aimed at maintaining a SBP mm/hg and no higher. Attempts at IV access should be made en route but may be attempted at the scene if approved by MEDICAL CONTROL. Transport should not be delayed for multiple attempts at initiation of an IV. Paramedic: 8. Apply ECG electrodes and determine cardiac rhythm. Contact Medical Control: Prophylactic intubation (MAI or RSI) may be required if airway compromise from neck swelling occurs. Consult MEDICAL CONTROL. MINIMIZE ON - SCENE TIME These protocols are unique to Cooke County EMS per Medical Director Page 18

20 Trauma Penetrating Injuries (Head & Face Wounds) General Guidelines: Head / Face Wounds Basic Life Support: 1. Evaluate patient according to the Initial Trauma Assessment and Treatment Protocol. (pg ) Maintain high index of suspicion for C-spine injury, tracheal injury, and/or blood vessel injury. 2. Prepare for rapid transport, even if vital signs are stable. 3. If impaled object - do not remove; refer to Impaled Object Protocol. (pg. 21) 4. Have suction set up and ready to clear airway of blood or secretions. 5. Elevate head of backboard 15 to 30 degrees - DO NOT elevate head by flexing neck! Intermediate: 6. If patient is unconscious or has a decreased LOC without a gag reflex and or rising ICP is suspected, endotracheal intubation should be performed to decrease intracranial pressure. If intubated then use, End-tidal CO2 monitor. Ventilate to maintain an EtCo2 of mmhg, otherwise ventilate at breaths/minute for adults and larger children and at breaths/min for children less than 4 years of age. 7. Attempt to establish 2 large bore IVS with Normal Saline and run at rate to be aimed at maintaining a SBP mm/hg and no higher. 8. Attempts at IV access should be made en route but may be attempted at the scene if approved by MEDICAL CONTROL. Transport should not be delayed for multiple attempts at initiation of an IV. Paramedic: 9. Apply ECG electrodes and determine cardiac rhythm. Contact Medical Control: Prophylactic intubation (MAI or RSI) may be required if airway compromise occurs. MINMIZE ON - SCENE TIME These protocols are unique to Cooke County EMS per Medical Director Page 19

21 Trauma Penetrating Injuries (Isolated Extremity Wounds) General Guidelines: Isolated Extremity Wounds Basic Life Support: 1. Evaluate patient according to the Initial Trauma Assessment and Treatment Protocol. (pg ) Check neurovascular status distal to wound (presence of pulse, feeling, and movement). 2. If impaled object - do not remove; refer to Impaled Object Protocol. (pg. 21) 3. Control external bleeding with direct pressure first, then pressure dressings. 4. Splint affected extremity. 5. Elevate affected extremity 15 to 30 degrees. 6. Prepare for rapid transport, even if vital signs are stable. Intermediate: 7. If significant blood loss at the scene, significant soft tissue swelling, heart rate > 120, or wound close to trunk or thigh area, attempt to establish 2 large bore IV with Normal Saline and run at appropriate rate to be aimed at maintaining a systolic blood pressure between mm/hg and no higher. 8. Attempts at IV access should be made en-route but may be attempted at the scene if approved by MEDICAL CONTROL. Transport should not be delayed for multiple attempts at initiation of an IV. Paramedic: 9. Apply ECG electrodes and determine cardiac rhythm. 10. Refer to Pain Management Protocol. (pg. 117) MINIMIZE ON - SCENE TIME These protocols are unique to Cooke County EMS per Medical Director Page 20

22 Trauma Impaled Objects Basic Life Support: 1. Evaluate patient according to the Initial Trauma Assessment and Treatment Protocol. (pg ) 2. In general, do not remove impaled object. If impaled object is causing airway compromise resulting in respiratory distress, and this distress cannot be corrected without removal of the foreign body, contact MEDICAL CONTROL immediately for further orders. 3. When possible, stabilize the impaled object on the body so that it does not move around and cause more internal injury. 4. Any impaled object to the torso (chest, abdomen, back, lower neck, or proximal extremities) should be considered a potentially life-threatening injury and treated as such. Transportation should be initiated as soon as possible, even if the patient appears stable. 5. If manpower is available and time exists during transport, continue further evaluation and treatment of patient according to the Initial Trauma Assessment and Treatment Protocol. (pg ) Intermediate: 6. If significant blood loss at the scene, significant soft tissue swelling, heart rate > 120, or wound close to trunk or thigh area, attempt to establish 2 large bore IV S of Normal Saline and run at appropriate rate to be aimed at maintaining a SBP between mm/hg and no higher. 7. Attempts at IV access should be made en route but may be attempted at the scene if approved by MEDICAL CONTROL. Transport should not be delayed for multiple attempts at initiation of an IV. Paramedic: 8. Apply ECG electrodes and determine cardiac rhythm. 9. Refer to Pain Management Protocol (pg. 117) MINIMIZE ON - SCENE TIME These protocols are unique to Cooke County EMS per Medical Director Page 21

23 Trauma Sucking Chest Wound Basic Life Support: 1. Evaluate patient according to Initial Trauma Assessment and Treatment Protocol. (pg ) 2. If patient is breathing inadequately, assist ventilations with 100% oxygen through mask 3. Seal the wounds as rapidly as possible, preferably with Vaseline-coated gauze or asherman chest seal, to prevent further collapse of the lung. * In general, the dressing should be sealed on two or three sides only. This allows it to act as a one-way valve allowing air in the pleural space (chest cavity) to get out when the lung expands, but preventing air on the outside from entering the chest cavity through the wound.* 4. Watch closely for signs and symptoms of a tension pneumothorax. If these signs develop, usually lifting one corner of the occlusive dressing will relieve the tension pneumothorax. 5. Prepare for rapid transport. 6. As time allows and manpower permits, continue evaluation and treatment of the patient according to the Initial Trauma Assessment and Treatment Protocol. (pg ) Intermediate: 7. Attempt to establish 2 large bore IVS and Normal Saline and run at rate to maintaining a SBP between mm/hg and no higher. Attempts at IV access should be made en route but may be attempted at the scene if approved by MEDICAL CONTROL. Transport should not be delayed for multiple attempts at initiation of an IV. *Note: If patient is awake and cooperative, have him/her cough (this removes as much air as possible from the chest cavity), and then apply the Vaseline gauze or Asherman Chest Seal System immediately afterwards. 8. If patient is breathing inadequately, assist ventilations with 100% oxygen through mask or endotracheal tube. If intubation is used, End-tidal CO2 monitor, ventilate to maintain an EtCo2 of mmhg. Paramedic: 9. Apply ECG electrodes and determine cardiac rhythm. Contact Medical Control: Prophylactic intubation (MAI or RSI) may be required if airway compromise occurs MINIMIZE ON SCENE TIME These protocols are unique to Cooke County EMS per Medical Director Page 22

24 Trauma Traumatic Brain Injury Clinical Definition: Any traumatic injury to the face or head which results in an injury to the brain, as manifested by some degree of impairment in mental function. Typically, these patients rage from being comatose to wild and combative. Basic Life Support: 1. Evaluate patient according to the Initial Trauma Assessment and Treatment Protocol. (pg ) Maintain high index of suspicion for C-spine injury. Provide supplemental oxygen. 2. If patient is hypoventilating, assist or provide ventilations (with supplemental oxygen) at a rate of Have suction hooked up and readily available. Be prepared to roll patient, if necessary, should vomiting occur. 4. Monitor Oxygen Saturation 5. Take seizure precautions. 6. Prepare for rapid transport. 7. Elevate head of backboard 15 to 30 degrees. DO NOT elevate the head by flexing the neck! Intermediate: 8. Appropriate airway management may require endotracheal intubation while observing C-spine precautions. If patient is unconscious or has decreased LOC without a gag reflex, endotracheal intubation with in-line cervical spine stabilization and hyperventilation should be performed to decrease increased intracranial pressure. If intubated, use, End-tidal CO2 monitor and ventilate to maintain an EtCo2 between mmhg, otherwise ventilate at breaths/minute for adults and larger children and at breaths/min for children less than 4 years of age. 9. Attempt to establish 2 large bore IV s of Normal Saline and run at appropriate rate to maintaining a SBP mm/hg and no higher. Attempts at IV access should be made en route but may be attempted at the scene only if approved by MEDICAL CONTROL. Transport should not be delayed for multiple attempts at initiation of an IV. Paramedic: 10. Apply ECG electrodes and determine cardiac rhythm. 11. If seizures occur and are prolonged (greater than seconds), administer Valium slow IV push in 2 mg increments, (10mg maximum for adult) until seizure stops. If intubation not performed prior to seizure, it should be performed after Valium has been administered so that hyperventilation may be more effectively performed and the airway is better protected. These protocols are unique to Cooke County EMS per Medical Director Page 23

25 12. If nausea / vomiting: Ondansetron (Zofran): 4 mg IVP, IM or Oral ODT; (Max 8 mg Q 4 hours); may repeat in 15 minutes if no improvement Pediatric Dosages of Ondansetron (Zofran): Ages 2 7: 1 mg IVP / IM or Oral ODT; (Max 2 mg Q 4 Hours); may repeat in 15 minutes if no improvement Ages 7 12: 2 mg IVP, IM or Oral ODT; (Max 4mg Q 4 Hours); may repeat in 15 minutes if no improvement Under 2 years of age.15 mg/kg IVP or Oral ODT; may repeat in 15 minutes if no improvement Contact Medical Control: Prophylactic intubation (MAI or RSI) may be required if airway compromise occurs. These protocols are unique to Cooke County EMS per Medical Director Page 24

26 Trauma Eye Injuries (Corneal Burns & Abrasions) Clinical Definition: These injuries usually occur when the eye is exposed to sources of high intensity light or ultraviolet radiation such as associated with tanning booths, or sun lamps, also corneal injuries may be produced by prolonged wearing of contact lenses. Basic and Intermediate: 1. Evaluate patient according to the Initial Trauma Assessment and Treatment Protocol. (pg ) 2. Lie patient down and have them close both eyes. 3. Bandage as necessary. Paramedic: 4. If available, and no contraindication exists, have patient open eyes and add 2 drops of a topical anesthetic for the eyes (such as Alcaine / Tetracaine) to the affected eye(s). Instruct patient not to rub their eyes once the medication has been administered. 5. Transport patient. These protocols are unique to Cooke County EMS per Medical Director Page 25

27 Trauma Eye Injuries (Blunt or Penetrating Eye) All Levels: 1. Evaluate patient according to the Initial Trauma Assessment and Treatment Protocol. (pg ) 2. Have the patient lie flat or with the head slightly elevated. 3. DO NOT attempt to open the injured eye(s). 4. Instruct the patient to close both eyes. 5. Bandage as necessary. 6. DO NOT place any type of compressive dressing over the injured eye(s), and be careful not to apply pressure to the eye. 7. DO NOT REMOVE any penetrating object from the eye (unless ordered by medical control) 8. Transport the patient. These protocols are unique to Cooke County EMS per Medical Director Page 26

28 Trauma Eye Injuries(Chemical Injuries to Eye) Basic and Intermediate: 1. Evaluate patient according to the Initial Trauma Assessment and Treatment Protocol. (pg ) 2. Flush the affected eye(s) with copious amounts of water or Normal Saline, using a minimum of 2 liters or more for each eye continued throughout transport. If the substance is alkaline in nature, perform continuous irrigation during transport. Contact lenses should be removed if present. Paramedic: 3. If available, and no contraindication exists, have patient open eyes and add two drops of a topical anesthetic for the eyes (such as Alcaine / Tetracaine) to the affected eye(s). Instruct patient not to rub their eyes once medication has been administered. 4. Transport patient. These protocols are unique to Cooke County EMS per Medical Director Page 27

29 Trauma- Burns (Thermal) Basic Life Support: 1. Evaluate patient according to the Initial Trauma Assessment and Treatment Protocol. (pg ) Look closely for any evidence of inhalation injury (hoarseness, stridor, sooty sputum, facial burns, and signed facial hair). If present, provide supplemental oxygen, preferably humidified. 2. Prepare for rapid transport, if significant burn or inhalation injury. 3. Remove any jewelry, belts, shoes, etc. from areas of burns as these objects may retain heat and increase the burn; also swelling of burned areas may make subsequent removal difficult. In addition, remove any burned or singed clothing that is not stuck to the underlying skin of the patient. 4. Assess depth of burn (first, second, third) as well as the total area of the burn using Lund & Brower burn chart / rule of nines (pg ) or fact that palmar surface of the patient s hand usually represents 1% of body surface area. 5. Perform local burn care as follows: a. Do not apply ice to burned area. b. Do not apply ointments or solutions to burns. c. Do not attempt to open blisters. d. Small burns (<10 of BSA): 1) If burn occurred less than 15 minutes prior to your arrival, cover burn with sterile towels or gauze sponges soaked with cool saline, water or non-menthol shaving cream otherwise apply dry dressing. e. Larger burns: a. Wear sterile gloves and mask until large burns are covered. b. Cover large burns with dry, sterile or clean sheets. Do not use wet dressings since they may cause hypothermia on large burns. c. Cover patients who have large burns with additional sterile or clean sheets or blankets to prevent loss of body heat. 6. Treat any associated injuries (bandage and splint). 7. If eyes are affected, refer to Eye Injury Protocol. (pg ) Intermediate: 8. IV therapy with Normal Saline should be initiated in patients with the following: a. Evidence of inhalation injury. b. Elderly or underlying chronic illnesses or other associated injuries that require an IV. c. Burn exceeds 10% BSA. d. Electrical burns. 9. Run IV (ml/h) at rate equal to ( 1 /4) X (Weight in kg) X (% BSA). These protocols are unique to Cooke County EMS per Medical Director Page 28

30 Paramedic: 10. Apply ECG electrodes and determine cardiac rhythm. 11. Monitor EtCo2 12. For patients with less than 10% BSA burn and no evidence of inhalation injury: 13. Consider Pain management: Morphine 10 mg SIVP (Max Dose 40 mg) AND Valium 10 mg SIVP (Max Dose 20 mg) May be repeated only if SBP is maintained <90 mmhg Contact Medical Control: If evidence of inhalation injury present with progressive airway compromise, monitor ETCO2. Medically Assisted Intubation (MAI) or Prophylactic intubation (RSI) may be required. Refer to the Airway Management for the Burn Victim. (pg. 122) Consult MEDICAL CONTROL These protocols are unique to Cooke County EMS per Medical Director Page 29

31 Trauma Burns (Chemical) Ensure Crew Safety! Basic Life Support: 1. Evaluate patient according to the Initial Trauma Assessment and Treatment Protocol. (pg ) Remove contaminated clothing and wash all exposed skin unless Lyme exposure is suspected. DO NOT USE WATER ON LYME. Contact Poison Control and Medical Control for instructions on specific chemicals. 2. Splint any fractures or deformities as required. Intermediate: 3. Start IV with Normal Saline and run TKO unless hypotension or clinical evidence of shock exists. 4. Run IV (ml/h) at rate equal to ( 1 /4) X (Weight in kg) X (% BSA). Paramedic Life Support: 5. Apply ECG electrodes and determine cardiac rhythm. Refer to appropriate arrhythmia protocol as required. 6. Consider Pain Management: Morphine 10 mg SIVP (Max Dose 40 mg) AND Valium 10 mg SIVP (Max Dose 20 mg) May be repeated only if SBP is maintained <90 mmhg Contact Medical Control These protocols are unique to Cooke County EMS per Medical Director Page 30

32 Trauma Burns (Electrical & Electrocution) Basic Life Support: 1. Evaluate patient according to Initial Trauma Assessment and Treatment Protocol. (pg ) 2. Cover entrance and/or exit wounds with dry sterile dressings. 3. Splint any fractures or deformities as required. Intermediate: 4. Start IV with Normal Saline and run TKO unless hypotension or clinical evidence of shock exists 5. Run IV (ml/h) at rate equal to ( 1 /4) X (Weight in kg) X (% BSA). Advanced Life Support: 6. Apply cardiac monitor and determine rhythm. Refer to appropriate arrhythmia protocol as required. 7. Consider Pain Management: Morphine 10 mg SIVP (Max Dose 40 mg) AND Valium 10 mg SIVP (Max Dose 20 mg) May be repeated only if SBP is maintained <90 mmhg Contact Medical Control These protocols are unique to Cooke County EMS per Medical Director Page 31

33 Trauma - Amputation Basic Life Support: 1. Evaluate patient according to the Initial Trauma Assessment and Treatment Protocol. (pg.11-14) 2. Control bleeding with direct pressure or pressure points. Tourniquet is used only as a last resort. 3. Remove gross contaminants on part by rinsing with saline solution. No other attempt should be made to debride the part. 4. Wrap amputated part in moistened saline gauze and place in plastic bag or container. Seal the plastic tightly, so fluid cannot come in contact with the amputated part. Place sealed container in iced solution of water or saline. Intermediate: 5. Initiate IV Normal Saline if indicated. Run TKO unless hypotensive or clinical evidence of shock exists. Paramedic: 6. Apply ECG electrodes and determine cardiac rhythm. 7. Consider Pain Management; refer to the Pain Management Protocol. (pg. 117) Contact Medical Control: These protocols are unique to Cooke County EMS per Medical Director Page 32

34 Trauma - Pregnant Trauma Patient In order to adequately care for the mother and unborn child that have been traumatized, one MUST be aware of the following facts: 1. The average maternal heartbeat will increase by 10 to 15 beats per minute when compared to the non-pregnant patient. 2. The systolic and diastolic blood pressure of the pregnant patient will often decrease by 10 to 15 mmhg in the second trimester of pregnancy and then return to normal by term. 3. The pregnant patient undergoes a significant increase in circulating blood volume - about 40 to 50%. This represents as increase in both plasma and red blood cells. However, there is usually a greater increase in plasma compared to the increase in red blood cells, thereby resulting in a relative anemia for many pregnant patients. 4. The pregnant patient may lose 30 to 45% of her circulating blood volume before hypotension develops. 5. When the pregnant patient is lying flat on her back, the enlarged uterus can cause significant compression of the inferior vena cava, thereby reducing venous return to the heart by up to 25 or 30%. This can then result in hypotension. Therefore when possible, pregnant patients should be transported in the left lateral decubitus position. If it is necessary to immobilize the patient supine, then the backboard should be tilted upward 20 to 30 degrees towards the patient s left. This will help to roll the pregnant uterus away from the inferior vena cava. 6. Gastric emptying and motility are decreased during pregnancy. This, combined with the compressive effects of the enlarging uterus on the stomach, increases the risk of aspiration in patients with a decreased level of consciousness. 7. Trauma to the pregnant patient can result in very significant amounts of OCCULT bleeding - either intrauterine or retroperitoneal. 8. Abruptio placenta is the leading cause of traumatic fetal death. Vaginal bleeding is seen in about 75% of cases. Maternal hemorrhage that does not result in decreased blood pressure can still reduce fetal blood flow by 90-95%. Trauma significant enough to cause shock in the mother is associated with Fetal Death. Contact Medical Control: Consider: An NG tube These protocols are unique to Cooke County EMS per Medical Director Page 33

35 Trauma - Pediatric Trauma Patient Clinical Definition: This protocol applies to pediatrics < 18 y/o & <40 kg or any patient < 12 y/o. Individual protocols apply to all injured patients and should be applied to the pediatric patient with reference to this protocol. When the protocols differ, a special reference is noted in the general protocol. Pediatric Differences: Normal Pediatric Vital Signs: 1. Blood pressure: systolic 80 + two times age Diastolic 2 /3 systolic pressure 2. Pulse: Newborns Infants Preschool School age Respirations: Newborns Infants Preschool School age Blood Volume: The normal total blood volume of a child is about ml/kg. Estimated Pediatric Endotracheal Tube Sizes: Age Size Newborn months year years years years years > 14 years These protocols are unique to Cooke County EMS per Medical Director Page 34

36 Shock: 1. Shock in a child is demonstrated by a faster than normal heart rate; cool and pale extremities; evidence of poor perfusion; and a systolic blood pressure less than 70 mmhg. Children have excellent compensatory systems and the appearance of a fall in blood pressure represents severe shock. 2. A child in traumatic shock has lost at least 25% of their total blood volume. 3. Treatment of shock: Basic: 4. High flow 100% oxygen. Intermediate: 5. At least one large bore IV with Normal Saline. As with adults, attempts to establish IV access are usually made enroute but may be made at the scene, if long transport are anticipated after consulting MEDICAL CONTROL. Transport should not be delayed for multiple attempts at initiation of an IV. If long transports are necessary, maximum volumes and flow rates should be determined by MEDICAL CONTROL 6. When replacing volume loss in a child suffering from hemorrhagic shock, give an initial fluid bolus of 20 cc/kg. If the vital signs then stabilize and the child no longer appears to be in shock, run the IV at a TKO rate while continuing to transport. If the first fluid bolus of 20 cc/kg does not stabilize the child s vital signs, then give a second fluid bolus of 20 cc/kg. This means that the child has probably lost at least one half of his/her total blood volume and will need blood transfusions upon arrival at a health care facility. Paramedic: 7. Apply ECG electrodes and determine cardiac rhythm. These protocols are unique to Cooke County EMS per Medical Director Page 35

