2010 EMS Biocare Emergency Medical Services Clinical Protocols

Transcription

2010 EMS Biocare
Emergency Medical Services
Clinical Protocols
2010 EMS Biocare
Emergency Medical Services Clinical Protocols
Table of Contents
Signature Authorization…………………………………..………………………….
Acknowledgments………………………………….………..……………………….
i
ii
Suggested Operating Guidelines Pages SOG 1-19
Levels of provider functioning under EMS Biocare...........................................
Provider identification........................................................................................
Patient Definition...............................................................................................
Radio and phone reports...................................................................................
Inability to establish Medical Control contact (8111).........................................
Duties of Allied Health providers........................................................................
On-scene dispute between EMS providers........................................................
Delegated practice statement............................................................................
Patient confidentiality.........................................................................................
Patient competency...........................................................................................
Patient refusing treatment or transportation.......................................................
Informed consent...............................................................................................
Consent for medical treatment...........................................................................
Geographic response area................................................................................
Disaster response..............................................................................................
Medication policy...............................................................................................
Interfacility transfers...........................................................................................
Advanced directives / DNR Orders....................................................................
Dead on Scene (DOS) patients.........................................................................
Patient Care Records (PCR).............................................................................
Domestic Violence reporting..............................................................................
Suspected abuse/neglect of elderly or child reporting.......................................
Treating and transporting prisoners...................................................................
Mandatory Medical Director notification.............................................................
Transport of the patient receiving blood/blood products....................................
Protocol Page.....................................................................................................
SOG-1
SOG-1
SOG-1
SOG-2
SOG-2
SOG-3
SOG-3
SOG-3
SOG-3
SOG-4
SOG-5
SOG-6
SOG-7
SOG-7
SOG-7
SOG-8
SOG-9
SOG-10-11
SOG-12-14
SOG-14-15
SOG-16
SOG-17
SOG-18
SOG-18
SOG-19
SOG-19
Universal Patient Care Protocol Pages UPC 1-2
UPC 1-2
Arrhythmia Protocols Pages AR1-4
Atrial Fibrillation/Flutter with rapid ventricular response...................................
Ventricular Tachycardia (VT)............................................................................
Supraventricular Tachycardia (SVT).................................................................
Bradycardia.......................................................................................................
AR-1
AR-2
AR-3
AR-4
Cardiac Arrest Protocols Pages CA1-4
Cardiac Arrest-AED/No monitor........................................................................
Cardiac Arrest Asystole/PEA.............................................................................
Cardiac Arrest Ventricular Fibrillation/Pulseless VT..........................................
Cardiac Arrest Post resuscitation care...............................................................
REVISED: 12/18/2009
2010 EMS Biocare Protocols
CA-1
CA-2
CA-3
CA-4
TOC-1
2010 EMS Biocare
Emergency Medical Services Clinical Protocols
Table of Contents
Medical Emergencies Protocols Pages MED1-14
Acute Coronary Syndrome (ACS) / Chest Pain.................................................
Allergic Reaction / Anaphylaxis..........................................................................
Behavioral / Patient Restraint............................................................................
Diabetic / Glucose Emergencies........................................................................
Drowning / Submersion injury............................................................................
Heat and Cold related disorders........................................................................
Pain Management..............................................................................................
Pharmacologically Assisted Intubation (PAI).....................................................
Rapid Sequence Intubation (RSI) Optional........................................................
Respiratory Distress..........................................................................................
Seizures.............................................................................................................
Stroke (CVA).....................................................................................................
MED-1
MED-2
MED-3-4
MED-5
MED-6
MED-7
MED-8
MED-9
MED-10
MED-11
MED-12
MED-13
Obstetric Emergencies Protocols Pages OB1-4
General treatment..............................................................................................
Uncomplicated childbirth....................................................................................
Abruptio Placenta and placenta previa..............................................................
Breech presentation..........................................................................................
Prolapsed Cord..................................................................................................
Postpartum hemorrhage....................................................................................
Eclampsia / Pre-eclampsia................................................................................
Apgar score........................................................................................................
Neonatal resuscitation........................................................................................