37 Trauma - Isolated Musculo-Skeletal Injury Clinical Criteria: Muscular skeletal injuries with absolutely no potential for head, abdominal, chest or multi-system injury. Examples, isolated extremity fracture, crush injury and / or burn. Mechanism of injury consistent of an isolated muscular skeletal event with deformity, swelling and ecchymosis to the injured site. Pain present upon movement or palpation of the injury site and is normotensive patient without allergies or other contraindications. Basic: 1. C-spine control ABC s 2. Hemorrhage control 3. Oxygen as needed, SaO2 (if available) 4. Serial Vital signs 5. Splint/Immobilize appropriately 6. If the patient has no signs of the following, than C-Collar should be applied, but not placed on backboard: a. No Neck or Back Pain b. No Numbness or Tingling c. No Weakness of Extremities d. No Pain upon Palpation of Neck or Back e. No Pain on Motion of Neck or Back 7. If the patient has any of the above sign and/or symptoms or if there is significant mechanism, FULL C-SPINE PRECATIONS INCLUDING C-COLLAR AND BACKBOARD must be utilized. Intermediate: 8. IV of Normal Saline, large bore if: a. Open or closed femur Fracture b. Hypotension or other S/S of shock c. Obvious gross deformity Paramedic: 9. Apply ECG electrodes and determine cardiac rhythm. 10. Consider Pain Management; refer to the Pain Management Protocol. (pg. 117) Contact Medical Control: If possible multi-system trauma, abdominal and / or head injury, must contact medical control for pain management These protocols are unique to Cooke County EMS per Medical Director Page 36

38 Trauma - Acute Blunt Spinal Cord Injury Clinical Definition: This protocol should be used for treatment of the patient with acute blunt spinal cord injury Basic: Establish and maintain manual c-spine stabilization 1. Determine the nature of the injury. 2. Evaluate and treat ABC s according to protocol. 3. Assess for defining characteristics of SCI including: Partial, complete or suspected Loss of sensory and / or motor function in the upper and / or lower Extremities. 4. Immobilize and stabilize spine. 5. Prepare for rapid transport. Intermediate: 6. Establish 2 large bore IV s with NS, infuse at TKO rate. Paramedic: 7. If indicated, intubate using C-Spine precautions. 8. Apply ECG electrodes and determine cardiac rhythm, treat per arrhythmia protocol if indicated. 9. Continue evaluation as per the Initial Trauma Assessment and Treatment Protocol (pg ), with frequent neurologic assessments. Contact Medical Control: Prophylactic intubation (MAI/RSI) may be required if airway compromise occurs. These protocols are unique to Cooke County EMS per Medical Director Page 37

39 Trauma - Domestic Violence Call for law enforcement support, stage if necessary until law enforcement secures the scene. 1. Assess the scene for safety. 2. Call for law enforcement support, stage if necessary until law enforcement secures the scene. 3. ABC s maintained and support. 4. Treat injuries per trauma protocol. 5. Talk to patient alone in a safe, private environment. Use direct simple questions such as: Who caused these injuries? Are you in a relationship with someone who hurts or threatens you? 6. Look for history of domestic violence, behavioral and physical clues. These protocols are unique to Cooke County EMS per Medical Director Page 38

40 Medical Protocols These protocols are unique to Cooke County EMS per Medical Director Page 39

41 Medical Abdominal Pain / Nausea / Vomiting Clinical Definition: Non-traumatic abdominal pain. Basic: Assess and treat ABC s Oxygen per patient VS, including SaO2 Consider Orthostatic VS (if possible) (pg. 153) Intermediate: IV, Normal Saline Paramedic: EKG For severe nausea and vomiting: Ondansetron (Zofran): OR Promethazine: 4mg IVP, IM or Oral ODT (Max 8mg every 4 hours); May repeat in 15 minutes if no improvement mg IVP; mg IM; Start with lowest dose Contact Medical Control: Must contact medical control for pain management consideration These protocols are unique to Cooke County EMS per Medical Director Page 40

42 Medical Allergic Reaction (Mild) Clinical Definition: Urticaria and itching without dyspnea or hypotension. Basic: Assess and treat ABC s VS, including SaO2 Oxygen per patient Intermediate: IV, Normal Saline Paramedic: EKG, 12 lead Benadryl: 25 mg IVP or 50 mg IM Contact Medical Control These protocols are unique to Cooke County EMS per Medical Director Page 41

43 Medical Allergic Reaction (Moderate) Clinical Definition: Urticaria, itching and dyspnea without hypotension. Note: if significant wheezes see Asthma Protocol. (pg. 64) Basic: Assess and treat ABC s VS, including SaO2 Oxygen per patient EPIPEN, if patient prescribed. Intermediate: IV, Normal Saline Paramedic: EKG, 12 lead & ETCO2 Epinephrine (1:1,000): Benadryl: Dexamethasone: 0.5 mg SQ 50 mg IVP or 50 mg IM 8 mg IVP OR Methylprednisolone: 125 mg IVP Contact Medical Control: Repeat Epinephrine (1:1,000): 0.3 mg SQ If patient has moderate to severe dyspnea, meds may be given prior to IV access These protocols are unique to Cooke County EMS per Medical Director Page 42

44 Medical Allergic Reaction Severe (Anaphylaxis) Clinical Definition: Urticaria, edema, dyspnea and hypotension (BP < 90 systolic). Note: if significant wheezes see Asthma Protocol. (pg. 64) Basic: Assess and treat ABC s VS, including SaO2 Oxygen per patient EPIPEN, if patient prescribed. Intermediate: IV, Normal Saline Paramedic: EKG, 12 lead & ETCO2 Epinephrine (1:10, 000): 0.5 mg IVP or IN; may repeat once during transport OR Epinephrine (1:1000): Benadryl: Dexamethasone: 0.5 mg SQ; may repeat once during transport 50 mg IVP or 50 mg IM 8 mg IVP OR Methylprednisone: 125 mg IVP Contact Medical Control These protocols are unique to Cooke County EMS per Medical Director Page 43

45 Clinical Definition: Unresponsive, no respirations, no pulse Medical Cardiac Arrest Basic: Assess ABCs AED, as soon as available CPR (Utilize Lucas if available) Maintain airway with appropriate adjunct and ventilate with 100% O2 Intermediate: IV, Normal Saline May consider vasopressin before intubation Endotracheal Intubation, apply ETCO2 Paramedic: Refer to appropriate protocol: Asystole PEA VF and Pulseless VT Contact Medical Control These protocols are unique to Cooke County EMS per Medical Director Page 44

46 Medical Asystole Paramedic: CPR (Utilize Lucas if available) Confirm asystole in two leads Measure SaO2 Intubate and ventilate with 100% O2 IV, Normal Saline Consider and treat possible causes: Hypoxia ventilate Acidosis ventilate very well, Sodium Bicarbonate 1 meq/kg IVP during prolonged CPR Overdose. Narcan if suspected narcotic overdose Diabetic reactions.. See diabetic emergencies Hyperkalemia.. Sodium Bicarbonate 1 AMP Hypokalemia Hypothermia. Passive re-warming, warmed fluids Hyperthermia... Aggressive external cooling, cooled fluids Vasopressin: 40 units IVP; may repeat in 20 minutes AND Epinephrine (1:10,000): 1 mg IVP or IN; 3 5 minutes apart; 2 mg via ET; repeat every 3 5 minutes Consider: End tidal CO2 monitoring maintain at mmhg. Do not over ventilate SaO2 may help confirm tube placement and adequate ventilations Consider NG tube placement Contact Medical Control After 10 minutes of ETCo2 Monitoring, if still less than 10 mmhg with confirmed tube placement; Contact Medical Control to consider termination of efforts. These protocols are unique to Cooke County EMS per Medical Director Page 45

47 Medical Pulseless Electrical Activity (PEA) Paramedic: CPR (Utilize the Lucas if available) Intubate and ventilate with 100% O2 IV, Normal Saline, WO to 500 cc Vasopressin: 40 units IVP; may repeat in 20 minutes AND Epinephrine (1:10,000): 1 mg IVP or IN; 3 5 minutes apart; 2 mg via ET, may repeat every 3 5 minutes Consider and treat cause: Hypovolemia fluids and position Hypoxia. oxygenation and airway management Tension Pneumothorax.. needle chest decompression Hypothermia. re-warming with warmed fluids Acidosis. ventilation and Sodium Bicarbonate 1 meq/kg IVP Massive acute myocardial infarction. TCP Cardiac Tamponade Hyperkalemia Sodium Bicarbonate 1 AMP Massive pulmonary embolism Drug overdoses such as Tricyclics, digitalis, beta-blockers, and calcium channel blockers. Refer to Poisoning and Overdose. (pg. 72) Contact Medical Control: These protocols are unique to Cooke County EMS per Medical Director Page 46

48 Medical VF / Pulseless VT Paramedic: o EKG, quick look with paddles o For un-witnessed V-Fib / V-Tach (Utilize Lucas if available) o For Witness V-Fib / V-Tach defibrillation immediately o Defibrillation 200j; followed by 2 full minutes of CPR o Intubate and ventilate with 100% O2 (without delay in chest compressions) o IV, NS or D5W Vasopressin: 40/U IV; repeat every 20 minutes AND Epinephrine (1:10,000): 1 mg, IVP or IN; 3 5 minutes; 2 mg via ET, may repeat every 3 5 minutes Defibrillation: 300j seconds after each administration. Cordarone: 300 MG IVP Consider 2 nd dose of: Cordarone: 150 mg IVP in 3 5 min Defibrillation: 360j seconds after each administration. Magnesium Sulfate: (For Torsades de Pointe only) 1 2 g IV or IO (dilute in 10 ml of D5W for IV bolus) Defibrillation: 360j seconds after each administration Consider NG tube Contact Medical Control: These protocols are unique to Cooke County EMS per Medical Director Page 47

49 Medical Post Resuscitation (ROSC) NOTE: If patient in bradycardia, refer to bradycardia protocol. DO NOT treat post resuscitation narrow complex tachycardia, which may be caused by medications given during resuscitation. Basic: Assess and treat ABC s VS, including SaO2 & O2 per patient Intermediate: IV, Normal Saline, D5W Paramedic: EKG, 12 lead & ETCO2, If converted after defibrillation or cardioversion ONLY: Watch closely for lethal dysrhythmias If converted after medication, follow bolus with appropriate drip: Cordarone: 150 mg in 100 cc D5W, run at 50 ml/hour If patient hypotensive (BP < 90 systolic) after 5 min: Fluid challenge: 250 cc IV Normal Saline Dopamine: 10 mcg/kg/min IVPB to raise BP > 100 systolic; titrated to effect OR Levophed: mcg/kg/min IVB; >100 mmhg; <120 mmhg; titrate to effect (Max 3 mcg/min) MUST USE IV PUMP Consider NG tube Contact Medical Control These protocols are unique to Cooke County EMS per Medical Director Page 48

50 Medical Bradycardia Clinical Definition: HR < 60 with one or more of the following: SBP < 90, PVC s, altered LOC, chest pain and dyspnea Basic: Assess and treat ABC s VS, including SaO2 Oxygen per patient Intermediate: IV, Normal Saline Paramedic: EKG, 12-lead Atropine: 1.0 mg Rapid IVP; repeat every 3 5 min to Max 0.04 mg/kg If suspected beta-blocker overdose administer: 1 mg Glucagon IM and 1 g 10% Calcium Chloride SIVP; may repeat every 2 minutes; MAX dose 5 mg If suspected calcium channel blocker overdose administer: 1 gram 10% Calcium Chloride IVP TCP (external pacing) highly recommended if available. Valium: 2 10 mg IVP or IN OR Ativan: 1 2 mg IVP or IN OR Versed: 5 mg IVP or IM If hypotensive: These protocols are unique to Cooke County EMS per Medical Director Page 49

51 Dopamine: 10 mcg/kg/min IVPB titrated to raise BP > 100 Systolic; MUST USE IV PUMP Contact Medical Control: Medical PSVT Stable Clinical Definition: BP > 90 without serious signs and symptoms and a pulse of at least 150 Basic: Assess and treat ABC s VS, including SaO2 Oxygen per patient Vagal maneuvers Intermediate: IV, Normal Saline, antecubital vein or higher Paramedic: EKG, 12-lead Adenosine: 6 mg rapid IVP followed by a flush; repeat at 12 mg every 1 2 min (Max 30 mg) *Adenosine is contraindicated in patients taking TEGRITOL and PERSANTIN* Contact Medical Control: If wide complex PSVT: Cordarone: 150 mg bolus slowly over 10 minutes; Diluted in 20cc of D5W These protocols are unique to Cooke County EMS per Medical Director Page 50

52 Medical PSVT Unstable Clinical Definition: SBP < 90, a pulse of at least 150, chest pain, dyspnea, decreased LOC, pulmonary congestion, CHF and MI Basic: Assess and treat ABC s VS, including SaO2 Oxygen per patient Vagal maneuvers Intermediate: IV, Normal Saline, antecubital vein Paramedic: EKG, 12-lead if available Synchronized cardioversion: Premedicate if time permits Valium: 100j, 200j, 300j, 360j 2 10 mg IVP,IM or IN OR Ativan: 1 2 mg IVP, IM or IN OR Versed: 5 mg IVP or IM Contact Medical Control: Cordarone: 150 mg over 10 minutes; Diluted in 20 cc of D5W; max 300 mg May repeat in 10 minutes if needed These protocols are unique to Cooke County EMS per Medical Director Page 51

53 Clinical Definition: BP > 90 without serious S/S Medical VT- Stable Basic: Assess and treat ABC s Cough version Oxygen per patient VS, including SaO2 Intermediate: IV, Normal Saline Paramedic: EKG, 12-lead Cordarone: OR Magnesium Sulfate: (For Torsades de Pointes only) 150 mg over 10 minutes; Diluted in 20cc of D5W; Max 300 mg May repeat in 10 minutes if needed 1 2 grams IVP Synchronized cardioversion: Premedication if time permits Valium: 100j, 200j, 300j, 360j 2 10 mg IVP, IM or IN OR Ativan: 1 2 mg IVP, IM or IN OR Versed: 5 mg IVP or IM Contact Medical Control These protocols are unique to Cooke County EMS per Medical Director Page 52

54 Medical - VT Unstable Clinical Definition: BP < 90 systolic altered LOC, dyspnea, diaphoresis or chest pain Basic: Assess and treat ABC s VS, including SaO2 Oxygen per patient Intermediate: IV, Normal Saline Paramedic: EKG, 12-lead if available Synchronized cardioversion: Premedicateiif time permits: Valium: 100j, 200j, 300j, 360j 2 10 mg IVP, IM or IN OR Ativan: 1 2 mg IVP, IM or IN OR Versed: 5 mg IVP or IM If ventricular rate >150 Immediate cardioversion is indicated. Medications listed below are relatively low priority. If delays in synchronization occur and clinical condition is critical, go immediately to unsynchronized shocks. Cordarone: 150 mg over 10 minutes; Diluted in 20cc in D5W OR Magnesium Sulfate: (For Torsades de Pointes only) 1 2 g IVP Contact Medical Control These protocols are unique to Cooke County EMS per Medical Director Page 53

55 Acute Coronary Syndrome (Chest Pain) Clinical Definition: Chest, back, neck, jaw pain indicative of myocardial ischemia, dyspnea, diaphoresis, syncope, and cyanosis with nausea, vomiting and dizziness. Basic: Assess and treat ABC s VS, including SaO2; O2 per pt Complete survey of exclusion criteria for thrombolytics ASA 324 mg PO NOTE: If the patient has taken 325 mg within the last twelve (12) hours, do not give more ASA Intermediate: IV, Normal Saline Paramedic: EKG, 12 LEAD; Serial EKG S; Right side 12 lead (reverse V4) to RULE OUT INFERIOR WALL MI. Consider transport to a hospital with a CARDIAC CATH LAB. (For ACUTE MI refer to STEMI protocol pg. 56) Nitroglycerin: 0.4 mg SL; repeat every 5 minutes x 3 doses *Nitrates are given for venous dilation not for Analgesia* *Be cautious with Nitrates in right side or Inferior Wall MI* ETCO2 If hypotensive with SBP < cc Bolus If patient is anxious may consider: Ativan: 1 2 mg SIVP OR Valium: 2 10 mg For Vasodilation / Pain consider: Morphine: 2 10 mg IVP; 2 mg increments every 5 min (Max dose of 10 mg) Continued on next page These protocols are unique to Cooke County EMS per Medical Director Page 54

56 Pain Management Fentanyl: mcg IVP; 25 mcg increments every5 minutes (Max 100 mcg) For Nausea and / or vomiting Ondansetron: 4 mg IVP, IM or Oral ODT (Max 8 mg; every 4 hours) OR Promethazine: mg IVP; IM; start with lowest dose Cardiac Chest Pain Metoprolol: 5 mg SIVP; repeat every 5 minutes x3; Hold if SBP <100 and/or HR <55 OR Nitro Drip: 2 20 mcg/min; Maintain Systolic >90 mmhg; titrate to effect MUST IV PUMP Contact Medical Control Dopamine: Dobutamine 10 mcg/kg/min to raise BP > 100 systolic; titrated to effect mcg/kg/min; start at 10 mcg/kg/min These protocols are unique to Cooke County EMS per Medical Director Page 55

57 Medical - STEMI Clinical Definition: Patients with non-traumatic chest, back, neck and /or jaw pain with ST-segment elevation in 2 or more contiguous leads and reciprocal changes are present or a new onset LBBB. Basic: ABC s VS, including SaO2 every 5 minutes (Initial BP must be manual) Oxygen per patient ASA 324 mg PO Intermediate: 2 large bore IV s and / or lock; at least one antecubital vein; preferably in the same arm. Paramedic: EKG; 12-LEAD with a good baseline; Serial 12 Leads; Right side 12 Lead (reverse V4) to RULE OUT INFERIOR WALL MI. Transport directly to the appropriate hospital with a CARDIAC CATH LAB Transmit 12-Lead immediately and contact appropriate HOSPITAL FOR STEMI ALERT ETCO2 Nitroglycerine: 0.4 mg SL; repeat every 5 minutes x 3 doses For Vasodilation consider Morphine: 2 10 mg IVP; 2mg increments every 5 minutes (Max dose of 10 mg) For Pain Management Fentanyl: mcg IVP; mcg increments every 5 minutes (Max 100 mcg) Continued on next page These protocols are unique to Cooke County EMS per Medical Director Page 56

58 For nausea and / or vomiting Ondansetron: 4 mg IVP, IM or Oral ODT (Max 8 mg; Q 4 hours) OR Promethazine: mg IVP; IM; start with lowest dose Metoprolol: 5 mg SIVP; repeat every 5 minutes x3; Hold if SBP <100 and/or HR <55 OR Nitro Drip: 10 mcg/min; Maintain Systolic >90 mmhg; titrate to effect Max 20 mcg; MUST USE IV PUMP Contact Medical Control: IF SBP <90 consider Dopamine: Dobutamine: 10 mcg/kg/min to raise BP >100 systolic; titrate to effect 2 20 mcg/kg/min IVPB; must start at 10 mcg/kg/min These protocols are unique to Cooke County EMS per Medical Director Page 57

59 Medical - Induced Hypothermia Clinical Indication: Return of spontaneous circulation after cardiac arrest. Intubated patients that are well ventilated with ETCO2 > 30. Contraindications: Traumatic Arrest Apparent Pregnancy < than 18 years old PARAMEDIC LEVEL ONLY: Assure patent airway MUST maintain continuous cardiac, O2 saturation and ETCO2 monitoring at all times. Ensure vascular access with a minimum of 2 large bore IV s Get an initial rectal temperature INVASIVE COOLING PROCEDURE: Medicate for sedation (also for continued sedation) and shivering Versed: 5 mg; may repeat only once in 20 minutes; maintain SBP 100 OR Ativan: 1 2 mg SIVP OR Valium: 10 mg SIVP OR Etomidate: 0.3 mg/kg IVP, over 30 seconds OR Ketamine 1 2 mg SIVP, over 1 minute Remove clothing (Ensure privacy) Apply Ice/cold packs directly on skin, axilla and groin for maximum cooling effects. Rapidly Infuse Cold Saline: 30 ml/kg IV/IO: max 2 Liters (2000 ml) These protocols are unique to Cooke County EMS per Medical Director Page 58

60 If hypotensive may consider: Levophed: mcg/kg/min IVPB; SBP 100 (Max dose 3 mcg/kg/min) MUST USE IV PUMP Temperature goal C (89.6 to 93.2 F) Reassess rectal temperature Discontinue cooling measure if < 33C (91.4 F) Continue to monitor temperature > 33C (91.4 F) and no shivering Contact Medical Control: If the patient has return to spontaneous circulation while enroute to NTMC-ED; Contact Medical Control immediately. DO NOT DELAY TRANSPORT TO COOL!!!!!!! If patient becomes pulseless again, discontinue cold saline infusion follow proper protocol. Ice packs may remain in place. Remember: Patient may develop metabolic alkalosis with cooling. DO NOT HYPERVENTLIATE. Patient must be transported to a hospital that will continue induced hypothermia; must transport to one of the following facilities: Denton Regional Medical Center Texas Health Presbyterian Denton Wise Regional Medical Center Decatur These protocols are unique to Cooke County EMS per Medical Director Page 59

61 Medical Cardiogenic Shock Clinical Definition: BP < 90 systolic in the absence of trauma, altered LOC, tachycardia or other arrhythmias, diaphoresis, pulmonary congestion and tachypnea. Basic: Assess and treat ABC s VS, including SaO2 Oxygen per patient Intermediate: IV, Normal Saline Paramedic: EKG, 12 lead & ETCO2 Dobutamine OR Levophed: OR Dopamine: 2 20 mcg/kg/min IVPB; must start at 10 mcg/kg/min; If known cardiogenic shock use 1 st ; MUST USE IV PUMP mcg/kg/min IVPB; SBP >100; titrate to effect (MAX dose 3 mcg/kg/min) MUST USE IV PUMP 10 mcg/kg/min IVPB; titrated to raise BP > 100 systolic; MUST USE IV PUMP Contact Medical Control: These protocols are unique to Cooke County EMS per Medical Director Page 60

62 Medical Hypotension /Shock Unexplained Clinical Definition: BP < 90 systolic, with S/S: pale, cold, clammy skin, syncope, vomiting and/or diarrhea with intake and output. Basic: Assess and treat ABC s VS, including SaO2 & O2 per patient Place patient in Trendelenberg Position Consider orthostatic VS (if possible) Intermediate: IV, Normal Saline Fluid challenge: cc Normal Saline Paramedic: If hypotensive after 10 minutes, repeat fluid challenge Discontinue fluid challenge if S/S of Pulmonary Edema arises Second IV optional. EKG, 12 Lead If still hypotensive after adequate volume resuscitation: Levophed: mcg/kg/min IVPB; titrate to raise SBP >100; Titrate to effect (Max dose 3 mcg/kg/min) MUST USE IV PUMP Contact Medical Control: If sepsis is suspected then consider: Vasopressin Drip: 10 units in 250cc D5W run at 15 cc/hr; titrated to maintain SBP < 100 Dopamine: 10 mcg/kg/min IVPB; titrate to raise SBP > 100; if Bradycardic These protocols are unique to Cooke County EMS per Medical Director Page 61

63 Medical Hypertensive Crisis Clinical Definition: Systolic BP > 200 or Diastolic > 120, headache, blurred vision, numbness and chest pain Basic: Assess and treat ABC s VS, including SaO2 Oxygen per patient Evaluate arm drift, facial droop, and speech impairment for stroke. If present, refer to Stroke Protocol. (pg. 63) Intermediate: IV, Normal Saline Paramedic: EKG, 12 lead Nitroglycerine: 0.4 mg SL; repeat every 5 minutes x 3 doses Contact Medical Control: Nitro Drip: OR Labetalol: 2 20 mcg/kg/min; SBP >90 mmhg; titrate to effect; MUST USE IV PUMP 10 mg IVP; repeat after 10 minutes for a total of 20 mg OR Metoprolol 5 mg; repeat every 5 minutes x 3; Hold if SBP >100 and/or HR <55 These protocols are unique to Cooke County EMS per Medical Director Page 62

64 Medical Stroke Clinical Definition: Unilateral weakness, paralysis, facial droop and speech impairment Basic: Assess and treat ABC s VS, including SaO2 & O2 per patient Evaluate arm drift, facial droop, and speech impairment Determine time of onset; early notification if less than 3 hours and go to stroke center If greater than 3 hours closest appropriate facility Complete exclusion criteria survey for thrombolytics and Rapid NIH Stroke Score Intermediate: IV, Normal Saline Dextrose stick: if < 80 or signs of Hypoglycemia: Thiamine: 100 mg D50: 25 g IVP Paramedic: EKG, 12 lead Contact Medical Control: Metoprolol: 5 mg; repeat every 5 minutes x 3; Hold if SBP >100 and/or HR <55 Labetalol: 10 mg IVP; repeat after 10 minutes for a total of 20 mg If Patient is stable; Transport rapidly to the closest stroke center. (If possible) Consideration should be made, if patients need a primary or comprehensive stroke center These protocols are unique to Cooke County EMS per Medical Director Page 63

65 Medical Asthma Clinical Definition: Respiratory distress, wheezing on expiration, coughing, tripod positioning and / or accessory muscle use. Basic: Assess and treat ABC s VS, including SaO2 & O2 per patient Albuterol: 2.5 mg nebulized updraft; may repeat once in 10 min Intermediate: IV, Normal Saline. Fluid bolus 250cc; may repeat once Paramedic: EKG, 12 lead & ETCO2 Terbutaline Magnesium Sulfate Decadron 0.25 mg SQ 1 gram IVP 4 mg IVP OR Solu-medrol 125 mg IV If IV unobtainable: Decadron Morphine 4 mg; can be added to nebulized treatment 4 mg; can be added to nebulized treatment Continuous updraft Epinephrine (1:1,000) 0.3 mg SQ Consider CPAP Contact Medical Control: IF STATUS ASTHMATICUS PREPARE TO INTUBATE These protocols are unique to Cooke County EMS per Medical Director Page 64

66 Medical CHF and Pulmonary Edema Clinical Definition: Severe respiratory distress, cyanosis, diaphoresis, adventitious lung sounds, JVD, altered LOC and, chest pain. Basic: Assess and treat ABC s VS, including SaO2 Oxygen per patient, consider BVM Elevate head 30 degrees from supine Intermediate: IV, Normal Saline Paramedic: EKG, 12 Lead & ETCO2 Nitroglycerin: 0.4 mg SL; repeat every 5 minutes x 3 doses Nitrates are given for venous dilation not as an analgesic to chest pain Consider, with severe dyspnea and pulmonary edema: Morphine: Lasix: 2 5 mg IVP; 2 mg increments every 5 minutes (Max dose of 10 mg) mg/kg IVP Consider CPAP BE PREPARE TO INTUBATE Contact Medical Control: Dopamine: 10 mcg/kg/min to raise BP > 100 systolic; titrate to effect Nitro Drip: 2 20 mcg/kg/min; maintain SBP >90 mmhg; titrate to effect; MUST USE IV PUMP These protocols are unique to Cooke County EMS per Medical Director Page 65

67 Medical COPD Clinical Definition: Dyspnea with history of chronic bronchitis and / or emphysema Basic: Assess and treat ABC s VS, including SaO2 Oxygen per patient Mild dyspnea: 1 2 LPM via NC Severe dyspnea: LPM via NRB or BVM Albuterol: 2.5 mg nebulized updraft, may repeat once in 10 min OR DuoNeb: 3 ml nebulized updraft; may repeat once in 10 min Intermediate: IV, Normal Saline Paramedic: EKG, 12 lead & ETCO2 Terbutaline: Decadron: 0.25 mg SQ 4 mg IVP OR Solu-medrol: 125 mg IV Consider CPAP NOTE: Epinephrine is not an alternate drug! For Anxious Patient s may consider: (must use with caution) Ativan 1 mg SIVP OR Valium 2 5 mg SIVP Contact Medical Control These protocols are unique to Cooke County EMS per Medical Director Page 66

68 Medical- Pneumonia/ Bronchitis Clinical Definition: Dyspnea with adventitious breath sounds and history of respiratory infection, productive purulent cough, fever, chest wall pain, and no evidence of CHF (pedal edema, JVD, pertinent cardiac history). Basic: Assess and treat ABC s VS, including SaO2 & O2 per patient Encourage productive coughing. Suction as needed. Albuterol: 2.5 mg nebulized updraft; may repeat once in 10 min Intermediate: IV, Normal Saline 250 cc/hour Paramedic: EKG, 12 lead ETCO2 Consider CPAP Contact Medical Control These protocols are unique to Cooke County EMS per Medical Director Page 67

69 Medical - Seizure Clinical Definition: Active seizures (tonic/ clonic) and / or postictal Basic: Assess and treat ABC s VS, including SaO2 & O2 per patient Intermediate: IV, Normal Saline Dextrose stick: if < 80 or signs of Hypoglycemia: Thiamine: 100 mg D50: 25 g IVP Paramedic: EKG, 12 lead If seizures are prolonged or recurrent consider: Valium: OR Ativan: 5 mg IVP, IN, or rectal; may repeat as needed every 5 minutes until Max dose of 20 mg 1 mg SIVP or IN, may repeat as needed or 2 mg every 5 minutes (MAX 8 mg) OR Versed 3 5 mg IVP or IN; may repeat in 20 minutes Contact Medical Control: NOTE: If Valium is given to patients suspected of using alcohol, ensure and monitor airway These protocols are unique to Cooke County EMS per Medical Director Page 68

70 Medical Dehydration Clinical Definition: Normotensive with tachycardia and other signs/symptoms including poor skin turgor with little or no urine output, dry mucous membrane and evidence of a dehydration mechanism (vomiting, diarrhea, fever, poor oral intake) Basic: Assess and treat ABC S VS including SaO2 Oxygen per patient Consider orthostatic VS (if possible) (pg. 153) Intermediate: IV Normal Saline cc fluid bolus; may consider repeating bolus (Max 1000cc) Paramedic: EKG, 12 Lead Contact Medical Control: These protocols are unique to Cooke County EMS per Medical Director Page 69

71 Medical Diabetic Emergencies Clinical Definition: Symptoms related to altered blood glucose levels Basic: Assess and treat ABC s VS, including SaO2 & O2 per patient If alert, and suspected hypoglycemia, administer Oral Glucose Intermediate: IV, Normal Saline Dextrose stick If < 80 or signs of Hypoglycemia: If alert, administer Oral Glucose If altered LOC: Thiamine: 100 mg D50: 25 g IVP Repeat dextrose stick in 3 5 minutes If > 250 and S/S of DKA: IV infusion of NS 250 cc/hr Paramedic: If IV unobtainable: Glucagon: 1 mg IM or IN EKG, 12 lead Contact Medical Control: NOTE: Diabetic emergencies are sometimes mistaken for other illnesses such as: (CVA, substance abuse, ETOH abuse or withdrawal) Be sure to thoroughly assess patient and treat all symptoms. If there is any doubt, consult medical control. These protocols are unique to Cooke County EMS per Medical Director Page 70

72 Medical Altered Mental Status Clinical Definition: Unresponsive or disoriented patient without a clear mechanism for altered mental status. Refer to appropriate protocols as needed (diabetes, head injury, etc.) Basic: Assess and treat ABC s VS, including SaO2 Oxygen per patient Intermediate: IV, Normal Saline Dextrose stick: if < 80 or signs of hypoglycemia: Thiamine: 100 mg D50: 25 g IVP Paramedic: If pupils are constricted and/or respiratory depression: Narcan: 2 mg IVP or IN; may repeat as needed EKG, 12 lead Contact Medical Control These protocols are unique to Cooke County EMS per Medical Director Page 71

73 Medical Overdose / Poisoning Clinical Definition: Known/ suspected ingestion, injection, inhalation, or absorption of harmful substance Basic: Assess and treat ABC s Oxygen per patient If contact poisoning, brush off or flush with H2O NOW VS, including SaO2 Intermediate: IV, Normal Saline Paramedic: EKG, 12 lead & ETCO2 If altered mental status; refer to Altered Mental Status Protocol. (pg. 71) If known organophosphate poisoning: Atropine: Charcoal 2 mg IVP or IM; repeat every 5 minutes as needed; high dose may be required 50 g PO (only if alert) Benadryl: (Dystonic reaction): 25 mg; 50 IM Sodium Bicarbonate: 50 meq /L IVP (Tricyclic antidepressant) If suspected ETOH poisoning: 250cc NS fluid bolus given over 20 minutes If suspected/known narcotic overdose: Narcan 2 mg IVP Contact Medical Control: If patient refuses transport and / or is in potential danger, contact Medical Control and law enforcement. These protocols are unique to Cooke County EMS per Medical Director Page 72

74 Medical Behavioral / Emotionally Disturbed Assess patient, scene, and contact control hospital. Treat life-threatening injuries. Assess the situation and call for law enforcement support. If the patient appears dangerous or has lethal weapons, or appears in danger of losing control, or has violent disruptive or self-destructive impulses, the law enforcement personnel may aid in providing the necessary physical restraints. Approach the patient in a direct, honest manner: o Maintain continuous contact with the patient. o Encourage the patient to discuss situational stresses. o Check for emotional instability (mood swings), paranoid delusions, and depression. Avoid restraining the patient, if possible, but once restraints are applied, DO NOT REMOVE until accepted by receiving facility. Treat non-life-threatening injuries as the patient allows. Refer to Chemical Restraint Protocol. (pg. 74) These protocols are unique to Cooke County EMS per Medical Director Page 73

75 Medical Chemical Restraint For patients with agitation, severe anxiety, and, or with violent aggressive appearance. Note: It is imperative to maintain the safety of the crew first and the patient second! Basic: If patient is approachable, VS including SaO2 Contact Law Enforcement if Pt is not approachable. Consider takedown options Oxygen if tolerated Intermediate: IV Normal Saline, large bore if tolerated Paramedic: EKG/12 Lead if tolerated Geodon 20 mg IM ONLY; DO NOT REPEAT OR Haldol: 5 mg SIVP, over 1 minute or 10 mg IM Ativan: 1 mg SIVP or 2 mg IM; (If normotensive, no respiratory distress) OR Versed: 5 mg Slow IVP or IM (for severe agitation) May repeat Haldol and / or Ativan in 10 minutes if not controlled Thiamine: 100 mg IV or IM VS, O2, IV, EKG, Blood Glucose as soon as tolerated Contact Medical Control: For notification and/or if not effective with 2 nd dose These protocols are unique to Cooke County EMS per Medical Director Page 74

76 Medical Carbon Monoxide Basic: Remove victim from source Assess and treat ABC s VS, including SaO 2 High flow oxygen Intermediate: IV, Normal Saline. Paramedic: EKG, 12 lead & ETCO2 If patient is in severe respiratory distress then may consider CPAP Contact Medical Control These protocols are unique to Cooke County EMS per Medical Director Page 75

77 Medical Heat Cramps / Exhaustion Clinical Definition: Hot and humid weather with cramping in the extremities with associated nausea, vomiting, syncope episode with profuse sweating and tachycardia. Basic: Assess and treat ABC s VS, including SaO2 & O2 per patient External cooling: o Remove to cool environment o Remove excessive clothing o Cover with wet sheet o Fan patient o Ice packs to groin, axilla, and neck o Ice packs around IV tubing Do not allow patient to shiver. If shivering occurs stop cooling and lightly cover patient Intermediate: IV, Normal Saline cc Bolus; may repeat bolus (Max 1000cc) Dextrose stick: If < 80 or signs of Hypoglycemia: If alert, administer Oral Glucose If altered LOC: Thiamine: 100 mg D50: 25 g IVP Paramedic: EKG, 12 lead Contact Medical Control: If available, and if the patient is not nauseated, give fluids PO (H2O with a little salt or Gatorade). Do not massage cramping muscles. These protocols are unique to Cooke County EMS per Medical Director Page 76

78 Medical Heat Stroke Clinical Definition: Absence of sweating, reddened skin altered LOC, seizures and core temp > 105. Basic: Assess and treat ABC s VS, including SaO2 & O2 per patient Aggressive external cooling: o Remove to cool environment o Remove excessive clothing o Cover with wet sheet o Fan patient o Ice packs to groin, axilla, and neck o Ice packs around IV tubing Do not allow patient to shiver. If shivering occurs stop cooling and lightly cover patient. Intermediate: IV, Normal Saline cc Bolus; may repeat bolus (Max 1000cc) Dextrose stick: if < 80 or signs of Hypoglycemia: Thiamine: 100 mg D50: 25 g IVP Paramedic: If the patient is having seizures or if shivering consider: Valium: 5 10 mg IVP (Max 10 mg) OR Ativan: 1 2 mg SIVP OR Versed: 5 mg IVP or IM; may repeat after 20 minutes EKG, 12 lead Contact Medical Control These protocols are unique to Cooke County EMS per Medical Director Page 77

79 Medical Hypothermia Mild to Moderate: Core temp of 90º - 95º, shivering and possible altered LOC. Basic: Assess and treat ABC s VS, including SaO2 Oxygen per patient Begin external warming: o Remove wet clothing o Wrap in blanket o Heat packs to groin, axilla, neck, lateral chest o Heat packs around IV tubing Intermediate: IV, Normal Saline Dextrose stick: if < 80 or Signs of hypoglycemia: Thiamine: 100 mg D50: 25 g IVP Paramedic: EKG, 12 lead if available Consider Pain management; refer to Pain Management Protocol. (pg. 117) Contact Medical Control to consider: Severe: core temp < 90º, no shivering, cyanosis, altered LOC and apnea Treat as mild or moderate except, if pulseless with BP < 60 systolic, begin CPR. Maintain good basic life support. Contact MEDICAL CONTROL as to whether to begin advanced life support. These protocols are unique to Cooke County EMS per Medical Director Page 78

80 Medical Radiation Notify nearest HAZMAT team The vast majority of accidents involving radioactive materials occur in facilities in which these materials are used daily. In these circumstances, rescue squads should seek and follow the professional advice that is readily available to them in these centers. For accidents involving radioactive materials where professional guidance is unavailable, the following guidelines should be followed: 1. Assess scene, patient, and contact controlling hospital, which is expected to coordinate this care and control with law enforcement, fire control, and state agencies. 2. If victims without serious injury are involved in the accident: a. Do not enter the area suspected of having radioactive material present. b. Do not permit spectators to enter the area. c. Do not allow the victim(s) to leave the area d. After conferring with the emergency physician, treat the victim s other injuries. e. Notify the hospital that a patient exposed to radiation is being transported. 3. If victims with serious injury are involved in the accident: a. Treat life-threatening injuries. b. Remove the patient from the hazard area as soon as possible. c. Remove contaminated outer clothing and wash all exposed skin. d. Obtain vital signs every 10 minutes. e. Search for and treat other injuries. f. Wrap the patient in a blanket. g. Notify the hospital that a patient exposed to radiation is being transported. These protocols are unique to Cooke County EMS per Medical Director Page 79

81 Medical Snake Bite Basic: Assess and treat ABC s VS, including SaO2 Oxygen per patient Keep victim quiet Remove all jewelry and tight clothing from the affected limb which is maintained at heart level Treat for shock Immobilize the affected part at heart level If available, the dead snake should be transported to the hospital for proper identification Consider outlining the effective site to and note the time of outline to assists with watching for swelling Intermediate: IV, Normal Saline Paramedic: EKG, 12 lead Consider Pain management; refer to Pain Management Protocol. (pg. 117) Contact Medical Control These protocols are unique to Cooke County EMS per Medical Director Page 80

82 Medical Sexual Assault Assess scene, patient, contact control hospital, and contact law enforcement with patient permission or to protect crew safety. Treat life-threatening injuries. Offer emotional support. Concentrate history of medical aspects of the case. Search for and treat other injuries. (If possible, do not disturb the scene of assault or remove any clothing.) When contacting law enforcement and the control hospital, do not identify the victim by name. Do your utmost to protect the patient s privacy. Before transporting the patient to the hospital, discourage them from taking a shower, bath or douche, brush teeth or changing their clothing. Arrangements may need to be made for additional clothing that the patient can wear home. PATIENT MUST BE TRANSPORTED TO DRMC. This is the only facility that currently has a sane nurse. These protocols are unique to Cooke County EMS per Medical Director Page 81

83 OB / GYN Protocols These protocols are unique to Cooke County EMS per Medical Director Page 82

84 OB / GYN Vaginal Bleeding Clinical Definition: Non-traumatic vaginal bleeding in the absence of labor. Basic: Assess and treat ABC s Oxygen per patient VS, including SaO2 If severe bleeding, examine vaginal area and retain any tissue or clots. Place a sterile dressing over vaginal opening and leave loose. Intermediate: IV Normal Saline; may increase IV rate or multiple IV s should be established if shock is present. Paramedic: EKG Contact Medical Control: For severe nausea and vomiting: Ondansetron (Zofran): 4 mg IVP, IM or Oral ODT; may repeat (Max 8 mg Q 4 hours) OR Promethazine: mg IVP; mg IM Possible causes: Abruptio Placenta: Placentia Previa: Spontaneous Abortion: pain, uterine contractions, may appear to be normal labor. painless, bright red hemorrhaging, usually at end of second trimester. abdominal cramps, vaginal hemorrhage, back pain, presence of tissue of fetus. Do not attempt placental delivery. These protocols are unique to Cooke County EMS per Medical Director Page 83

85 OB/GYN Pre Eclampsia / Eclampsia Clinical Definition: Gestation > 20 weeks and hypertension (BP > 140 systolic and/or > 90 diastolic) with peripheral edema, moderate to severe nausea/vomiting, severe headache, hyperreflexia and proteinuria. Basic: Assess and treat ABC s Oxygen per patient Assess VS, including SaO2, with patient on left side, every 5 minutes Intermediate: IV, Normal Saline Paramedic: EKG Magnesium sulfate: 4-6 g in 50 cc of Saline over 20 min IVPB; or 2 g IM, If unable to obtain IV Contact Medical Control: Consider repeating: Magnesium sulfate: 2 grams IM Consider if hypertensive: Labetalol: 20 mg IVP For seizures refractory to Mag Sulfate consider: Valium: 2-10 mg IVP OR Ativan: 1 mg IVP, IN; repeat as needed every 5 minutes until to 2 mg These protocols are unique to Cooke County EMS per Medical Director Page 84

86 OB/GYN - Labor Clinical Definition: Back and /or abdominal cramping or pain with gestation > 20 weeks. Basic: Assess and treat ABC s Perform visual exam; check for crowning (if present, prepare for delivery) Oxygen per patient VS, including SaO2 Intermediate: IV Normal Saline Paramedic: EKG Contact Medical Control: For severe nausea and vomiting: Ondansetron (Zofran): 4 mg IVP, IM or Oral ODT; may repeat (Max 8 mg q 4 hours) Transport as soon as possible, if delivery not imminent If preterm labor less than 34 weeks gestation then consider: Terbutaline: Magnesium sulfate: Morphine:.25 mg SQ 4 6 g / 50 cc over 20 min IVPB OR 2 grams IM; if unable to obtain IV 2 10 mg IVP; repeat every 5 minutes at 2 mg increments (Max 10 mg) These protocols are unique to Cooke County EMS per Medical Director Page 85