OB-1
OB-1
OB-1
OB-1
OB-1
OB-2
OB-2
OB-2
OB-3
Toxicological Emergencies Protocols Pages TOX1-2
TOX1-2
Traumatic Emergencies Protocols Pages TR1-4
General Management.......................................................................................
Spinal Immobilization........................................................................................
Sexual Assault..................................................................................................
Tasered patients...............................................................................................
Burns.................................................................................................................
TR-1
TR-1
TR-3
TR-3
TR-4
Drug Formulary Pages FORM1-32
FORM 1-32
Appendix Pages APX1-12
•
•
•
•
•
•
•
Age Specific definitions
Summary of approved procedures by certification level
Tracheosotomy tubes and stomas
Circulatory support
ETCO2
Ventricular Assist Device
Failed airway Procedure
Documents and Forms
•
•
•
North Central Texas Trauma Regional Advisory Council Bypass guidelines
Form 8111
Out of Hospital DNR
REVISED: 12/18/2009
TOC-2
PROTOCOL COMMITTEE ACKNOWLEDGEMENTS
The following departments and individuals helped in creating the protocol clinical guidelines and should be
recognized for all of their efforts. It is because of their hard work and efforts that have made these
protocols possible.
Rich Henkel, Biocare, Committee Chairman
Robert Simonson, DO, Biocare Medical Director
Robert Spranger, Biocare
Rick Coleman, Biocare
Kristin Burke, Biocare
Scott Vetterick, Frisco Fire Department
Kelly Walthall, Frisco Fire Department
Ron Franks, Corsicana Fire Department
Joe McClure, Corsicana Fire Department
Kelly Wolfe, Careflite
Robert Knappage, Sachse Fire Department
Ron Simmons, Rowlett Fire Department
Chris Weinzapfel, Rowlett Fire Department
Claude Causey, Rowlett Fire Department
Chief Mark Lee, Murphy Fire Department
REVISED: 11/16/2009
Suggested Operating Guidelines
These new protocols were developed as a result of YOUR request for change. This book is divided into sections. The
general information section contains information required by the Medical Director and Texas Department of State Health
Services. The treatment sections contain algorithms and treatment modalities for a variety of patient care scenarios. The
final section contains clinical information for high risk, low frequency procedures and a drug formulary for the drugs
contained within the protocol. A great deal of effort was put into the development of this document to help you provide the
absolute highest level of patient care possible. But as in-depth as these protocols may be, they are only as good as the
provider who applies them in a skilled and caring manner.
This document cannot anticipate or address every emergency condition seen in the field. Therefore, provider education,
experience and judgment must be a part of the clinical decision making process. As always you should use every
available resource to help guide you in patient care. In some cases that resource may be a Biocare Medical Control
Physician. The protocols are guidelines to be used to facilitate treatment when situations arise. They are not meant as a
cook book or as a list of procedures that MUST be done. Each situation is different and treatment should be performed
accordingly.
All patient encounters should follow the core principles of Universal Patient Care including universal precautions, airway
management, oxygenation, circulatory support, trauma management, patient assessment and any other treatment or
intervention specified within a protocol.
LEVELS OF PROVIDER FUNCTIONING UNDER EMS BIOCARE
The specific duties of an EMS provider outlined within this document are based on Texas Department of State Health
Services (TDSHS) certification / licensure and EMS Biocare authorization to function at a given level of care. All
Emergency Medical Services (EMS) personnel are required to be familiar with the contents of this document as it relates
to their specific level of certification and skill authorization.
ECA
EMT- BASIC
May utilize any procedure or
medication as outlined under
the ECA section on page
APX-2 Summary of approved
medications and procedures
by certification level, located in
the appendix.
ECA and EMT-B on page
APX-2 Summary of approved
the appendix.
INTERMEDIATE
PARAMEDIC
ECA, EMT-B and Intermediate
sections on page APX-2
Summary of approved
the appendix.
every section on page APX-2
Summary of approved
the appendix.
PROVIDER IDENTIFICATION
Texas EMS rules require any licensed EMS provider and registered First Responder Organization to ensure that all of its
employees wear proper identification while providing patient care, with identification to include, but not limited to, the
personnel’s initial of the first name, last name, certification / license level, and name of service.