87 OB/GYN - Delivery Clinical Definition: Active labor with presentation of fetus, delivery of infant and placenta. NOTE: Refer to the Labor Protocol (pg. 85) to prepare patient for delivery. All Levels: Preparations: Open OB kit. Place mom supine with knees bent. Place clean sheet under buttocks. Put on sterile gloves, if possible. Have mom pant between contractions. Inspect for crowning. Provide supplemental Oxygen to all delivery patients. Procedure: As crowning begins, apply gentle pressure to infant s head (take caution of fontanelle). Continue gentle pressure as head delivers. With bulb syringe, suction infant s mouth then nose. Check for umbilical cord around neck. If present, gently slip cord from around neck. If unable to slip around head, apply clamps 2" apart and cut in between, then unwrap cord from around neck. Gently guide head downward to assist shoulder delivery. Be prepared to support infant, delivery is quicker at this point. Suction again, mouth then nose. Note time of delivery. Dry infant and wrap in infant insulating blanket to keep warm. Clamp cord at 6" from infant and another at 2" distal from the first clamp. Cut cord. Perform APGAR scoring at 1 and 5 minutes (treat infant per score). Refer to Pediatric Post Delivery Protocol. (pg.91) Placenta: Placenta will deliver approximately 20 minutes after birth. If severe bleeding persists: Treat for shock to level of training. Gently massage abdominal area over uterus to cause contractions and placenta delivery. Transport. Retain placenta and transport to hospital. Contact Medical Control These protocols are unique to Cooke County EMS per Medical Director Page 86

88 Clinical Definition: Presentation of buttocks or feet first. OB/GYN Delivery (Breech Presentation) NOTE: Best delivered in hospital, however if delivery is imminent assist as follows: Basic: Assess and treat ABCs VS, including SaO2 & O2 per patient Intermediate and Paramedic: IV, Normal Saline Procedure: Prepare mother for delivery as described in the Delivery Protocol. (pg. 86) Allow fetus to deliver spontaneously up to the level of the umbilicus. If the fetus is in a front presentation, gently extract the legs downward after the buttocks are delivered. After the legs are clear, support the baby s body with the palm of the hand and volar surface of the arm. After the umbilicus is visualized, gently extract 4 to 6 inch loop of cord to allow delivery without traction on the cord. Gently rotate the fetus to align the shoulders in an anterior-posterior position. Continue with gentle traction until the axilla is visible. Gently guide the infant upward to allow delivery of the posterior shoulder then gently guide the infant downward to deliver the anterior shoulder. Be aware that the head often is delivered without difficulty. If the head is not delivered in 2 3 minutes, use two fingers in a V on either side of the nose to provide an airway and transport immediately. Complete delivery procedure as described in the Delivery Protocol. (pg. 86) Contact Medical Control These protocols are unique to Cooke County EMS per Medical Director Page 87

89 OB/GYN Delivery (Cord Presentation) Clinical Definition: Umbilical cord presents with or before presenting part of fetus. NOTE: Transport Immediately. Basic: Assess and treat ABCs Oxygen via non-rebreather VS, including SaO2 Intermediate and Paramedic: IV, Normal Saline Procedure: Place mother in knee-chest or Trendelenberg position on left side. TRANSPORT IMMEDIATELY. Instruct mother to pant with each contraction to prevent bearing down. Apply moist sterile dressing to the exposed cord to minimize temperature changes that may cause umbilical artery spasm. With a gloved hand, gently push the fetus back into the vagina and elevate the presenting part to relieve pressure on the cord. The cord may spontaneously retract, but NO ATTEMPT SHOULD BE MADE TO REPOSITION THE CORD. DO NOT REMOVE HAND. Contact Medical Control These protocols are unique to Cooke County EMS per Medical Director Page 88

90 Clinical Definition: Presentation of extremity. OB/GYN Delivery (Limb Presentation) NOTE: Transport Immediately. Basic: Assess and treat ABCs Oxygen via non-rebreather VS, including SaO2 Intermediate and Paramedic: IV, Normal Saline Procedure: Place mother in knee-chest or Trendelenberg position on left side. TRANSPORT IMMEDIATELY. Contact Medical Control These protocols are unique to Cooke County EMS per Medical Director Page 89

91 Pediatric Protocols These protocols are unique to Cooke County EMS per Medical Director Page 90

92 Clinical Definition: Care and evaluation of the newborn infant. All Levels: Pediatric Post Delivery Ensure patent airway, suctioning mouth and nose. Prevent heat loss. Dry neonate and keep warm. Cover with dry wrappings. Be sure to cover the head. Place infant on the back or side with the neck slightly extended in the sniffing position. Provide tactile stimulation to induce respirations if necessary. Appropriate methods are slapping or flicking the soles of the feet and rubbing the infant s back. Perform APGAR scoring at 1 and 5 minutes. If Respiratory Distress: Rate > 80 consistently, nasal flaring, grunting or retractions and SaO2 < 96%, consistently: Blow by 10 LPM Sat < 90, apnea: O2 via minute If Bradycardia: Rate : Blow by O2 at 10 LPM Rate < 80: CPR, O2 via BVM at minute Contact Medical Control: The APGAR SCORE Sign min 5 min Appearance (skin color) Blue, pale Body pink, extremities blue Completely pink Pulse rate (heart rate) Absent Below 100 Above 100 Grimace (irritability) No response Grimaces Cries Activity (muscle tone) Limp Some flexion of extremities Active motion Respiratory (effort) Absent Slow and irregular Strong cry Total Score: These protocols are unique to Cooke County EMS per Medical Director Page 91

93 Pediatric Neonatal Resuscitation Clinical Definition: Resuscitation of the depressed neonate (infant born at >38 weeks gestation, less than 30 days old). NOTE: Transport immediately Basic: Assess and treat ABCs. Dry and keep infant warm. Place infant on back with neck in sniffing position. If meconium is present refer to the Meconium Staining Protocol. After delivery, use mild stimulation (drying, warming, suctioning) to induce respirations. If respiratory response is slow, shallow, or absent begin positive-pressure ventilation (40 60) with pediatric bag valve mask and supplemental oxygen. If heart rate <100, initiate positive-pressure ventilation with supplemental oxygen if not already done. If heart rate < 80, begin chest compressions If central cyanosis is present in an infant with spontaneous respirations and an adequate heart rate, administer blow-by oxygen at 5 L/min. Intermediate: Endotracheal intubation is indicated if BVM ventilation is ineffective. ETCO2 ventilate at breaths/min to maintain an EtCo2 between mmhg. IV/IO Normal Saline. Paramedic: EKG. Refer to appropriate protocol If shock present: 10 cc/kg fluid bolus, repeat at 10 cc/kg Contact Medical Control These protocols are unique to Cooke County EMS per Medical Director Page 92

94 Pediatric Meconium Staining Clinical Definition: Presence of fetal stool in amniotic fluid. Basic: Suction mouth, pharynx, and nose in that order. Provide blow-by oxygen. Intermediate and Paramedic: Suction hypopharynx under direct visualization. If the neonate is depressed or the meconium is thick or particulate, perform direct endotracheal suctioning using the ET tube as a suction catheter. Quickly intubate the trachea and apply suction to the proximal end of the endotracheal tube while withdrawing the tube. Repeat the intubation-suction-extubation cycle until no further meconium is obtained. Do not ventilate between intubations. Continue resuscitative measures as needed. Contact Medical Control These protocols are unique to Cooke County EMS per Medical Director Page 93

95 Pediatric - Asystole Remember: Cardiac arrest in pediatric patients is almost always due to respiratory arrest Basic: ENSURE PROPER VENTILATIONS Determine pulselessness Begin CPR with good ventilations and supplemental O2 Intermediate: Intubate EtCo2 then ventilate at breaths/min to maintain an EtCo2 between mmhg IV or IO, Normal Saline Paramedic: Determine cardiac rhythm (confirm Asystole in 2 leads) Epinephrine (1:10,000): 0.01 mg/kg IV/IO/ET/IN; repeat every 3 5 minutes Consider the causes Hypoxemia Tension Pneumothorax Acidosis Cardiac Tamponade Hypovolemia Hypothermia Hypoglycemia Contact Medical Control These protocols are unique to Cooke County EMS per Medical Director Page 94

96 Pediatric Pulseless Electrical Activity (PEA) Basic: Determine pulselessness. Begin CPR with good ventilations and supplemental O2. Determine possible causes: if TRAUMA, transport NOW. Intermediate: Intubate. EtCo2 then ventilate at breaths/min to maintain an EtCo2 between mmhg IV or IO, Normal Saline Paramedic: Determine cardiac rhythm Epinephrine (1:10,000):.01 mg/kg IV/IO/ET/IN; repeat every 3 5 minutes Contact Medical Control: Possible causes: Hypoxemia Tension Pneumothorax Acidosis Cardiac Tamponade Hypovolemia Hypothermia Hypoglycemia These protocols are unique to Cooke County EMS per Medical Director Page 95

97 Pediatric VF / Pulseless VT Remember: Cardiac arrest in pediatric patients is almost always due to respiratory arrest. Basic: ENSURE PROPER VENTILATIONS Determine pulselessness Begin CPR with good ventilations and supplemental O2 Intermediate: Intubate EtCo2 then ventilate at breaths/min to maintain an EtCo2 between mmhg IV/ IO, NS Paramedic: Determine cardiac rhythm (quick look) If un-witnessed V-Fib / V-Tach perform 1 minute of CPR prior to Intubation and Defibrillation Defibrillate: 2 j/kg, 4j/kg, 4j/kg. Epinephrine (1:10,000): 0.01 mg/kg IV/IO/ET/IN; repeat every 3 5 minutes Defibrillate: 4j/kg after each dose. Cordarone: 5 mg/kg IV bolus Defibrillate: 4j/kg after each dose. Contact Medical Control These protocols are unique to Cooke County EMS per Medical Director Page 96

98 Pediatric Post Resuscitation (ROSC) Basic: Continue 100% O2 via NRB or BVM VS, including SaO2 Intermediate: IV, Normal Saline, or D5W. Paramedic: If bradycardic, see Bradycardia Protocol (pg. 99) Up to one year: rate < 80 One to eight years: rate < 60 Contact Medical Control: If converted from ventricular rhythm and no previous medications given and patient hypotensive after 5 minutes Dopamine: mcg/kg/min IVPB; titrated to effect These protocols are unique to Cooke County EMS per Medical Director Page 97

99 Pediatric Unstable Narrow Complex Tachycardia Clinical Definition: Narrow complex Tachycardia (<0.08 sec) infants > 220 bpm, children >180 bpm with signs and symptoms of hypoperfusion. Consider underlying causes of tachydysrhythmias. Do not treat sinus tachycardia in pediatric patients. Basic and First Responder: Ensure airway patency Oxygen per patient Complete VS, SaO2 monitor if available Intermediate: IV/IO of Normal Saline, or saline lock Dextrose-stick if < 60 see hypoglycemia protocol (pg. 105) Paramedic: ECG 12 lead if practical Vagal Maneuvers ( if this can be done in a timely manner) Synchronous Cardioversion at j/kg, may repeat at 2 j/kg May pre-medicate with Ativan or Valium if time permits. Dosing per Broselow tape Adenosine: 0.1 mg/kg rapid IV push (max first dose 6 mg); may double the dose once and then may repeat Cordarone: 5 mg/kg IV over minutes Contact Medical Control These protocols are unique to Cooke County EMS per Medical Director Page 98

100 Pediatric - Bradycardia Clinical Definition: Up to one year with ventricular rate < 80. One to eight years with ventricular rate < 60. Basic: Ensure patent airway VS, including SaO2 Intermediate: IV or IO, Normal Saline Paramedic: Epinephrine (1:10,000): 0.01 mg/kg IV/IO/ET/IN; repeat every 3 5 min Consider possible causes: Hypoglycemia Respiratory Compromise Acidosis Medical History Atropine: 0.02 mg/kg IV/IO/ET/IN; repeat in 3 5 min Max of 0.04 mg/kg; Minimum single dose: 0.1 mg; Maximum single dose: 0.5 mg Fluid challenge: 10 cc/kg of Normal Saline If severe respiratory compromise, intubation may be necessary. ETCO2, if available. Contact Medical Control These protocols are unique to Cooke County EMS per Medical Director Page 99

101 Clinical Definition: Non-traumatic abdominal pain. Pediatric Abdominal Pain (Vomiting) Basic: Assess and treat ABC s Oxygen per patient VS, including SaO2 Intermediate: IV, Normal Saline Paramedic: EKG For severe nausea and vomiting: Ondansetron (Zofran): Ages 2 and under: 15 mg/kg; Contact Medical Control Ages 2 7: 1 mg IVP, IM or Oral ODT (Max 2 mg Q 4 Hours); May repeat in 15 minutes with no improvement Ages 7 12: 2 mg IVP, IM or Oral ODT (Max 4 mg Q 4 Hours); May repeat in 15 minutes with no improvement Contact Medical Control These protocols are unique to Cooke County EMS per Medical Director Page 100

102 Pediatric Allergic Reaction (Mild) Clinical Definition: Urticaria, itching, without dyspnea or hypotension Basic and Intermediate: Ensure patent airway VS, including SaO2 Oxygen per patient Paramedic: EKG Benadryl: 1.0 mg/kg IM; MAX 25 mg Contact Medical Control These protocols are unique to Cooke County EMS per Medical Director Page 101

103 Pediatric Allergic Reaction (Moderate) Clinical Definition: Urticaria, itching, dyspnea without hypotension. NOTE: If significant wheezes: see Pediatric Asthma Protocol. (pg. 110) Basic: Ensure patent airway VS, including SaO2 & O2 per patient EPIPEN, if patient prescribed. Intermediate: IV, Normal Saline Paramedic: Benadryl: Epinephrine (1:1,000): 1.0 mg/kg IV/IM; MAX 25 mg mg/kg SQ; MAX 0.3 mg EKG If patient has moderate to severe dyspnea, meds may be given prior to IV access Dexamethasone: 0.1 mg/kg IVP OR Methylprednisolone: 1 mg/kg IVP Contact Medical Control: Repeat the Epinephrine (1:1,000): 0.01 mg/kg SQ These protocols are unique to Cooke County EMS per Medical Director Page 102

104 Pediatric Allergic Reaction Severe (Anaphylaxis) Clinical Definition: Urticaria, edema, dyspnea and hypotension. NOTE: If significant wheezes: refer to Pediatric Asthma Protocol. (pg. 110) Basic: Ensure patent airway VS, including SaO2 & O2 per patient EPIPEN, if patient prescribed. Intermediate: IV, Normal Saline Paramedic: Benadryl: Epinephrine (1:10,000): 1.0 mg/kg IV/IM; MAX 25 mg 0.01 mg/kg slow IV/IO/IN; MAX 0.3 mg EKG Repeat Epinephrine (1:10,000): 0.01 mg/kg IV/IO/IN If patient has moderate to severe dyspnea, meds may be given prior to IV access Dexamethasone: 0.1 mg/kg IVP OR Methylprednisolone: 1 mg/kg IVP Contact Medical Control These protocols are unique to Cooke County EMS per Medical Director Page 103

105 Pediatric Altered Mental Status Clinical Definition: Unresponsive or disoriented patient without a clear mechanism for altered mental status. Refer to appropriate protocols as needed (diabetes, head injury, etc.) Basic: Ensure patent airway VS, including SaO2 High flow oxygen, assist respirations via BVM, if needed Intermediate: IV, Normal Saline Dextrose stick: if < 80 or if signs and symptoms of hypoglycemia: Preterm infants: Children under 3 years: Children 3 years or older: D10: 5 10 cc/kg IV D25: 2 4 cc/kg IV, slowly D50: 1 cc/kg IV Glucagon for confirmed hypoglycemia: 1 mg IM/IN, if IV not available Paramedic: EKG Contact Medical Control: Narcan: 0.1 mg/kg IV/IO/IN; MAX SINGLE DOSE 2.0 mg * D10 may be prepared with D50 diluted 1:4 with sterile H20. * D25 may be prepared with D50 diluted 1:1 with sterile H20. These protocols are unique to Cooke County EMS per Medical Director Page 104

106 Pediatric - Hypoglycemia Clinical Definition: Symptoms related to altered blood glucose levels. Basic: Ensure patent airway VS, including SaO2 Oxygen as tolerated If alert, and suspected hypoglycemia, administer Oral Glucose Intermediate: IV, Normal Saline Dextrose stick: if < 60: Preterm infants: Children under 3 years: Children 3 years or older: D10: 5 10 cc/kg IV D25: 2 4 cc/kg IV, slowly D50: 1 cc/kg IV Glucagon for confirmed hypoglycemia: 1 mg IM/IN, if IV not available Paramedic: EKG Contact Medical Control: *D10 may be prepared with D50 diluted 1:4 with sterile H20 * D25 may be prepared with D50 diluted 1:1 with sterile H20 These protocols are unique to Cooke County EMS per Medical Director Page 105

107 Pediatric - Hyperthermia Basic: Ensure patent airway VS, including SaO2 High flow oxygen Rapid external cooling: o Remove to cool environment. o Remove all clothing. o Sponge with cool water. o If shivering occurs, stop cooling. o Avoid large amounts of fluid PO o Fan patient. Intermediate: IV, Normal Saline at cc/kg/hour, wrap ice packs around IV tubing. Paramedic: Valium: to stop shivering or seizure activity. Ativan (if available) if Valium unavailable: mg/kg slow IVP mg/kg SIVP; Rectal mg/kg CONTACT MEDICAL CONTROL FOR ORDERS TO REPEAT: MAX 4 mg Contact Medical Control These protocols are unique to Cooke County EMS per Medical Director Page 106

108 Pediatric - Hypothermia Clinical Definition: Core temperature < 90 degrees, cessation of shivering activity and / or altered mental status. Basic: Ensure patent airway VS, including SaO2 Oxygen at highest concentration, assist with BVM if necessary. Warm oxygen by wrapping heat packs around tubing Cardiac arrest should be treated with CPR only External warming: o Move to warm environment. o Remove wet clothing. o Wrap in blankets. o Heat packs to neck, groin, and axilla. Intermediate: IV, NS; Warm fluids by wrapping tubing with heat packs or pre-warmed fluids Paramedic: EKG Dextrose stick: if < 80 or sign and symptoms of hypoglycemia: Preterm infants: Children under 3 years: Children 3 years or older: D10: 5 10 cc/kg IV D25: 2 4 cc/kg IV, slowly D50: 1 cc/kg IV Contact Medical Control: Use cardiac drugs only on medical control order. Minimize rough handling or agitation of patient. These protocols are unique to Cooke County EMS per Medical Director Page 107

109 Pediatric Near Drowning Basic: C-spine precautions Ensure patent airway Suction as needed VS, including SaO2 High flow oxygen Intermediate: IV, Normal Saline Airway management as necessary. ETCO2, if available Paramedic: EKG (see appropriate protocol) Contact Medical Control Consider water temperature and possible hypothermia. Transportation is necessary due to complications that may arise later. These protocols are unique to Cooke County EMS per Medical Director Page 108

110 Pediatric Overdose / Poisoning Clinical Definition: Known / suspected ingestion / injection/inhalation / absorption of harmful substance. Basic: Ensure patent airway Determine overdose substance VS, including SaO2 If contact poisoning, brush off or flush with H2O NOW High flow oxygen, assist respirations via BVM, if needed If altered mental status see Pediatric Altered Mental Status Protocol (pg. 104) Intermediate: IV, Normal Saline Paramedic: EKG If ingested poisoning: Activated Charcoal: < 1 year: 1 g/kg > 1 year: g Contact Medical Control These protocols are unique to Cooke County EMS per Medical Director Page 109

111 Pediatric - Asthma Clinical Definition: Respiratory distress, wheezing on expiration, coughing, tripod positioning and / or accessory muscle use. Basic: Assess and treat ABC s VS, including SaO2 Oxygen per patient Albuterol: 2.5 mg nebulized updraft; ONLY HALF dose if under 2 years; may be repeated once in 10 minutes; only with Medical Control Permission Intermediate IV, Normal Saline Paramedic: EKG, 12 lead & ETCO2 Monitor If steroid dependent: Decadron: mg/kg IV/IO/IM OR nebulized updraft Continuous updraft Epinephrine (1:1,000): Terbutaline: 0.01 mg/kg SQ OR nebulize updraft.5 mg; MAX single dose SQ 0.3 mg 0.25 mg SQ OR nebulized in 2 cc saline Contact Medical Control These protocols are unique to Cooke County EMS per Medical Director Page 110

112 Pediatric - Bronchiolitis Clinical Definition: History of upper respiratory infection, rapid onset, hacking cough, audible wheezing, lethargy and, may be febrile. Under 2 years of age. Basic: Ensure patent airway VS, including SaO2 Oxygen, humidified (blow-by if delivery device not tolerated) Position of comfort If febrile: Tylenol Suspension: 15 mg/kg PO or RECTAL Albuterol: 2.5 mg nebulized updraft; ONLY HALF dose if under 2 years; may be repeated once in 10 minutes; only with Medical Control Permission Intermediate: IV Normal Saline Paramedic: EKG Epinephrine (1:1000).5 mg nebulized updraft; may repeat after 10 min Contact Medical Control: Epinephrine (1:1,000): 0.01 mg/kg SQ These protocols are unique to Cooke County EMS per Medical Director Page 111

113 Pediatric - Croup Clinical Definition: History of upper respiratory infection, barking cough, most common at night, ages 6 months to 4 yrs. Do not examine throat Basic and Intermediate: Ensure patent airway VS, including SaO2 Oxygen, humidified (blow-by if delivery device not tolerated) Position of comfort If febrile: Tylenol Suspension: 15 mg/kg PO OR RECTAL Paramedic: EKG Decadron 0.1 mg/kg IVP OR nebulized updraft Consideration: Epinephrine (1:1000).5 mg nebulized updraft; may repeat after 10 min Contact Medical Control These protocols are unique to Cooke County EMS per Medical Director Page 112

114 Pediatric - Epiglottis Clinical Definition: Rapid onset, high fever, sore throat, drooling, inspiratory stridor, tri-pod positioning. Less than 5 y/o, do not examine throat or place anything in mouth. These patients require rapid transport. Basic and Intermediate: Ensure patent airway VS, including SaO2 Oxygen, humidified (blow-by if delivery device not tolerated) Position of comfort Paramedic: EKG Decadron 0.1 mg/kg, nebulized updraft Contact Medical Control: If complete airway obstruction: Attempt intubation or Cricothyroidotomy Agitation can increase edema or swelling. *AVOID IV IF POSSIBLE* These protocols are unique to Cooke County EMS per Medical Director Page 113

115 Pediatric Obstructed Airway / Foreign Body Basic: If patient able to cough, allow patient to relieve obstruction on his / her own If patient unable to relieve obstruction, perform Heimlich maneuver appropriate to age Intermediate Attempt to visualize obstruction and remove with Magill Forceps Oxygen and intubation, as needed Transport immediately Paramedic: IV Normal Saline only in deteriorating patients Contact Medical Control: *Cricothyroidotomy, only if all other efforts fail * These protocols are unique to Cooke County EMS per Medical Director Page 114

116 Clinical Definition: Active seizures (tonic/ clonic) or postictal. Basic: Pediatric - Seizures Ensure patent airway. Determine possible cause: Elevated Temperature; Head Injury; Medical History Protect patient from injury. VS, including SaO2. Oxygen as tolerated. Intermediate: IV, Normal Saline Dextrose stick: if < 80 or signs and symptoms of hypoglycemia: Preterm infants: Children under 3 years: Children 3 years or older: D10: 5 10 cc/kg IV D25: 2 4 cc/kg IV, slowly D50: 1 cc/kg IV Paramedic: EKG Valium: 0.1 mg/kg IV/IO/IN, or 0.5 mg/kg RECTAL; may repeat in 5 min OR Ativan mg/kg SIVP over 2 minutes; Rectal mg/kg CONTACT MEDICAL CONTROL FOR ORDERS TO REPEAT: MAX 4 mg Narcan: Glucagon: 0.1 mg/kg IVP, or 2 mg IM (If suspected narcotic overdose) 1 mg IM/IN; if IV not available Contact Medical Control: * D10 may be prepared with D50 diluted 1:4 with sterile H20. * D25 may be prepared with D50 diluted 1:1 with sterile H20. These protocols are unique to Cooke County EMS per Medical Director Page 115

117 Appendix: Procedure Section These protocols are unique to Cooke County EMS per Medical Director Page 116

118 Pain Management (General Protocol) Evaluate Pain Scale: 0-10, with 10 being the worst; Ask about Patient allergies to medications and, ask the patient if they want pain management. Verify no neurological deficits indicating head injury. If a possibility of a head injury or multi-systems trauma, contact Medical Control prior to medication administration. Administer one of the following: Morphine: Adult: 2 5 mg increments Slow IVP, Q 5 minutes (MAX dose of 20mg) Pediatric < 2 years: 0.1mg/kg Slow IVP Q 5 minutes (MAX of 10 mg) Fentanyl: Nubain: Adult: mcg Slow IVP; May repeat after 5 minutes (MAX of 100 mcg) Pediatric < 2 years:.5mcg/kg Slow IVP, may repeat after 5 minutes (MAX of.5mcg/kg) Adult: 5 10 mg SIVP; may repeat 5 mg, after 10 min Pediatric: Not Recommended: Contact Medical Control Valium: Adult: 2 10 mg SLOW IVP Pediatric: 0.1 mg/kg Slow IVP (MAX does of.5mg/kg) Ativan Adult: 1 2 mg SIVP Pediatric: Dose per Broselow For severe nausea and vomiting due the effect of pain meds: Ondansetron: Adult: 4 8 mg IVP, IM or Oral ODT Pediatric: Age: 2 7; 1 mg IVP, IM or Oral ODT (MAX dose of 2 mg Q 4 hours) Age: 7 12; 2 mg IVP, IM or Oral ODT (MAX dose of 4 mg Q 4 hours); May repeat in 15 min if no improvement Promethazine: Adult: mg IVP; mg IM, Start with lowest dose Pediatric: Contact Medical Control for Dosage Pain Management for Burn patients: Morphine 10 mg (Max Dose 40 mg) AND Valium 10 mg SIVP (Max Dose 20 mg) May repeat if SBP is maintained > 90 mmhg These protocols are unique to Cooke County EMS per Medical Director Page 117

119 Medication Assisted Intubation (MAI) Clinical Definition: In the patient in whom intubation is required and has an Altered Level of Consciousness (LOC) with Glasgow Coma Score of < 8, impending respiratory failure/arrest or airway obstruction, or an intact gag reflex consider Medically Assisted Intubation (MAI), for contraindications see RSI Protocol. Recommendations: Contact Medical Control for Medically Assisted Intubation (MAI) Orders If no contraindications to the oral tracheal intubation approach, it will be your best choice. Procedure: Patient preparation as described in the RSI protocol is standard. Refer to RSI Protocol. (pg ) In lieu of Succinylcholine/ Administer (may consider): Ketamine: 1 2 mg/kg SIVP, over 1 minute OR Etomidate:.3 mg/kg OR Fentanyl mcg Consider Hurricane Spray Consideration: *If sedation is adequate then proceed with intubation* If at any time you feel you are losing control of the airway with this protocol, you may consider repeating: Etomidate: 0.3 mg/kg IVP OR Fentanyl: mcg IVP If still no success, then return to traditional RSI Protocol. Refer to RSI Protocol. (pg ) These protocols are unique to Cooke County EMS per Medical Director Page 118

120 Rapid Sequence Induction for Intubation (RSI) Clinical Indications: Altered Level of Consciousness (LOC) with Glasgow Coma Score of < 8, impending respiratory failure and, respiratory arrest, and/or airway obstruction. Contraindications: Inability to ventilate the patient if paralyzed as in acetyl cholinesterase Disorders, neuromuscular disorders (muscular dystrophies, MG, etc ) Only personnel credentialed by the Medical Director are to attempt RSI in the field. Qualified RSI providers are to be identified by a list to ED staff and Posted in Last page of this Protocol Book. Medical Director will update as needed. If patient is bradycardia, pre-medicate with: *Contact Medical Control for clearance to proceed with RSI* Atropine: mg IV Prepare for endotracheal intubation :( have the needle Cricothyroidotomy kit & suction prepared and at the patient s side) For Sedation: Ketamine 1 2 mg/kg SIVP, over 1 minutes OR Etomidate: 0.3 mg/kg IPV, over 30 seconds OR Versed: 5 mg IVP When sedation is achieved: Succinycholine: 1 1.5mg/kg IVP When patient is paralyzed and unable to intubate; place alternate airway (King Airway, TTJV, Cricothyroidotomy) and Ventilate with use of pulse ox and ETCO2. Effective ventilation of some form MUST BE ACHIEVED!!!!! These protocols are unique to Cooke County EMS per Medical Director Page 119

121 Secure and confirm tube placement and transport For continued sedation: Versed: 1 5 mg IVP, every10 minutes for a total of 20 mg in 1 hour; (Pediatric dose 0.1 mg/kg) OR Fentanyl: mcg every 5 minutes For continued pain management: Morphine: 2 5 mg IVP, every 5 minutes or until pain is relieved; (Pediatric dose 0.1 mg/kg) For continued paralysis: Rocuronium (ROC): mg/kg These protocols are unique to Cooke County EMS per Medical Director Page 120

122 Continued Sedation / Paralysis Clinical Indications: For use in the intubated patient who demonstrates a lack of tolerance for the presence of the ET tube and must remain sedated and paralyzed for airway protection during transport. Under no circumstances should a paralytic be administered to any patient who is not appropriately pain medicated and sedated. PARAMEDIC ONLY Verify tube placement via ETCO2 monitoring, auscultation of lung fields, and absence of air in the epigastrium during ventilation. Findings must be documented. Verify patency of IV For continued sedation: Ketamine: 1 2 mg/kg SIVP over 1 minutes OR Versed: mg IVP OR Ativan: 1 2 mg IVP For continued paralysis: Rocuronium (ROC): mg/kg IVP Ensure Adequate and Effective Ventilation is ongoing for Duration of Transport These protocols are unique to Cooke County EMS per Medical Director Page 121

123 Airway Management for the Burn Victim Clinical Definition: In the patient in which intubation is required and who likewise is the victim of a burn, this requires some unique considerations. These are based on the physiologic considerations that these patients are predisposed to electrolyte shifts and may have depressed cardiovascular reserves. These are some of the reasons we should do our best to avoid the traditional agents which include Succinylcholine. Recommendations: If no contraindications to the nasotracheal approach, this might be your first line of choice. If you need patient cooperation and relaxation and nasotracheal is not possible or fails, then a modified RSI should be utilized. Procedure: Contact Medical Control for Medically Assisted Intubation (MAI) Orders. Patient preparation as described in the RSI protocol is standard. (See RSI Protocol pg. 119) In lieu of Succinylcholine and Etomidate: Administer (may administer 2 nd dose if inadequate sedation for intubation): Morphine 10 mg IVP (Max Dose 40 mg) OR Ativan 4 mg SIVP (Max 20 mg) OR Valium 10 mg IVP (Max 20 mg) May repeat the above regimen but, SBP must remain < 90 mmhg Consideration: If you feel you are losing control of the airway with this protocol, you may consider other options to include: Ketamine 1 2 mg/kg SIVP OR Etomidate: 0.3 mg/kg IVP OR Fentanyl: mcg IVP If still no success, then return to traditional RSI Protocol. Refer to RSI Protocol. (pg ) These protocols are unique to Cooke County EMS per Medical Director Page 122

124 Air Evacuation Protocol The following criteria justify but do not require air evacuation for adult trauma patients: 1. Estimated ground transport to the nearest Level I/II Trauma Center is greater than the response and transport time for the helicopter and the patient has one of the following injuries or conditions (The helicopter may carry blood, if requested. If so, only the response time should be considered.): a) Multisystem blunt or penetrating trauma with unstable vital signs. b) Penetrating injury to head, neck, chest, abdomen, or groin. c) Burns > 20% TBSA (2nd or 3rd degree) or involving face, airway, hands, feet or genitalia. d) Amputations with the potential for reimplantation. e) Paralysis or other signs of spinal cord injury. f) Flail chest. g) Open or suspected depressed skull fracture. h) Open or unstable pelvis fracture. i) Two or more proximal bone fractures 2. Patient extrication time greater than 20 minutes 3. Number of critically injured patients exceeds capabilities of local EMS agencies. 4. Closest hospital is on diversion for trauma patients. 5. Ambulance access to the scene, or away from the scene, is impeded by road conditions, weather conditions, or traffic. The following criteria justify air evacuation for pediatric trauma patients: 1. Experienced or at risk for developing acute respiratory failure or respiratory arrest and is not responsive to initial therapy. 2. Invasive airway procedure with assisted ventilation. 3. Respiratory rate less than 10 or greater than 60 breaths per minute. 4. Systolic blood pressure: Neonate: Infant (< 2 yr): Child (2-5 yr): Child (6-12 yr): less than 60 mmhg less than 65 mmhg less than 70 mmhg less than 80 mmhg 5. Near drowning with signs of hypoxia or altered mental status. The following criteria justify air evacuation for Medical Patients: 1. Acute MI with Cardiogenic shock or patient not eligible for TPA 2. Acute CVA which is defined as onset less than 3 hours 3. Other acute medical conditions that require immediate specialized treatment These protocols are unique to Cooke County EMS per Medical Director Page 123

125 Pacing (Transcutaneous) Clinical Indication: For temporary pacing in patients with symptomatic bradycardia. 1. Attach lead wires to the adhesive electrode pads. 2. Apply anterior adhesive electrode on left side of sternum over the point of maximum intensity; posterior electrode just below the left scapula. If possible, place pads on clean dry skin. If necessary, trim hair. 3. Turn pacer on. DO NOT start current flow. 4. Set pacer rate to Increase milliamp setting by 20's until capture is obtained or up to the maximum energy available. Electrical capture: Mechanical capture: wide QRS and tall, broad T-waves. palpable pulse, rise in BP, improved LOC, skin color/temp. 6. Once capture is obtained begin decreasing milliamp setting by 5's until capture is lost. Then increase by 5's until capture is regained. (Obtain stimulation threshold.) 7. Confirm mechanical capture. 8. If no response is obtained from maximum pacing output, interrupt pacing and continue with the appropriate cardiac protocol. Intermittently check for possible capture using maximum pacer setting. 9. If mechanical capture is obtained, interrupt pacing every 2 3 minutes to check for return of spontaneous pulse for 5 10 seconds. These protocols are unique to Cooke County EMS per Medical Director Page 124

126 DNR Protocol A. Pursuant to Title 25, Part I, Chapter , certified EMS personnel shall honor out of hospital DNR orders encountered during their official duties. B. Procedures that shall be withdrawn or withheld pursuant to these orders are: 1. Cardiopulmonary resuscitation; 2. Endotracheal intubation or other advanced airway management; 3. Artificial ventilation; 4. Defibrillation; 5. Transcutaneous cardiac pacing; and 6. Administration of cardiac resuscitation medications. C. Patient Identification: 1. For purposes of identification a patient under this section may be wearing a Texas Department of Health bracelet or necklace bearing the standardized DNR logo; and/or 2. An official DNR form may be present and completed in its entirety with appropriate legible signatures. D. On-Site DNR Dispute Resolution Process: 1. If EMS personnel encounter a patient that is wearing an official DNR bracelet or necklace and is not presented with an official DNR order form, said EMS personnel shall honor such bracelet or necklace as if the DNR form is present; 2. Should EMS personnel encounter a patient wearing an official DNR bracelet or necklace and/or is presented with an official DNR order form and is instructed by a person identifying themselves as family member or the legal guardian of the patient to resuscitate the patient, said EMS personnel shall begin normal resuscitative measures: a. If there is conflicting instructions between family members, resuscitative measures will be begun and medical control shall be contacted for instructions; and b. If medical control cannot immediately be contacted, resuscitative measures will be continued and transport expedited; and c. The family member(s) or legal guardian will be required to accompany the crew to the hospital. 3. Circumstances of the DNR dispute shall be fully documented to include the full name(s), address (es), phone number(s), and relationship(s) to the patient of those persons involved in the dispute. E. Recordkeeping - Records shall be maintained on each incident in which an out-of-hospital order or DNR identification device is encountered by EMS personnel, and the number of cases in which there is an on-site revocation of the DNR order shall be recorded. These protocols are unique to Cooke County EMS per Medical Director Page 125

127 1. The data documented shall include: a. An assessment of the patient's condition; b. Whether an identification device and a DNR form was used to confirm DNR status and patient identification number; c. Any problems relating to the implementation of the DNR order; d. The name of the patient's attending physician; and e. The full name, address, telephone number, and relationship to the patient of any witness used to identify the patient. 2. A photocopy of the original DNR form shall be made and retained with patient's EMS run report. 3. Annually, the EMS administration shall provide a report to the EMS Medical Director and the Bureau of Emergency Management with the following information: a. Number of times personnel have been presented with DNR documentation; b. Number of times there was a problem and the DNR order could not be honored; and c. Any problems that were encountered using the standardized form. F. Out of State DNR orders - EMS Personnel may accept an original out-of-hospital DNR order that has been executed in any other state if there is no reason to question the authenticity of the order. 1. EMS personnel may not accept any out-of-state identifying devices to include bracelets or necklaces. 2. If there is any question of validity of the DNR order, the responding EMS personnel shall attempt to contact medical control. a. If medical control cannot be immediately contacted for direction, the responding EMS personnel shall begin resuscitative measures. G. Failure to honor a DNR order: 1. If there are any indications of unnatural or suspicious circumstances, the EMS personnel shall begin resuscitation efforts until such time as a physician directs otherwise. 2. The indications of unnatural or suspicious circumstances shall be fully documented. H. Pregnant persons - EMS personnel may NOT withhold resuscitation efforts from a person known by them to be pregnant. These protocols are unique to Cooke County EMS per Medical Director Page 126

128 Transtracheal Jet Ventilation Clinical Indications: Inability to open and maintain the airway and all other methods to obtain an airway have failed. Contraindications: Transection of the trachea with significant damage to the cricoid cartilage; and the inability to palpate landmarks. Procedure (if equipment available): 1. Maintain ventilation and airway clearance attempts while preparing equipment. 2. Assemble appropriate equipment, 13G cannula with 10ml syringe attached, oxygen tubing firmly connected to flow meter then connect with LPM flow, Y piece regulator oxygen flow. 3. Identify the cricothyroid membrane in the midline between the thyroid cartilage (Adams Apple) and the cricoid cartilage (Next Prominent Cartilage down from the Thyroid Cartilage) 4. Cleanse site with alcohol prep. 5. Insert cannula tip through the skin and membrane in one firm push in the Midline, Angled at 45 degrees downward until a give is felt. 6. Aspirating on the syringe as the cannula is inserted; air will freely enter the syringe as the cannula enters the trachea, confirming tracheal entry. 7. Slide cannula over the needle into the trachea and secure. Attach the high pressure tubing to the catheter and oxygen source at 50 psi. Ventilate patient with 1 5 second burst at a rate of per minute. 8. Secure Transtracheal Jet Ventilation device securely. These protocols are unique to Cooke County EMS per Medical Director Page 127

129 Surgical Cricothyroidotomy Contraindications: There are no absolute contraindications in the patient who will not survive without a definitive airway, but remember that a patient who has sustained a trauma to the neck area may have a hematoma and incision into this area can result in significant bleeding. Procedure: 1. Patient should be placed in the supine position with the neck maximally exposed. 2. Locate the cricothyroid membrane utilizing anatomical landmarks. 3. Surgically prep the area with alcohol/betadine. Use aseptic technique if possible. 4. Stabilize thyroid cartilage with one hand, make a 2.5 cm vertically oriented incision and identify the membrane, it is imperative this entire procedure maintain itself in the midline of the neck. 5. Puncture the membrane with the scalpel and then place either a hemostat or trouseau dilator in the incised site. 6. Pass an ET tube of at least 6.0 in size, and attach to BVM. 7. Ventilate and check for correct placement with chest rise, breath sounds, end tidal CO2, and tube humidification. 8. If possible inflate cuff and secure the tube in place. Complications 1. Bleeding at the site 2. Aberrant placement of the tube into pre-tracheal fascia and dissection of subcutaneous air into soft tissues of neck. These protocols are unique to Cooke County EMS per Medical Director Page 128

130 Nasotracheal Intubation Note: This procedure requires a spontaneous breathing patient. Remember that this procedure is unpleasant, and the patient will want to resist so cervical spine movement should be anticipated!!!!!!! Indications: 1. Inability to open the mouth (e.g. clenching teeth) 2. Suspected cervical spine injury IF ability to perform in-line technique oral tracheal is in doubt! 3. Dental Injuries and/or gagging or resisting laryngoscope placement Contraindications: 1. Basilar skull fracture and severe nasal or mid-facial deformity 2. Apnea, upper Airway Obstruction and acute epiglottitis 3. Care should be taken with patients on anticoagulants and with patients with known or suspected coagulopathies and are potential candidates for thrombolytic agent (cardiac or CNS). 4. Children under 8 years of age Complications: 1. Nasal Trauma and turbinate fractures 2. Epistaxis and/or perforation of pharyngeal wall 3. Brain Intubation and infection Procedure without paralysis: 1. Select the largest and least obstructed nostril, may consider inserting a lubricated nasal airway to help dilate the nasal passage. 2. Appropriately position and secure patient provide emotional support and explain procedures. 3. Premedicate with hurricane spray. 4. Appropriately pre-oxygenate the patient. 5. Administer Lidocaine 1.5mg/kg before intubating patient s with suspected Closed Head Injury. 6. Administer appropriate sedation as needed unless contraindicated. 7. Select appropriate sized ET tube (may need a size small then used for oral intubation). 8. Lubricate ET Tube liberally with water soluble gel. 9. Insert the tube bevel inward. The tube is designed to insert into the right nare. If inserting into the left nare invert the tube and insert then rotate 180 degrees upon reaching the hypopharynx. The tube should be inserted perpendicular to the horizontal plane, along the floor of the nasopharynx and not toward the frontal sinus. NEVER FORCE THE TUBE. 10. Gently pass the tube while listening to breath sounds or for a positive whistle if using a BAAM. 11. Pass the tube on inspiration, confirm placement by: auscultation of breath sounds, observing for symmetrical chest wall movement, patient s inability to speak, presence of vapor in the tube, Positive end tidal CO2, improved oxygen saturation and then secure the tube in place. These protocols are unique to Cooke County EMS per Medical Director Page 129