The TDSHS and EMS Biocare does not recommend or enforce a specific type of identification badge, but only that
identification be prominently displayed during patient care.
PATIENT DEFINITION
A patient can be defined as “any person who, upon contact with an EMS system, presents with a complaint, circumstance,
and/or condition that might require further assessment or treatment. “
REVISED: 12/18/2009
SOG-1
RADIO OR PHONE REPORTS
It is not necessary, nor required, to contact BIOCARE MEDICAL CONTROL for routine patient care considered part of a
protocol. However, contact should be made with the destination hospital as soon as possible in the following situations:
x
x
x
x
x
x
major trauma (allows the trauma team to be mobilized),
cardiopulmonary or respiratory arrest,
difficulty in establishing or maintaining an airway,
acute MI or stroke (potential thrombolytic or cardiac catheterization patients),
unstable obstetrical patient (breech birth, shoulder dystocia, etc.),
when diversion to the closest facility occurs due to patient instability.
A provider does not need to wait until a protocol directs them to contact Biocare Medical Control; nor are they required to
complete all interventions prior to establishing contact when guidance is urgently needed.
However, contact must be attempted before proceeding past any black box with the words
contact BIOCARE MEDICAL CONTROL contained within it. For legal and quality improvement purposes, all medical
consultations or orders must be obtained via the recorded phone line at 214-947-8486.
Once communication with Biocare Medical Control has been established (with the exception of an initial notification), all
decisions regarding the protocols and care plans should be made through that physician. Thereafter, standing orders are
only valid when immediate intervention is warranted.
Verbal reports to the destination hospital should include the following elements as indicated by patient condition:
x Identify unit and level of provider
x Estimated time of arrival (ETA)
x Mental status
x Patient’s age and sex
x Patient’s chief complaint
x Brief pertinent history of the present illness
x Pertinent physical exam findings
x Baseline vital sign assessments
x Emergency care given and the patient’s response to care given
x Major past medical history including pertinent medications and drug allergies
Transporting units will advise receiving facility of changes in patient’s status.
INABILITY TO ESTABLISH CONTACT WITH MEDICAL CONTROL (“GOING 8111”)
On the rare occasion that the patient is so unstable that a delay in treatment could threaten life or limb, and, after goodfaith attempts, the provider cannot contact a BIOCARE MEDICAL CONTROL physician; the protocol shall become as standing
order and the provider may initiate all needed care described below a contact BIOCARE MEDICAL CONTROL black box. This
may include circumstances when a Biocare physician is unable to respond to a phone request within 2 minutes of phone
contact.
Anytime patient care has been performed outside of Biocare protocol the provider must:
x
x
x
x
continue attempting to establish contact with the destination facility,
notify the receiving physician (after arrival or by radio/phone) of all said care,
thoroughly document the care provided, number of attempts to establish medical consultation, and the suspected
reason for the communication failure,
fax a completed out of contact (8111) form to EMS Biocare within 24 hrs of the incident to 214-947-8416.
REVISED: 12/18/2009
SOG-2
DUTIES OF ALLIED HEALTHCARE PROVIDERS
Allied healthcare providers (CNA, RN, LVN, PA, and NP etc.) may assist certified Biocare EMS providers in accordance
with Biocare protocols up to their skill level and competency only at the discretion of the in-charge paramedic. Should no
ALS provider be on-scene, non-EMS certified health care providers must first contact BIOCARE MEDICAL CONTROL prior to
initiating any ALS interventions.
ON-SCENE DISPUTE BETWEEN EMS PROVIDERS
x
x
x
Disagreements about patient care are always to be handled in a professional manner, away from the patient when
possible, and should not detract from or reduce patient care.
Biocare suggested guidelines or patient care protocols can be consulted first to help resolve treatment disputes.
However, should a dispute remain unresolved or a protocol or guideline does not specifically address an issue, then
Biocare Medical Control MUST be contacted for dispute resolution.
Disputes should not be mentioned in patient care reports. A separate written report is to be completed for any
unresolved dispute arising at the scene which required physician intervention. This written report is to be faxed to
EMS Biocare within 24 hrs of the incident to 214-947-8416.