131 Orotracheal Intubation Advantages: 1. To provide controlled, precise oxygenation and ventilation. 2. To protect against aspiration and is a route for drug administration? Indications: 1. Apnea, respirations <8 and/or GCS < 8 2. CHI with increased ICP 3. Pulse Oximetry <90% with respiratory Distress 4. COPD with Altered Level of Consciousness and/or evidence of airway burns Contraindications: 1. Cervical Spine injury unless using in-line stabilization 2. Severe Facial Trauma, fracture of the larynx and/ or upper Airway Obstruction Complications: 1. Cervical Strain, neurologic injury 2. Soft tissue injuries to the mouth, lips, tongue or pharynx. 3. Dental Injuries, vocal Cord Spasm or Injury and/or Tracheal / Bronchial rupture 4. Right main-stem intubation, esophageal intubation, vomiting and aspiration 5. Vasovagal responses such as bradycardia, tachycardia, dysrhythmias 6. Cardiac Arrest with interruption of CPR Procedure without paralysis: 1. Position patient in the sniffing position. For trauma patient s maintain in-line stabilization. 2. Pre-oxygenate the patient 3. Atropine mg/kg for patients <8 years, or 0.5mg for bradycardic adults. 4. Lidocaine 1.5 mg/kg for potential closed head injuries. 5. If indicated utilize Benzocaine spray to reduce the activity of the gag reflex. 6. Administer sedation as needed unless contraindicated 7. Apply traction in an anterior direction displacing the tongue and the epiglottis until the glottic opening is visualized. 8. Insert the endotracheal tube from the right corner of the mouth and watch it pass through the vocal cords. 9. Inflate the cuff with 5 10 cc of air. 10. Confirm tube placement by checking for bilateral chest rise, bilateral breath sounds, vapor and condensation in the tube, absence of gurgling over the epigastrium, improved oxygen saturation, presence of ETCO2, improvement in color. 11. Secure the tube in place. These protocols are unique to Cooke County EMS per Medical Director Page 130

132 King Airway Clinical Indications: Following two (2) unsuccessful attempts to place an endotracheal tube, or if it appears additional endotracheal intubation attempts would be unsuccessful, use of the King Airway should be considered. Contraindications: 1. Patients who are conscious or who have an intact gag reflex 2. Patients under four (4) feet in height 3. Patients with known esophageal disease (varicese, alcoholism, cirrhosis etc.) or ingestion of caustic substances Precautions: 1. The KING LT-D does not protect the airway from the effects of regurgitation and aspiration. 2. High airway pressures may divert gas either to the stomach or to the atmosphere. 3. Intubation of the trachea cannot be ruled out as a potential complication of the insertion of the KING LT-D. 4. After placement, perform standard checks for breath sounds and utilize an appropriate carbon dioxide monitor as required by protocol. 5. Lubricate only the posterior surface of the KING LT-D to avoid blockage of the ventilation apertures or aspiration of the lubricant. 6. The KING LT-D is not intended for re-use. 7. During transition to spontaneous ventilation, airway manipulations or other methods may be needed to maintain airway patency. Procedure: 1. Test cuff inflation system by injecting the maximum volume of air into the cuffs. Remove all air from both cuffs prior to insertion. 2. Apply a water-based lubricant to the beveled distal tip and posterior aspect of the tube, taking care to avoid introduction of lubricant in or near the ventilatory openings. 3. Pre-oxygenate patient with 100% oxygen for at least 1 minute. 4. Position the head. The ideal head position for insertion of the KING LT-D is the "sniffing position". The angle and shortness of the tube also allows it to be inserted with the head in a neutral position. 5. Hold the KING LT-D at the connector with dominant hand, hold mouth open and apply chin lift. 6. With the KING LT-D rotated laterally 45-90o such that the blue orientation line is touching the corner of the mouth, introduce tip into mouth and advance behind base of tongue. Never force the tube into position. 7. As tube tip passes under tongue, rotate tube back to midline (blue orientation line faces chin). 8. Without exerting excessive force, advance KING LT-D until proximal opening of gastric access lumen is aligned with the teeth or gums. 9. With a syringe inflate the KING LT-D; inflate cuffs with the minimum volume necessary to seal the airway at the peak ventilatory pressure employed (just seal volume). 10. Attach the BVM to the 15 mm connector of the KING LT-D. While gently bagging the patient to assess ventilation, simultaneously withdraw the airway until ventilation is easy and free flowing (large tidal volume with minimal airway pressure). 11. Depth markings are provided at the proximal end of the KING LT-D which refers to the distance from the distal ventilatory openings. When properly placed with the distal tip and cuff in the upper esophagus and the ventilatory openings aligned with the opening to the larynx, the depth markings give an indication of the distance, in cm, from the vocal cords to the upper teeth. 12. Attach ETCO2 monitoring device to adaptor and follow guidelines for its use. 13. Confirm proper position by auscultation, chest movement and verification of CO2 by capnography. Do not let go of tube until secured. Secure KING LTS-D to patient using tape or an approved commercial device. DO NOT COVER THE PROXIMAL OPENING OF THE GASTRIC ACCESS LUMEN. 14. Immediately following successful placement of the King Airway, apply an appropriately sized cervical collar. If the C-collar doesn t fit; manual inline stabilization should be utilized if transported; blankets, towels and tape should be used appropriately to restrict cervical spinal motion. No exceptions. 15. If an Adult or pediatric patient is to be transported, they must be secured to a backboard. ONCE INSERTED SUCCESSFULLY, DO NOT REMOVE These protocols are unique to Cooke County EMS per Medical Director Page 131

133 Needle Chest Decompression Protocol Indication: Patient in respiratory distress with at least 4 of the following clinical signs of tension pneumothorax: a. Dyspnea with use of accessory muscles of respiration b. Marked decrease or absent breath sounds in the axilla on affected side* c. Hypertympany to percussion of anterior chest on affected side* d. Deviation of trachea away from affected side e. Pulse oximetry below 92% despite 100% O2 by mask f. High or increasing resistance to ventilation in the intubated patient g. Penetrating or blunt trauma to the chest h. Subcutaneous emphysema Procedure: ABC s, if patient not ventilating secure airway 1. ECG 2. Obtain a size IV catheter at least one and one half inches long 3. Locate the second intercostal space at the mid-clavicular line on the affected side of the chest 4. Prepare the skin with antiseptic solution 5. Align the needle with the top if the third rib and press the needle through the chest wall at a 90 degree angle to the anterior chest wall 6. Once in the pleural space stabilize the catheter and advance the catheter over the needle 7. Leave the catheter open to the air as long as air can be felt coming from the catheter flutter valve and stop cock optional if available or asherman chest seal. Reassess ABC s and contact Medical Control and report results These protocols are unique to Cooke County EMS per Medical Director Page 132

134 Intra Nasal Mucosal Atomization Device (MAD) 1. Disconnect MAD from the included syringe 2. Fill syringe with the desired volume of solution and eliminate remaining air. 3. Connect MAD to the syringe. If using MAD with 6 extension, eliminate air in tubing and bend into position. Tubing will remain in fixed position. 4. Place MAD tip in the nostril or oropharyngeal cavity. 5. Compress the syringe plunger to spray atomized solution into the nasal or oropharyngeal cavity. 6. Re-use the MAD on the same patient as needed, and then discard. 7. Do not place the MAD tip within the trachea. 8. Do not use the MAD on more than one patient. These protocols are unique to Cooke County EMS per Medical Director Page 133

135 Portable Ventilator Criteria for use: Paramedic Only with Medical Director Approval (Check-off) 1. Any patient that has been successfully intubated with an endotracheal tube. 2. Any patient that is in severe respiratory distress requiring the use of a BVM or endotracheal intubation. 3. Any Patient in cardiac arrest that needs ventilator support. 4. Transfer of ventilated patients from an acute care facility. Procedure for use: 1. Connect ventilator oxygen supply tubing to wall mounted oxygen. 2. Connect flexible vent circuit to vent and test lung. Adjust end-tidal and respirations per minute. Approximately 5 10ml/kg (Ideal Body Weight) initially for tidal volume and breaths per minute on Assist-Control setting. Titrate tidal volume as necessary to deliver adequate ventilations. I-times should be at about 1.5 seconds. For in-field use, PEEP will generally not be used. With test lung in place, verify acceptable ventilator operation. 3. If patient is a hospital transfer, utilize hospital vent settings as a guideline. 4. Verify proper tube placement prior to connecting to ventilator. 5. If patient is intubated, connect flexible vent circuit to patient. Verify positive lung sounds and adequate chest rise and fall. Observe for fogging in tube. Ensure that ETCO2 device is connected (if available). 6. Monitor pulse oximetry and ETCO2 for verification of tube placement as well as proper ventilatory support. Adjust vent settings as necessary to maintain SPO2 above 93% and ETCO2 in a range of 35 45mmHg. Precautions: 1. As with any mechanical device, failure is possible. Always have a BVM ready for use. Monitor the patient continuously. In the event of ventilator failure, disconnect patient from ventilator and provide respiratory support with BVM. 2. Monitor Patient for pneumothorax. If pneumothorax is present see pneumothorax protocol and discontinue use of ventilator. These protocols are unique to Cooke County EMS per Medical Director Page 134

136 Tidal Volumes Chart Pediatric Ventilator Tidal Volumes Dose Preterm New Born 6 Months 1 Year 3 Years 6 Years 10 Years 11 Years 12 Years 14 Years Pounds 3 lbs 7 lbs 15 lbs 22 lbs 33 lbs 44 lbs 66 lbs 77 lbs 88 lbs 110 lbs Kilograms 1.5 kg 3 kg 7 kg 10 kg 15 kg 20 kg 30 kg 35 kg 40 kg 50 kg 7ml/kg ml 49 ml 70 ml 105 ml 140 ml 210 ml 245 ml 280 ml 350 ml 8ml/kg 12 ml 24 ml 56 ml 80 ml 120 ml 160 ml 240 ml 280 ml 320 ml 400 ml 9ml/kg 13.5 ml 27 ml 63 ml 90 ml 135 ml 180 ml 270 ml 315 ml 360 ml 450 ml 10ml/kg 15 ml 30 ml 70 ml 100 ml 150 ml 200 ml 300 ml 350 ml 400 ml 500 ml Adult Ventilator Tidal Volumes Dose Pounds 121 lb 132 lb 143 lb 154 lb 165 lb 176 lb 187 lb 198 lb 209 lb 220 lb 231 lb 242 lb Kilograms 55 kg 60 kg 65 kg 70 kg 75 kg 80 kg 85 kg 90 kg 95 kg 100 kg 105 kg 110 kg 7 ML/KG 385 ml 420 ml 455 ml 490 ml 525 ml 560 ml 595 ml 630 ml 665 ml 700 ml 735 ml 770 ml 8 ML/KG 440 ml 480 ml 520 ml 560 ml 600 ml 640 ml 680 ml 720 ml 760 ml 800 ml 840 ml 880 ml 9 ML/KG 495 ml 540 ml 585 ml 630 ml 675 ml 720 ml 765 ml 810 ml 855 ml 900 ml 945 ml 990 ml 10 ML/KG 500 ml 600 ml 650 ml 700 ml 750 ml 800 ml 850 ml 900 ml 950 ml 1000 ml 1050 ml 1100 ml These protocols are unique to Cooke County EMS per Medical Director Page 135

137 Blood Administration Indications: Trauma patients who upon assessment present with signs and symptoms of hypovolemic shock Procedure (Paramedic Level Only): 1. Evaluate patient for signs/symptoms of hypovolemic shock maintaining considerations for mechanism and site of injury, distance from nearest emergency facility, time to receive packed red cells to scene, time of extrication (if applicable), estimated time of arrival to Level 1 or Level 2 trauma facility (if available). 2. Notify supervisor of need for packed red cells at scene. Supervisor will contact Medical Control and appropriate facility and arrange for transport of 2 units of O negative packed red cells and appropriate blood tubing. 3. Initiate bilateral large bore IV therapy with Normal Saline (preferably warmed fluids). Try to verify medical history and possible allergies including prior transfusion reactions if any. Verify and closely monitor vital signs including temperature. 4. Upon arrival of packed red cells, verify that blood units are O negative. Verify with a second paramedic. Record unit ID numbers along with patient name and appropriate demographic information. 5. Initiate blood infusion via large bore IV line with Normal Saline. Record infusions start time. 6. Monitor patient vital signs including temperature every five minutes. Maintain continuous assessment for transfusion reaction (i.e.: signs/symptoms of anaphylaxis, increased temperature above normal, sudden onset of nausea/vomiting, continued hypotension, angina, dyspnea, coagulopathies). If possible transfusion reaction noted, discontinue blood therapy and treat presenting symptoms via appropriate protocol (Notify Medical Control). 7. Upon completion of transfusion, record time and vital signs. 8. Upon transfer of care, provide receiving personnel complete report regarding transfusion. 9. Upon completion of written patient care report; supervisor is to immediately provide a complete copy to either the lab/blood bank supervisor or nursing supervisor at facility that provided the packed red cells. Patient care report should specifically have all pertinent transfusion information including complete vital signs, unit numbers of packed red cells, to whom care was transferred and name of receiving facility. These protocols are unique to Cooke County EMS per Medical Director Page 136

138 Continuous Positive Pressure Indications: 1. Respiratory Distress indicated by low O2 saturation, high CO2 on capnography, RR>20 or RR<10 sustain or significantly increased work of breathing. 2. Patient s condition does not respond to supplemental oxygen. 3. Patient s respiratory distress is likely from COPD, CHF, asthma or pneumonia. 4. Patients on CPAP or Bi-Pap at site of transfer. Inclusion Criteria: 1. Awake and alert patients able to maintain airway. 2. Age >13 years 3. Medical patient with SBP >90 mmhg Exclusion Criteria: 1. Uncooperative, confused or significantly agitated patient 2. Unable to properly protect airway 3. Suspected Pneumothorax or Hemothorax 4. Significant chest wall trauma 5. RR<8 6. Hypotension not responsive to minimal fluid resuscitation 7. Near respiratory arrest 8. Unable to obtain proper seal of face mask Treatment: 1. Follow initial steps in appropriate protocol 2. Apply CPAP per manufacture procedure with initial setting of 0 1 cm H2O, FIO2 with 100% and titrate to effect. 3. Select proper mask. 4. Explain procedure to patient. Ask patient hold mask to face initially to confirm tolerance; after at least 3 minutes, patient can then be converted to straps. 5. Monitor closely for deterioration in condition: decreased mental status, increased work of ventilation, decreased O2 saturation, increased O2 concentration, drop in SBP to <95 mmhg or increased agitation. 6. Pressure can be decreased for stable patients without signs of respiratory distress to basic levels of pressure of 3 5 cm H2O and O2 concentration of 100%. 7. May use inline nebulizer if needed: see specific protocol. 8. If patient is deteriorating contact medical control or Captain regarding RSI or medically assisted intubation and BVM ventilation. These protocols are unique to Cooke County EMS per Medical Director Page 137

139 EZ IO Intraosseous Infusion The EZ IO device consists of a battery powered driver; a special needs assembly, right-angle extension tubing, and a wrist band. Indications: Patients where rapid, regular IV access is unavailable with any of the following Cardiac and / or respiratory arrest / respiratory failure Multi-system trauma with severe hypovolemia Severe dehydration with vascular collapse and / or loss of consciousness Contraindication: Fractures proximal to proposed insertion site Inability to locate landmark (significant edema) Excessive tissue at insertion site (obesity) Current or prior infection at proposed site Previous IO insertion or joint replacement at the proposed site Procedure: 1. Locate insertion site a. Proximal Tibia b. Distal Tibia c. Distal Femur d. Humeral Head 2. Clean insertion site with aseptic technique 3. Prepare EZ-IO driver and needle 4. Stabilize site and insert EZ-IO needle 5. Stabilize catheter hub and remove EZ-IO driver from needle set 6. Confirm placement 7. Flush with Lidocaine then with 10 ml of NS 8. Connect extension set and/or IV tubing 9. Place a pressure bag on solution (if needed) 10. Begin infusion (watch carefully for infiltration) 11. Apply dressing 12. Monitor EZ-IO site and patient condition These protocols are unique to Cooke County EMS per Medical Director Page 138

140 Rule of Nine s Adult These protocols are unique to Cooke County EMS per Medical Director Page 139

141 Rule of Nine s Child These protocols are unique to Cooke County EMS per Medical Director Page 140

142 Lund and Browder Burn Chart Parkland Burn Formula for fluid replacement: 4 ml x % BSA x kg 50% calculated in 1 st 8 hours Age in years Adult A-head (back or front) 9½ 8½ 6½ 5½ 4½ 3½ B-1 thigh (back or front) 2¾ 3¼ 4 4¼ 4½ 4¾ C-1 leg (back or front) 2½ 2½ 2¾ 3 3¼ 3½ These protocols are unique to Cooke County EMS per Medical Director Page 141

143 Classification of Burn Severity Reference Major Burns 1. Partial-thickness burns greater than 25% of body surface area in adults or greater than 20% in children or the elderly. 2. Full-thickness burns greater than 10% of BSA 3. All burns involving the face, eyes, hands, feet or perineum that may result in functional or cosmetic impairment. 4. Burns caused by caustic chemical agents. 5. Burns complicated by inhalation injury, major trauma or poor-risk patients. Moderate Burns 1. Partial-thickness burns 15% - 25% BSA in adults and 10% - 20% BSA in children or the elderly. 2. Less than 10% of BSA full-thickness burns. 3. Not involving the risk to specialized function such as the face, eyes, ears, hands, feet or perineum. Minor Burns 1. Burns less than 15% of BSA in adults or 10% of BSA in children or the elderly. 2. Less than 2% full-thickness burns. 3. No functional or cosmetic risk to special functional areas. These protocols are unique to Cooke County EMS per Medical Director Page 142

144 Pediatric Drug Chart NEW DOSE PRETERM BORN MONTHS YEAR YEARS YEARS YEARS YEARS YEARS YEARS WEIGHT POUNDS KG Heart Rate Respiratory Rate Systolic BP ET Blades ET Tube Defibrillation 2 J / KG 3j 6j 14j 20j 30j 40j 60j 70j 80j 100j 4 J / KG 6j 12j 28j 40j 60j 80j 120j 140j 160j 200j Adenocard.1 MG /KG 0.15mg 0.3mg 0.7mg 1mg 1.5mg 2mg 3mg 3.5mg 4mg 5mg.2 MG / KG 0.3mg 0.6mg 1.4mg 2mg 3mg 4mg 6mg 7mg 8mg 10mg Atropine.02 mg/kg 0.03mg 0.06mg 0.14mg 0.2mg 0.3mg 0.4mg 0.6mg 0.7mg 0.8mg 1mg Benadryl 1mg/kg 1.5mg 3mg 7mg 10mg 15mg 20mg 25mg 25mg 25mg 25mg Charcoal <1yr: 1 g/kg 1.5g 3g 7g >1 yr: 25-50g 25g 25g 25g 25g 50g 50g 50g D10 5cc/kg 7.5cc 10cc/kg 15cc D25 2cc/kg 6cc 14cc 20cc 4cc/kg 12cc 28cc 40cc D50 1cc/kg 15cc 20cc 30cc 35cc 40cc 50cc Dexamethasone 0.1 mg/kg 0.15mg 0.3mg 0.7mg 1mg 1.5mg 2mg 3mg 3.5mg 4mg 4mg Epi 1: mg/kg mg 0.015mg 0.035mg 0.05mg 0.075mg 0.1mg 0.15mg 0.175mg 0.2mg 0.25mg Epi 1: mg/kg 0.015mg 0.03mg 0.07mg 0.1mg 0.15mg 0.2mg 0.3mg 0.35mg 0.4mg 0.5mg Fluid Challenge 20cc/kg 30cc 60cc 140cc 200cc 300cc 400cc 600cc 700cc 800cc 1000cc Glucagon 1.0mg 1.0mg 1.0mg 1.0mg 1.0mg 1.0mg 1.0mg 1.0mg 1.0mg 1.0mg 1.0mg Lidocaine 2% 1.0mg/kg 1.5mg 3mg 7mg 10mg 15mg 20mg 30mg 35mg 40mg 50mg Methylprednisolone 1.0mg/kg 1.5mg 3mg 7mg 10mg 15mg 20mg 30mg 35mg 40mg 50mg 30mg/kg 45mg 90mg 210mg 300mg 450mg 600mg 900mg 1050mg 1200mg 1500mg Narcan.1mg/kg 0.15mg 0.3mg 0.7mg 1mg 1.5mg 2mg 3mg 3.5 mg 4mg 4mg Terbutaline.25mg.25mg.25mg.25mg.25mg.25mg.25mg.25mg.25mg.25mg.25mg Valium.1mg/kg 0.15mg 0.3mg 0.7mg 1mg 1.5mg 2mg 3mg 3.5mg 4mg 5mg.5mg/kg 0.75mg 1.5mg 3.5mg 5mg 7.5mg 10mg 15mg 17.5mg 20mg 25mg Sync Cardioversion.5j/kg 0.75j 1.5j 3.5j 5j 7.5j 10j 15j 17.5j 20j 25j 2j/kg 3j 6j 14j 20j 30j 40j 60j 70j 80j 100j Tylenol 15mg/kg 22.5mg 45mg 105mg 150mg 225mg 300mg 450mg 525mg 600mg 750mg Etomidate.3mg/kg 0.45mg 0.9mg 2.1mg 3mg 4.5mg 6mg 9mg 10.5mg 12mg 15mg Succinylcholine 1mg/kg 1.5mg 3mg 7mg 10mg 15mg 20mg 30mg 35mg 40mg 50mg 1.5mg/kg 2.25mg 4.5mg 10.5mg 15mg 22.5mg 30mg 45mg 52.5mg 60mg 75mg Versed.1mg/kg 0.15mg 0.3mg 0.7mg 1mg 1.5mg 2mg 3mg 3.5mg 4mg 5mg These protocols are unique to Cooke County EMS per Medical Director Page 143

145 Drug Calculations Calculating Drops per Minute gtts / min = volume to be infused X gtts/ml of administration set total time in minutes Calculating Solution Concentration mg in solution divided by ml in solution Calculating mg/min OR Calculating mcg/min (Lidocaine / Norepinephrine) gtts / min = volume on hand X drip factor X desired dose Dosage on hand Calculating mcg/kg/min gtts / min = desired dose X weight (kg) X drip factor Solution concentration These protocols are unique to Cooke County EMS per Medical Director Page 144