DELEGATED PRACTICE STATEMENT
Delegation of practice is defined as "the transfer of responsibility for the medical performance of one individual to another
while retaining accountability for the outcome." A physician that provides the medical supervision of an EMS system or
program is referred to as a Medical Director and the supervision provided is known as Medical Direction.
The Texas Health and Safety Code require that the provision of advanced life support and basic life support must be
under the medical supervision and control of a licensed physician. All Providers who function under EMS Biocare Medical
Control provide care under the approval and supervision of the EMS Medical Director, who is ultimately accountable for all
care rendered by EMS personnel under protocol.
PATIENT CONFIDENTIALITY
EMS professionals have an ethical responsibility to handle all information and documentation regarding a patient with the
utmost degree of confidentiality. Information obtained in confidence is not to be used or disclosed in a form that might
identify a patient without his or her consent.
Protected Health Information (PHI) is individually identifiable information such as name, social security number, condition,
address, age, past medical or mental health history. It is created by a healthcare provider and can be in oral or any
recorded form.
Key information to remember about Protected Health Information (PHI) is:
x
All information obtained during the course of evaluation, treatment or transport of a patient is considered confidential.
x
Patient information is only to be shared with those individuals considered part of the continuity of care or those
personnel assigned to a QI process (this does not include non-medical public safety entities such as law
enforcement).
x
Every effort should be made to ensure that the record will not be left unattended, open for public view or stored in
such a way as to compromise patient confidentiality.
x
Discussion of care issues with any person other than those involved in that patient’s care is prohibited.
REVISED: 12/18/2009
SOG-3
PATIENT COMPETENCY
Competency is ultimately defined by law, but mental capacity and competency is assessed and determined by medical
professionals based on patient presentation and mental status. Anyone at least eighteen (18) years of age who meets the
following criteria is considered to be competent and can legally accept or refuse evaluation, consent for treatment and/or
transportation, or sign or witness a legal document (e.g. Refusal of Care and Transport).
A patient may be deemed COMPETENT if they:
x
x
x
x
x
x
x
x
are oriented to person, place, time of day and circumstances of the situation,
are able to communicate (foreign/sign language may be used through an interpreter),
can demonstrate appropriate mental cognitive skills (understand instructions and repeat them back if normally able to
do so),
have no evidence of mental or judgmental impairment due to alcohol or drug use,
have no suicidal thoughts or show any indication of being a danger to themselves or others (If the patient has
attempted suicide, they may not refuse and law enforcement should be contacted for assistance),
have no evidence of bizarre, psychotic thoughts and/or behavior,
have no neurological disease or condition that could affect mental capacity and judgment (e.g. Alzheimer’s, senile
dementia, organic brain syndrome, major stroke),
have no findings suggestive of an impaired physiology that could potentially affect their decision making capabilities,
including;
¾ inadequate cerebral perfusion or injury (e.g., acute stroke),
¾ an acute alteration in body temperature,
¾ hypoglycemia or significant hyperglycemia,
¾ hypoxia,
¾ head trauma,
¾ hypoperfusion, hypotension, or shock,
¾ hepatic dysfunction or hepatic failure (hepatic encephalopathy).
A patient may be deemed INCOMPETENT if they cannot or are unable to;
x
x
x
respond knowingly and intelligently to questions about treatment or medical care,
participate in treatment decisions by means of rational thought processes,
understand basic medical treatment information including:
¾ the seriousness of the illness or injury,
¾ the medical treatment itself,
¾ the benefits and risks of any therapy or intervention,
¾ the consequences of refusal or lack of treatment,
¾ the risks and benefits of reasonable care alternatives.
REVISED: 12/18/2009
SOG-4
PATIENT REFUSING TREATMENT OR TRANSPORTATION
Any patient 18 years of age or older or legally emancipated who is competent to make decisions has a legal right to refuse
any aspect of treatment, including EMS transport even if said refusal could result in serious harm or death. An appropriate
patient care record should be completed on anyone deemed a patient that was assessed and/or treated by a Biocare
provider. This report must accurately and legibly reflect all care provided along with any interaction with the patient.