146 Dopamine Drip Chart 400 mg Dopamine / 250 ml D5W Concentration: 1600 mcg/ml Infusion Dose: 2 20 mcg/kg/min Body lbs Weight Kg: mcg/kg/min D R O P S P E R M I N U T E These protocols are unique to Cooke County EMS per Medical Director Page 145

147 Levophed (Norepinephrine) 4 mg in 500 ml D5W (8 mcg/ml) Initial Rate 1 mcg/min Maximum Rate 30 mcg/min Desired Dose (mcg/min) Rate in ml/hr 1 mcg/min 7 ml/hr 2 mcg/min 15 ml/hr 3 mcg/min 22 ml/hr 4 mcg/min 30 ml/hr 5 mcg/min 37 ml/hr 6 mcg/min 45 ml/hr 7 mcg/min 52 ml/hr 8 mcg/min 60 ml/hr 9 mcg/min 67 ml/hr 10 mcg/min 75 ml/hr 11 mcg/min 82 ml/hr 12 mcg/min 90 ml/hr 13 mcg/min 97 ml/hr 14 mcg/min 105 ml/hr 15 mcg/min 112 ml/hr 16 mcg/min 120 ml/hr 17 mcg/min 127 ml/hr These protocols are unique to Cooke County EMS per Medical Director Page 146

148 Nitroglycerin Drip Chart 25mg in 250 ml / Concentration 100 mg/ml 50 mg in 250 ml / Concentration 200 mg/ml Milliliter per hour Milligram per minute Milliliter per hour Milligram per minutes These protocols are unique to Cooke County EMS per Medical Director Page 147

149 Dobutamine Drip 250mg Dobutamine / 500 cc D5W Body lbs: Weight kgs: mcg/kg/min D R O P S P E R M I N U T E These protocols are unique to Cooke County EMS per Medical Director Page 148

150 Nasogastric Tube (NG Tube) Clinical Indications: Contraindications: Gastric decompression for intubated patients. Complications: 1. Suspected basilar skull fracture. 1. Nasal tissue trauma/hemorrhage 2. Facial trauma 2. Passage of tube into the trachea 3. Recent nasal surgery 3. Perforation of the esophagus 4. Known or suspected esophageal varicese 4. GI bleeding 5. Ingestion of caustic poisonings 5. Coiling of the tube into posterior pharynx 6. May induce gagging or vomiting; Aspiration Equipment: All necessary equipment should be prepared, assembled and available prior to starting the NG tube. Basic equipment should include: 1. Personal protective equipment (gloves, mask, face shield) 2. NG tube, 60 ml catheter tip syringe 3. Water-soluble lubricant 4. Adhesive tape 5. Suction 6. Stethoscope Procedure: 1. Prepare and assemble all equipment 2. Inspect the nares for deformity or obstructions to help determine best side for insertion of the NG tube. 3. Measure length of tube by placing the tip over the stomach area and extend it to the patient s ear lobe a. Note the marks on the tube used to measure. 4. Flex the neck if not contraindicated 5. Liberally lubricate the distal tip with water-soluble lubricate (KY Jelly) 6. Insert the tube along the floor of the nasal passage 7. Do not orient the tip upward into the turbinate s. 8. Continue to advance the tube until the appropriate distance is reached. 9. Confirm placement by injecting 20 cc of air and auscultating the epigastric region for the swish or bubbling of the air over the stomach. a. Gastric content may also be used to confirm placement 10. Secure the tube with tape to the nose and forehead or cheek 11. Decompression of the stomach of air and food can be done by connecting the tube to suction Documentation should include the following: 1. The procedure and any complications that may have occurred 2. Time of procedure and the results successful / unsuccessful. These protocols are unique to Cooke County EMS per Medical Director Page 149

151 Placement for 12 Lead Reference Precordial lead placement: 1. V 1: 4 th intercostal space just to the right of the sternum 2. V 2: 4 th intercostal space just to the left of the sternum 3. V 3: between V2 and V4 4. V 4: 5 th intercostal space mid clavicular line 5. V 5: anterior axillary line level with V4 6. V 6: mid axillary line level with V4 and V5 7. V4R: 5 th intercostal space in right mid-clavicular line The area the leads are looking at: 1. Leads I, AVL, V5, V6: lateral wall of left ventricle 2. Leads II, III, AVF: inferior wall of left ventricle 3. Leads V1, V2: septal wall of left ventricle 4. Lead V3, V4: anterior wall of the left ventricle 5. Lead V4R: right ventricle The following 12 lead variations should raise suspicion for Ischemia, Injury or infarction: Ischemia: Injury: Infarction: ST depression, possible T wave inversion ST elevation, possible T wave inversion ST elevation, possible T wave inversion, possible abnormal Q wave Acute Myocardial Infarction Location Location: Leads: Reciprocal Changes: Inferior (RCA): II, III, avf I, avl Septal (LAD): V1, V2 Anterior (LAD): V3, V4 II, III, avf Lateral (CIRC): I, avl, V5, V6 II, III, avf Posterior: V7, V8, V9 ST, V1 V4 Right Ventricle V4R None seen These protocols are unique to Cooke County EMS per Medical Director Page 150

152 Termination of Prehospital Resuscitation Policy: Unsuccessful cardiopulmonary resuscitation (CPR), and other advanced life support (ALS) interventions. This may be discontinued prior to transport when this procedure is followed. The initial and ending rhythm must be Asystole. Purpose: The purpose of this policy is to: Allow for discontinuation of prehospital resuscitation after delivery of adequate and appropriate ALS therapy. Allow for discontinuation of prehospital resuscitation for patients that show signs of obvious death. Procedure: 1. If a bystander or a first responder organization has initiated CPR or semi automatic defibrillation prior to arrival of EMS arrival and any of the below criteria (signs of obvious death) are present, CPR and ALS therapy may be discontinued by EMS unit: Patient must be >18 years of age. Patient must not be pregnant. Situation should not be related to hypothermic cause Extended downtime with Asystole on EKG ETCO2 remains < 10 mmhg after early successful advanced airway placement and with 20 minutes of Advanced Life Support. There has been absolutely no return of pulse, spontaneous respirations, eyes opening or movement, no motor response and no neurological activity. Consider how long the patient has been down without CPR and ALS. Determination of resuscitation efforts must be determined prior to transport!!!! MEDICAL CONTROL MUST BE CONTACTED PRIOR TO TERMINATION EFFORT!!!!! Note: Documentation should include initial rhythm, time ALS was started and stopped. These events will be needed to record time of death. These protocols are unique to Cooke County EMS per Medical Director Page 151

153 Spinal Immobilization Clearance Clinical Indications: This protocol is to be used only on patients that alert and oriented to person, place and event. These patients must have a positive neurological exam without any evidence of intoxication and no significant traumatic mechanism. Consider immobilization in any patients with arthritis, cancer or any underlying spinal or bone disease. Any patient involved in any mechanism that includes high-energy events such as ejection, high falls and abrupt deceleration crashes should be considered for spinal immobilization even in the absence of signs and/or symptoms. May use the acronym NSAIDS to help remember this protocol: N : Neurologic exam; Look for focal deficits such as tingling, reduced strength or numbness in any extremity. Does the patient present with one or more of these symptoms? S : Significant mechanism; was this a high energy event that may cause significant injuries? A : Alertness; is the patient oriented to person, place, time and event? Any changes in level of consciousness or was there a positive loss of consciousness? I : Intoxication; is there an indication that the patient may be intoxicated? Do they have decision making capabilities? D : Distracting injury; does the patient have an injury which is capable of producing significant pain causing distraction of possible neck or back pain? S : Spinal exam; is there a point of tenderness in the spinal process or tenderness with range of motion? The decision not to implement spinal immobilization precautions for patients is your responsibility. You must remember a normal exam may not be sufficient to rule out a spinal injury in children and the elderly. IF THE PATIENT HAS ANY COMPLAINTS OF THE ABOVE SIGNS AND / OR SYMPTOMS OR IF THERE IS SIGNIFICANT MECHANISM, FULL C-SPINE PRECAUTIONS INCLUDING C-COLLAR AND BACKBOARD MUST BE UTILIZED. These protocols are unique to Cooke County EMS per Medical Director Page 152

154 Orthostatic Blood Pressure Measurement Clinical Indications: Patients with suspected blood or fluid loss or dehydration with no indication for spinal immobilization This procedure should be considered while still inside the residence and/or before moving the ambulance. Safety of our patients always comes 1 st. Procedure: 1. Gather standard BP cuff and stethoscope. 2. With the patient supine, obtain pulse and blood pressure. 3. Place the patient in upright position. 4. Then with assistance ask patient to stand. (may need to assist pt in standing position) 5. If the systolic BP falls more than 10 mmhg or the pulse raises more than 10 bpm, the patient is considered to have positive orthostatic vital signs. 6. If the patient is experiencing dizziness upon sitting up or is obviously dehydrated based on history or physical exam, formal orthostatic examination should be omitted and fluid bolus initiated. These protocols are unique to Cooke County EMS per Medical Director Page 153

155 Start - Triage Guide System SIMPLE TRIAGE AND RAPID TRANSPORT Primary Triage Guidelines (Use triage bags with tape for rapid assessment) 1. Can the Patient Walk? Yes= Green; No = Go to Question 2 2. Can the Patient Obey? Yes= Go to Question 3; No= Go to Question 4 (Skip 3) 3. Does Patient Have Radial Pulse? Yes=Yellow; No=Red 4. Does Patient Breathe with open Airway? Yes=Red; No=Black Secondary Triage Guidelines (Use Mettags or equivalent) These protocols are unique to Cooke County EMS per Medical Director Page 154

156 Drug Guide These protocols are unique to Cooke County EMS per Medical Director Page 155

157 Pregnancy Category Rating for Drugs Category A Controlled studies in women fail to demonstrate a risk to the fetus in the 1 st trimester and no significant risk in later trimester. The possibility of fetal harm appears to be remote. Category B Either (1) animals reproductive studies have not demonstrated a fetal risk, but there no controlled studies in pregnant women, or (2) animal reproductive studies have shown an adverse effect that (other than decreased fertility) that was not confirmed in controlled studies on women in the 1 st trimester, but there is no evidence of risk in later trimesters. Category C Either (1) studies in animals have revealed adverse effects on the fetus, but there are no controlled studies in women or (2) studies in women and animals are not available. Drugs in this category should be given only if the potential benefits justify the risk to the fetus. Category D Positive evidence of human fetal risk exist, but the benefits for pregnancy women may be acceptable despite the risk, as in life-threatening diseases for which safer drugs cannot be used or are ineffective. An appropriate statement must appear in the WARNINGS section of the labeling of drugs in this category. Category X Studies in animals or human beings have demonstrated fetal abnormalities, there is evidence of fetal risk based on human experience or both; the risk of using the drug in pregnant women clearly outweighs any possible benefit. The drug is contraindicated in women who are or may become pregnant. An appropriate statement must appear in the CONTRINDICATIONS section of the labeling of drugs in this category. These protocols are unique to Cooke County EMS per Medical Director Page 156

158 Activated Charcoal Class: Adsorbent Actions: Absorbs toxins by chemical binding and prevents GI absorption. Onset: Immediate Duration: Continual while in GI tract Indications: Many oral poisonings and medication overdoses Contraindications: Side Effects: Corrosives, caustics, petroleum distillates (relatively ineffective, and may induce vomiting), GI bleeding May indirectly induce nausea & vomiting and may cause constipation or mild transient diarrhea Drug Interactions: Syrup of ipecac (adsorbed by activated charcoal, and will result in vomiting of the charcoal) Dosage: See Protocols Route: PO Pregnancy safety: Category C These protocols are unique to Cooke County EMS per Medical Director Page 157

159 Adenosine (Adenocard) Class: Antidysrhythmic Actions: Onset: It slows the conduction through AV node of the heart. It is cleared very rapidly, having a half-life of < 10 seconds. Immediately Duration: 10 seconds Indications: Symptomatic PSVT Contraindications: Sick sinus syndrome and second or third degree heart block Side Effects: Precautions: Dosage: Light-headedness, HA; Diaphoresis; Palpations; Chest pain; Flushing; Hypotension Shortness of breath; Nausea, metallic taste A reduced dose must be used in heart transplant recipients. BP, pulse and EKG should be monitored See Protocol Route: IV Pregnancy Safety: Category C These protocols are unique to Cooke County EMS per Medical Director Page 158

160 Albuterol (Proventil; Ventolin) Class: Sympathomimetic (B2 selective) Actions: Bronchodilator Onset: 5 15 minutes after inhalation Duration: 3 4 hours after inhalation Indications: Relief of bronchospasm in patient with reversible obstructive airway disease. Prevention of exercise-induced bronchospasm; Asthma Contraindications: Patient with known hypersensitivity; Symptomatic tachycardia Precautions: BP, Pulse and EKG result should be monitored Use caution in patients with known heart disease Side Effects: Palpations; Anxiety; Headache; Dizziness; Sweating Dosage: See Protocols Route: Inhalation Pregnancy safety: Category C These protocols are unique to Cooke County EMS per Medical Director Page 159

161 Amiodarone (Cordarone) Class: Class III Antidysrhythmic Actions: Onset: Prolongs action potential after refractory period; slows the sinus rate; increases PR and QT intervals; decreases peripheral resistance within minutes Duration: Variable Indications: Life-threatening cardiac dysrhythmias, such as V-Tach and V-Fib Contraindications: Side Effects: Dosage: Hypersensitivity to drug; severe sinus node dysfunction; cardiogenic shock 2 nd & 3 rd degree heart block; hemodynamically significantly bradycardia Hypotension; Headache; Dizziness; Bradycardia; AV conduction abnormalities Flushing; Abnormal salivation See Protocols Route: IVP Pregnancy Safety: Category D These protocols are unique to Cooke County EMS per Medical Director Page 160

162 Ammonia Ampule / Inhalants Class: Respiratory stimulant Actions: Indications: Elicits a response in a conscious patient be irritating mucous membranes of upper respiratory tract. It stimulates the vasomotor center of medulla causing an increase in blood pressure. Syncope; to determine level of consciousness Contraindications: None Side Effects: None Special Information: Dosage: Use with caution in patients with COPD or asthma - may cause bronchospasm Be sure patient has inhaled sufficient vapor to elicit a response 2 3 inhalants; break ampule and hold close to patient's nostrils Route: Inhalation These protocols are unique to Cooke County EMS per Medical Director Page 161

163 Aspirin (Acetylsalicylic acid) Class: Platelet inhibitor / anti-inflammatory Actions: Blocks platelet aggregation Onset: minutes Duration: 4 6 hours Indications: Cardiac chest pain; Acute Myocardial Infarction Contraindications: Hypersensitive to salicylates; GI bleeding; Active ulcer; Hemorrhagic strokes; Bleeding disorders Side Effects: Stomach irritation; heartburn or indigestion; Nausea / Vomiting; Allergic Reaction Drug Interactions: Decreased effects with antacids and steroids Increased effects anticoagulants, insulin, oral hypoglycemic, fibrinolytic agents Dosage: Adult: 324 Route: PO Pregnancy Safety: Category D These protocols are unique to Cooke County EMS per Medical Director Page 162

164 Atropine Class: Anticholinergic (Para-sympatholytic) Actions: Blocks acetylcholine receptors; increase heart rate; reduces GI secretions Onset: Rapid Duration: 2 6 hours Indications: Hemodynamically significant bradycardia; Organophosphate poisoning; Pediatric RSI Contraindications: Tachycardia; Unstable cardiovascular status in acute hemorrhage with myocardial ischemia Narrow-angle glaucoma Side Effects: Dosage: Tachycardia: Palpations; Dysrhythmias; Headache; Dizziness; Nausea / Vomiting Anticholinergic effects: Blurred vision, dry eyes, dilated pupils Flushed, hot, dry skin See Protocols Route: IV Pregnancy Safety: Category C These protocols are unique to Cooke County EMS per Medical Director Page 163

165 Benadryl (Diphenhydramine) Class: Antihistamine Actions: Blocks histamine receptors; some sedative effects. Onset: Max effects 1 3 hours Duration: 6 12 hours Indications: Anaphylaxis; Moderate to severe allergic reactions; Dystonic reactions Contraindications: Pt taking MOA inhibitors; Hypersensitivity; Narrow angle glaucoma Side Effects: Sedation; Dries secretions; Blurred vision; Hypotension; Palpations Dosage: See Protocols Route: IV / IM Pregnancy Safety: Category C These protocols are unique to Cooke County EMS per Medical Director Page 164

166 Benzocaine Spray 20% (Hurricane Spray) Onset: seconds Actions: Duration: When applied to the posterior region of the oropharynx, reduces the activation of the gag reflex. Used as a numbing agent to reduce sensation 15 Minutes Indications: Contraindications: When the patient needs intubation, gag reflex is present, but patient has no need or contraindications for use of narcotics or benzodiazepines. Hypersensitivity Side Effects: Tingling or burning may occur Precautions: Patients will have little or no gag reflex post use; Have suction prepared and ready. Dose: Spray posterior oropharynx with 1 2 metered sprays (50 100mg), to reduce gag reflex, in order to facilitate intubation. These protocols are unique to Cooke County EMS per Medical Director Page 165

167 Calcium Chloride 10% Class: Electrolyte Actions: Increases cardiac contractility Onset: 5 15 minutes Duration: Dose dependent (effects may persist up to 4 hours) Indications: Acute Hyperkalemia; Calcium Channel blocker toxicity Contraindications: Patients receiving digitalis Side Effects: Dosage: Bradycardia (may cause asystole); Hypotension; Metallic taste Severe local necrosis and sloughing following IM or IV infiltration See Protocols Route: IVP Pregnancy Safety: Category C These protocols are unique to Cooke County EMS per Medical Director Page 166

168 Dexamethasone (Decadron, Hexadrol) Class: Glucocorticoid (Steroid) Actions: Decreases cerebral edema; Anti-inflammatory; Suppresses the immune system Onset: 4 8 hours after parenteral administration Duration: hours Indications: Anaphylaxis (after epinephrine & diphenhydramine); Asthma; Chronic inflammation Contraindications: Active untreated infections; Hypersensitivity to the product Side Effects: Decreased wound healing and HTN; GI bleeding and Hyperglycemia Drug Interaction: Barbiturates and phenytoin can decrease dexamethasone effects Dosage: See Protocols Route: IV / IM Pregnancy Safety: Category C These protocols are unique to Cooke County EMS per Medical Director Page 167

169 Dextrose 50% Class: Carbohydrate, hypertonic solution Actions: Elevates blood glucose rapidly Onset: 1 minute Duration: Depends on the degree of hypoglycemia Indications: Suspected or known hypoglycemia (BS < 60 mg/dl); Altered level of consciousness Coma or seizure of unknown origin Contraindications: None in emergency setting Precautions: Blood sample should be drawn prior to administering D50 (if possible) Dosage: See Protocols Route: IVP Pregnancy Safety: Category C These protocols are unique to Cooke County EMS per Medical Director Page 168

170 Diazepam (Valium) Class: Benzodiazepine (Schedule IV Drug) Actions: Anticonvulsant; Skeletal muscle relaxant; Sedative Onset: (IV) 1-5 min; (IM) min Duration: (IV) 15 min 1 hour (IM) 15 min 1 hour Indications: Contraindications: Side Effects: Drug Interactions: Dosage: Major motor seizure; Status epilepticus; Premedication before cardioversion; Skeletal muscle relaxant; acute anxiety Hypersensitivity to the drug; Substance abuse; Shock; CNS depression as a result of head injury Respiratory depression Hypotension; Respiratory depression; Ataxia; Psychomotor impairment Confusion and Nausea May precipitate CNS depression and psychomotor impairment when the patient is taking other CNS depressant medications and should not be administered with other drugs because of possible precipitation (Incompatible with most fluids; should be administered into and IV of normal saline solution) See Protocols Route: IV / IM Pregnancy safety: Category D These protocols are unique to Cooke County EMS per Medical Director Page 169

171 Dobutamine (Dobutrex) Class: Sympathomimetic Actions: Primarily stimulates Beta-adrenergic receptors and less significant effects on beta and alpha adrenergic receptors Onset: 1 2 min; Peak after 10 Duration: minutes Indications: Inotropic support for patients with left ventricular dysfunction Contraindications: Tachydysrhythmias (A-fib / Atrial flutter); Severe Hypotension with signs of shock Drug Interaction: Incompatible with Sodium Bicarbonate and Lasix in same IV line Side Effects: Headache; dose related tachydysrhythmias; HTN, ventricular ectopy Dosage: See Protocols Route: Infusion Pregnancy Safety: Category C These protocols are unique to Cooke County EMS per Medical Director Page 170

172 Dopamine (Intropin) Class: Sympathomimetic Actions: Increased cardiac contractility; Causes peripheral vasoconstriction Onset: 2 4 minutes Duration: minutes Indications: Hemodynamically significant hypotension not resulting from hypovolemia Contraindications: Hypovolemic shock where complete fluid resuscitation has not occurred Side Effects: Ventricular tachyarrhythmia s; hypertension; palpations Precautions: Should not be administered in the presence of severe tachyarrhythmia s, V-fib and ventricular irritability; beneficial effects lost when dose exceeds 20 mcg/kg/min Dose: See Protocols Route: Infusion Pregnancy Safety: Category C These protocols are unique to Cooke County EMS per Medical Director Page 171

173 DuoNeb/ Combivent (albuterol / ipratropium) Class: Bronchodilator Actions: Prevention of bronchospasm Onset: 5 15 minutes after inhalation Duration: 3 4 hours after inhalation Indications: COPD; Emphysema Contraindications: Patients with known hypersensitivity to Albuterol, Proventil, Atrovent or Atropine Precautions: Use with cautious for patients with HTN; Coronary artery disease and seizures Monitor BP, Pulse and EKG when administering Side Effects: Palpations; Anxiety; HA; Dizziness; Sweating; Chest pain; Irregular heart beat Dosage: See Protocol Route: Inhalation Pregnancy Safety: Category C These protocols are unique to Cooke County EMS per Medical Director Page 172

174 Epinephrine 1:1000 Class: Sympathomimetic Actions: Bronchodilator Onset: 5 10 minutes SQ Duration: 5 10 minutes Indications: Severe asthma and allergic reaction; Anaphylactic shock Contraindications: Patients with underlying cardiovascular disease; Hypertension Side Effects: HA: Nausea; Restlessness; Weakness; Palpitations; Tachycardia Precautions: Protect from light; BP, pulse and EKG should be constantly monitored Dosage: See Protocols Route: SQ / Inhalation Pregnancy Safety: Category C These protocols are unique to Cooke County EMS per Medical Director Page 173

175 Epinephrine 1:10,000 Class: Sympathomimetic Actions: Onset: Increases heart rate and automaticity and cardiac contractile force; Increases myocardial electrical activity and systemic vascular resistance; Increases blood pressure 1 2 minutes IV / ET Duration: 5 10 minutes Indications: Cardiac Arrest; Anaphylactic shock Contraindications: None in emergency setting Side Effects: None in cardiac arrest Dosage: See Protocols Route: IV / ET Pregnancy Safety: Category C These protocols are unique to Cooke County EMS per Medical Director Page 174

176 Etomidate (Amidate) Class: Nonbarbiturate sedative / hypnotic, anesthetic Actions: Short acting hypnotic used to induce anesthesia; has a minimal effect on myocardial activity Onset: within 30 seconds Duration: 3 5 minutes Indications: Premedication for tracheal intubation Induction agent for rapid-sequence intubation for patients with BP 80 Contraindications: Hypersensitivity; Systolic BP < 80 (adults) Side Effects: Respiratory depression; Hypotension; Involuntary muscle movement Precaution: Make sure all RSI medications are prepared prior to induction Dosage: See Protocols Route: IVP Pregnancy Safety: Category C These protocols are unique to Cooke County EMS per Medical Director Page 175

177 Fentanyl (Sublimaze) Class: Opioid analgesic (Schedule II Drug) Actions: CNS depressant; decreases sensitivity to pain Onset: 7 8 minutes Duration: ½ hour 1 hour Indications: Severe Pain; Adjunct to rapid-sequence induction / sedation Contraindications: Side Effects: Respiratory depression; hypotension; Head Injury; hypersensitivity to opioids Shock and hemorrhage Nausea / Vomiting; Bradycardia; Hypotension / HTN Drug Interactions: Effects may be increased when given with other CNS depressants or skeletal muscle relaxants Dosage: See Protocol Route: IV / IM Pregnancy Safety: Category C Note: times more potent than Morphine These protocols are unique to Cooke County EMS per Medical Director Page 176

178 Furosemide (Lasix) Class: Loop diuretic Actions: Inhibits reabsorption of sodium chloride; Promotes prompt diuresis; vasodilation Onset: 5 20 minutes IV; Vascular effects within 5 minutes Duration: 2 hours Indications: CHF; Pulmonary edema Contraindications: Hypersensitivity; Pregnancy; Dehydration; Hypotension (BP < 90 systolic); Hypokalemia Side Effects: EKG changes; Hypotension; Dry mouth Dosage: See Protocols Route: IVP Pregnancy Safety: Category C These protocols are unique to Cooke County EMS per Medical Director Page 177

179 Geodon (ziprasidone) Class: Antipsychotic Actions: Changes the effects of chemicals in the brain Onset: Unknown Duration: Unknown Indication: Rapid control of acute agitation Contraindications: Recent Myocardial Infarction; Uncompensated heart failure; History of Prolonged QT syndrome Side Effects: Dizziness; HA; Bradycardia; Anxiety / Agitation; Insomnia; HTN; Vasodilation Dosage: 20 mg Route: IM ONLY Pregnancy Safety: Category C NOTE: DO NOT USE with elderly patients with dementia related psychosis, because of risk of death from cardiovascular events or infection. These protocols are unique to Cooke County EMS per Medical Director Page 178

180 Glucagon Class: Pancreatic hormone, insulin antagonist Actions: Onset: Causes breakdown of glycogen to glucose; Inhibits glycogen synthesis; Elevates blood glucose levels; Increases cardiac contractile force; Increases heart rate within 1 minute Duration: minutes Indications: Hypoglycemia without IV access (unable to take oral); Beta blocker overdose Contraindications: Hypersensitivity Side Effects: Few in emergency Drug Interactions: Effects of anticoagulants may be increased if given with glucagon Precautions: Only effective if there are sufficient stores of glycogen within the liver Dosage: See Protocols Route: IM Pregnancy Safety: Category B These protocols are unique to Cooke County EMS per Medical Director Page 179

181 Haldol (Haloperidol) Class: Major tranquilizer (Antipsychotic) Actions: Blocks dopamine receptors in the brain therefore altering mood and behavior Onset: minutes IM Duration: hours Indications: Acute psychotic episodes; Emergency sedation for severely agitated or delirious patients Contraindications: CNS depressant; coma; hypersensitivity Side Effects: Physical and mental impairment Dosage: See Protocols Route: IV / IM Pregnancy Safety: Category C These protocols are unique to Cooke County EMS per Medical Director Page 180

182 Ketamine (Ketalar) Class: Nonbarbiturate anesthetic Actions: Produces short acting amnesia without muscular relaxation Onset: within 30 sec Duration: 5 10 minutes Indication: Rapid Sequence Induction: Medically Assisted Intubation Contraindications: Stroke; Increased Cranial Pressure (ICP) Side Effects: HTN, Elevated heart rate, Hallucinations, Delusions, Explicit dreams Dosage: 1 mg/kg Route: Slow IV Push Pregnancy Safety: Category C NOTE: For Pediatric patients, MUST USE ATROPINE to help in prevention of hypersalvation These protocols are unique to Cooke County EMS per Medical Director Page 181

183 Labetalol (Normodyne) Class: Sympathetic Blocker Actions: Selectively blocks alpha receptors; non-selectively blocks beta receptors Onset: within 5 minutes Duration: 3 6 hours Indications: Hypertensive Crisis Contraindications: Side Effects: Hypersensitivity; Bronchial asthma; CHF; 2 nd / 3 rd degree heart blocks; Bradycardia; Cardiogenic shock; Pulmonary Edema Bradycardia; heart block; CHF; bronchospasm; hypotension Dosage: See Protocols Route: Slow IVP Pregnancy Safety: Category C These protocols are unique to Cooke County EMS per Medical Director Page 182

184 Levophed (Norepinephrine) Class: Sympathomimetic Actions: Causes peripheral vasoconstriction Onset: 1 3 minutes Duration: 5 10 minutes Indications: Acute hypotension; cardiogenic and neurogenic shock Post resuscitation with systolic <90mmHg Contraindications: Hypersensitivity; V-Fib; Tachy dysrhythmias Side Effects: Dizziness; Palpitations; Tachycardia; HTN, PVC s; Angina; Nausea / Vomiting Necrosis; Decreased urine output Dosage: See Protocols Route: Infusion; MUST USE IV PUMP Pregnancy Safety: Category D These protocols are unique to Cooke County EMS per Medical Director Page 183

185 Lidocaine (Xylocaine) Class: Antidysrhythmic (Class 1-B), local anesthetic Actions: Suppresses ventricular ectopic activity; increases ventricular fibrillation threshold Reduces velocity of electrical impulse through conductive system; Decreases ICP in head injuries Onset: seconds Duration: minutes Indications: Ventricular tachycardia / fibrillation Contraindications: Hypersensitivity; High degree heart blocks; PVC s in conjunction with Bradycardia Side Effects: Anxiety; Drowsiness; Confusion; Nausea / Vomiting; Widening of QRS Dosage: See Protocols Route: IV Pregnancy Safety: Category B These protocols are unique to Cooke County EMS per Medical Director Page 184

186 Lorazepam (Ativan) Class: Benzodiazepine (Schedule IV Drug) Actions: Anticonvulsant; Sedative Onset: minutes Duration: 6 8 hours Indications: Contraindications: Seizures; Sedation; Anxiety states; Premedication for cardioversion; Prevention of shivering in induced hypothermia Hypersensitivity; Respiratory depression; Hypotension Side Effects: Drowsiness; Respiratory depression; Hypotension; Apnea Precautions: Emergency resuscitation equipment should be available Dosage: See Protocols Route: IV / IM Pregnancy Safety: Category D These protocols are unique to Cooke County EMS per Medical Director Page 185

187 Magnesium Sulfate Class: Anticonvulsant / Antiarrhythmic / Reduces bronchospasm (Electrolyte) Actions: CNS depressant; Anticonvulsant; Antidysrhythmic Onset: (IV) Immediate; (IM) 3-4 hours Duration: (IV) 30 minutes; (IM) 3 4 hours Indications: Seizures of Eclampsia (toxemia of pregnancy); Torsades de pointe Contraindication: Shock; Heart Block Side Effects: Respiratory depression; Drowsiness Precaution: Dosage: Use with caution in patients receiving digitalis and patients in renal failure; Calcium chloride should be readily available as an antidote if respiratory depression occurs See Protocols Route: IV / IM Pregnancy Safety: Category B These protocols are unique to Cooke County EMS per Medical Director Page 186

188 Methylprednisone (Solu-Medrol) Class: Glucocorticoid (Steroid) Actions: Anti-inflammatory; Suppresses immune response Onset: 1 2 hours Duration: 8 24 hours Indications: Severe anaphylaxis; Asthma; COPD Contraindication: None in emergency setting Side Effects: GI bleeding; Prolonged wound healing; Suppression of natural steroids Precaution: Dosage: Onset of action may be 2 6 hours and thus should not be expected to be of use in the critical first hour following anaphylactic reaction; may raise blood sugars (caution in diabetes) See Protocols Route: IV / IM Pregnancy Safety: Category C These protocols are unique to Cooke County EMS per Medical Director Page 187

189 Metoprolol (Lopressor) Class: Beta blocking agent Action: Selectively blocks beta 2 adrenergic receptors (cardio-protective) Onset: 1 2 minutes Duration: 3 4 hours Indications: Contraindications: To reduce myocardial ischemia and damage in patients with AMI; PSVT; A - flutter and / or fibrillation Heart Failure; 2 nd / 3 rd degree heart block; Cardiogenic shock; Hypotension Side Effects: Bradycardia; AV conduction delays; Hypotension Precaution: BP, Pulse and EKG must be constantly monitored Dosage: See Protocol Route: Slow IV Push Pregnancy Safety: Category C These protocols are unique to Cooke County EMS per Medical Director Page 188

190 Midazolam Hydrochloride (Versed) Class: Benzodiazepine (Schedule IV Drug) Actions: Hypnotic; Sedative Onset: 1 3 min IV; dose dependent Duration: 2 6 hours; dose dependent Indications: Seizure; sedation; Pre-medication for tracheal intubation and cardioversion To help prevent shivering for induce hypothermia patients Contraindications: Hypersensitivity; Narrow-angle glaucoma; Respiratory depression; Hypotension Side Effects: Drowsiness; Hypotension; Amnesia; Respiratory depression; Apnea Dosage: See Protocols Route: IV / IM Pregnancy Safety: Category D These protocols are unique to Cooke County EMS per Medical Director Page 189

191 Morphine Sulfate Class: Narcotic Analgesic (Schedule II Drug) Actions: CNS depressant; Causes peripheral vasodilation; Decreases sensitivity to pain Onset: 1 2 minutes Duration: 2 7 hours Indications: Contraindications: Chest pain associated with myocardial infarction; Pulmonary edema with / without associated pain Moderate to severe acute / chronic pain Hypersensitivity; Respiratory insufficiencies; Asthma; Bronchospasm; Intracranial pressure (ICP) Side Effects: Dizziness; Altered level of consciousness; Hypotension; Respiratory depression Nausea / Vomiting Precautions: Should have naloxone (Narcan) available in case of respiratory depression and hypotension Dosage: See Protocols Route: IV / IM Pregnancy Safety: Category B These protocols are unique to Cooke County EMS per Medical Director Page 190

192 Naloxone (Narcan) Class: Narcotic Antagonist Actions: Reverses narcotic effects Onset: within 2 minutes Duration: minutes Indications: Narcotic overdoses; to rule out narcotic of unknown origin Contraindication: Hypersensitivity Side Effects: None Precaution: Use with caution in narcotic dependent patients who may experience withdrawal symptoms Dosage: See Protocols Route: IV / IM / ET (ET dose is more than IV dose) Pregnancy Safety: Category B These protocols are unique to Cooke County EMS per Medical Director Page 191

193 Nitroglycerin (Sublingual Spray) Class: Vasodilator (Nitrate) Actions: Smooth muscle relaxant; Reduces cardiac work; Dilates coronary arteries and systemic arteries Onset: 1 3 minutes Duration: minutes Indication: Angina; Chest pain associated with myocardial infarction; Hypertension emergencies Contraindication: Side Effects: Hypersensitivity; Hypotension; Head injury; CVA Recent use (within hours) of Cialis, Levitra and/or Viagra Hypotension; HA; Nausea / Vomiting; Dizziness Precaution: Dosage: Use caution with suspected / known inferior MI; BP must be constantly monitored; must be protected from light; expires quickly once opened 1 spray SL every 3 5 minutes for a total of 3 doses Route: SL Pregnancy Safety: Category C These protocols are unique to Cooke County EMS per Medical Director Page 192

194 Nitroglycerin Drip Class: Vasodilator Actions: Smooth muscle relaxant; Reduces cardiac work; Dilates coronary arteries and systemic arteries Indications: Contraindications: Precautions: Consider: Chest pain of suspected cardiac origin (hospital transport time > 15 minutes) HTN; CHF with acute pulmonary edema Hypersensitivity; Hypotension; Head injury; CVA Recent use (within hours) of Cialis, Levitra and/or Viagra Monitoring of all vital signs and EKG must be monitored. Once administration starts, may drastically drop blood pressure (if hypotension occurs. administer a fluid bolus of 250cc); Consider having a 2 nd IV line (for fluid bolus if needed) Suspected / known inferior MI When piggybacking with other solutions, place nitro line as close to IV site as possible Contact medical control prior to administration; Must be in glass bottle with low sorb tubing Dosage: Route: 2 20 mcg/kg/min; titrated to effect; CONTACT MEDICAL CONTROL PRIOR TO STARTING INFUSION; MUST USE IV PUMP Infusion Pregnancy Safety: Category C These protocols are unique to Cooke County EMS per Medical Director Page 193

195 Nubain (nalbuphine hydrochloride) Class: Opioid Actions: Potent analgesic, CNS depressant Onset: (IV) 2 3 minutes; (IM) 15 minutes Duration: 3 6 hours Indications: Moderate to severe pain Contraindications: Side Effects: Head Injuries, Increased Intracranial Pressure (ICP); Myocardial Infarctions with N/V Use caution in patients with history of drug abuse Dizziness, HA, Vertigo, Respiratory depression; Bradycardia, HTN, Tachycardia Dosage: 5 10 mg; may repeat at 5 mg after 10 minutes Route: Pregnancy Safety: IV / IM / SQ Category B NOTE: Can be reversed with Narcan; NOT for use in patients with CHEST PAIN. These protocols are unique to Cooke County EMS per Medical Director Page 194

196 Oxygen Class: Gas Actions: Necessary for cellular metabolism; increases arterial oxygen tension and hemoglobin saturation Indications: Contraindications: Hypoxia; SaO2 < 95%; Ischemic chest pain; respiratory insufficiency; Confirmed or suspected carbon monoxide poisoning None Side Effects: Drying of mucous membranes Consider: Obtain SaO2 readings before and after O2 administration Dosage: Route: Low concentrations via 1 6 LPM High concentrations via LPM High concentrations via 15 LPM Inhalation These protocols are unique to Cooke County EMS per Medical Director Page 195

197 Promethazine (Phenergan) Class: Phenothiazine, antihistamine (Anti-emetic) Actions: Antiemetic; mild anticholinergic activity; potentiates actions of analgesics Onset IV rapid Duration: 4 6 hours Indications: Nausea / Vomiting; to potentiate the effects of analgesics; may be used for sedation Contraindications: CNS depression from alcohol, barbiturates or narcotics Side Effects: May impair mental and physical ability; Sedation; Dizziness; Nausea / Vomiting Dosage: See Protocols Route: IV / IM Pregnancy Safety: Category C These protocols are unique to Cooke County EMS per Medical Director Page 196

198 Rocuronium Bromide (Zemuron) Class: Non-depolarizing neuromuscular blocker (Paralytic Agent) Actions: Paralyzes skeletal muscles including respiratory muscles Onset: seconds Duration: minutes Indications: To achieve paralysis to facilitate endotracheal intubation / ventilation Contraindications: Hypersensitivity Side Effects: Prolonged paralysis; Tachycardia; Apnea Precautions: Dosage: Should not be administered unless skilled in endotracheal intubations are present, intubation equipment must be available, O2 and resuscitative drugs must be available; must be stored in refrigerator See Protocol Route: IVP Pregnancy Safety: Category C These protocols are unique to Cooke County EMS per Medical Director Page 197

199 Sodium Bicarbonate Class: Buffer, alkalinizing agent, electrolyte supplement Actions: Combines with excessive acids to form a weak volatile acid Onset: 2 10 minutes Duration: minutes Indications: Contraindications: Late in the management of cardiac arrest; Tricyclic antidepressant OD; Severe refractory to hyperventilation Hypersensitivity Side Effects: Alkalosis Dosage: See Protocols Route: IV Pregnancy Safety: Category C These protocols are unique to Cooke County EMS per Medical Director Page 198

200 Succinycholine (Anectine) Class: Neuromuscular blocker (Paralytic Agent) / (depolarizing) Actions: Skeletal muscle relaxant; Paralyzes skeletal muscles including respiratory muscles Onset: Less than 1 minute Duration: 5-10 minutes after single dose Indications: To achieve paralysis to facilitate intubation Contraindications: Hypersensitivity Side Effects: Prolonged paralysis; Hypotension; Bradycardia Precautions: Dosage: Should not administered unless skilled in endotracheal intubation; must have all intubation equipment readily available; must have O2 and emergency resuscitative drugs available See Protocols Route: IVP Pregnancy Safety: Category C These protocols are unique to Cooke County EMS per Medical Director Page 199

201 Terbutaline (Brethine) Class: Sympathomimetic Actions: Relaxes bronchial smooth muscles by stimulating beta2 receptors; Bronchodilator Onset: 15 minutes SQ Duration: 1 1/2 4 hours Indications: Reversible bronchospasm associated with chronic COPD; Asthma; Preterm labor Contraindications: Hypersensitivity Side Effects: Nervousness; Tremors; Dizziness; Weakness; Headache; Nausea / Vomiting; Increases heart rate Precaution: Use with caution in patients with hyperthyroidism, diabetes and seizure disorder Dosage: See Protocols Route: SQ Pregnancy Safety: Category B These protocols are unique to Cooke County EMS per Medical Director Page 200

202 Tetracaine (Alcaine) Class: Topical ophthalmic anesthetic Actions: Anesthetizes globe of eyeball Onset: within 30 seconds Duration: minutes Indications: Short-term relief from eye pain or irritation; patient comfort before eye irrigation Contraindications: Hypersensitivity to drug or caine drugs; lacerations or globe penetrations are present Side Effects: Burning and stinging sensation Dosage: See Protocol Route: Eye drops Pregnancy Safety: Category C These protocols are unique to Cooke County EMS per Medical Director Page 201

203 Thiamine (Vitamin B1) Class: Vitamin (B1) Actions: Cofactor / coenzymes in glucose metabolism Onset: Rapid Duration: Depends on the degree of deficiency Indications: Coma of unknown origin; Alcoholism; Malnutrition Contraindication: None in emergency setting Side Effects: Rare Dosage: See Protocols Route: IV / IM Pregnancy Safety: Category A These protocols are unique to Cooke County EMS per Medical Director Page 202

204 Tylenol Suspension (Acetaminophen) Class: Analgesic / Antipyretics Actions: Fever reducer Onset: ½ - 2 hours Duration: 2 4 hours Indications: Fever Contraindication: Hypersensitivity Side Effects: Hemolytic anemia; Rash / Urticaria Precautions: Dosage: Use cautiously in patient with any type of liver disease and / or long term alcohol use because therapeutic doses may cause hepatotoxicity See Protocols Route: PO / Rectally Pregnancy Safety: Category B These protocols are unique to Cooke County EMS per Medical Director Page 203

205 Vasopressin (Pitressin) Class: Posterior pituitary hormone (ADH) Actions: Potent peripheral vasoconstrictor Onset: Immediately Duration: Variable Indications: Cardiac Arrest Contraindications: None used in emergency setting Side Effects: Ischemic chest pain; Abdominal distress; Sweating Dosage: See Protocols Route: IV / IO/ ET Pregnancy Safety: Category C These protocols are unique to Cooke County EMS per Medical Director Page 204

206 Zofran (Ondansetron) Class: Selective Serotonin (Anti-emetic) Actions: Causes interruption of the Serotonin 5 - HT3 receptors responsible for vomiting in the brain Onset: Immediate Duration: Unknown Indications: Contraindications: Active nausea and vomiting and as an adjunct to prevent nausea / vomiting associated with narcotic analgesic Hypersensitivity Side Effects: Headache; constipation and dizziness Dosage: See Protocols Route: IV / IM / Orally Pregnancy Safety: Category B These protocols are unique to Cooke County EMS per Medical Director Page 205