MINORS
Medical treatment may be administered to a minor upon routine completion of the appropriate consent forms(s) by a
parent or legal guardian. When a minor is unable to consent to his/her own medical treatment and the parent / legal
guardian having the power to consent cannot be contacted and actual notice to the contrary has not been given by the
parent / legal guardian, any of the following persons may consent to medical treatment of a minor:
x
x
x
x
x
x
x
x
A grandparent,
An adult brother or sister,
An adult aunt or uncle,
An educational institution in which the minor is enrolled that has received written authorization to consent from the
parent or legal guardian,
Any adult who has care and control of the minor and has written authorization to consent from the person having the
power to consent as otherwise provided by law,
Any court with control over a suit affecting the parent-child relationship where a child is the subject,
An adult responsible for the actual care, control, and possession of a child under the jurisdiction of a juvenile court or
committed by a juvenile court to the care of an agency of the state or country; or
A peace officer who has lawfully taken custody of a minor, if the peace officer has reasonable grounds to believe the
minor is in need of immediate medical treatment.
A copy of the written consent authorization should be attached to the consent when available.
Medical treatment may be administered to a minor without the consent of a parent or guardian if the parent signs a written
statement setting forth the grounds on which the minor has capacity to consent to his own medical treatment.
A minor may consent to hospital, medical, surgical, and dental care if the minor:
x
x
x
x
x
x
x
Is sixteen (16) years of age or older and resides separate and apart from his parents, managing conservator or
guardian, whether with or without the consent of the parents, managing conservator or guardian and regardless of the
duration of such residence, and is managing his/her own financial affairs, regardless of the source of the income; or,
Is on active duty with the armed services of the United States of America; or,
Presents evidence that his disabilities of minority have been removed by court order; or,
Consents to the diagnosis and treatment of any infectious, contagious, or communicable disease which is required by
law or regulation adopted pursuant to law to be reported by the licensed physician or dentist to a local health officer or
the Texas Department of State Health Services, including venereal disease; or,
Is unmarried and pregnant, and consents to hospital, medical, or surgical treatment other than abortion related to her
pregnancy; or,
Consents to examination and treatment for drug addiction, drug dependency, or any other condition directly related to
drug use; or,
Is unmarried and has actual custody of his/her own biological child and consents to medical, dental, psychological, or
surgical treatment for the child.
¾
¾
¾
If unsure whether it is appropriate to allow someone to give consent or refuse treatment of a minor, BIOCARE
MEDICAL CONTROL should be consulted.
Minors that are also parents should be treated as an adult, capable of giving consent for their child as long as
they are competent. Parents may not refuse medical care for their children if the child is suffering from a lifethreatening illness or injury.
If a child’s injuries are suspected of being from abuse, Child Protective Services must be notified.
If none of the above criteria are met, contact BIOCARE MEDICAL CONTROL.
REVISED: 12/18/2009
SOG-5
ADULTS
If a patient receives a procedure or medication, is conscious (or regains consciousness) and then refuses transport every
effort should be made to encourage them to be transported by EMS. If the patient still refuses offers of transport and is
assessed as competent, they may refuse ambulance transport. However, if the patient has been given a medication that
could impair their judgment, BIOCARE MEDICAL CONTROL must be contacted before a refusal is signed (also consider law
enforcement assistance as needed).
If a patient refuses treatment or transport, the EMS provider must;
x
determine that the patient is capable of taking action or care for his or her own well being,
x
discuss with the patient the need for treatment and/or transport. If the patient still refuses treatment or transport and it
is felt that the patient’s condition requires treatment or transport, allow family, friends or co-workers to help convince
the patient of the need for treatment or transport,
x
describe the potential consequences of their decision including options for further evaluation/care,
x
advise the patient to immediately contact appropriate medical care (911, ER, private physician, etc.) if a worsening or
progression of their illness or injury occurs,
x
at a minimum, thoroughly document the following information (may not be possible if a patient declines to provide
information):
¾
efforts to inform the patient of illness or injury and patient’s understanding of options discussed,
¾
GCS if any head trauma has occurred,
¾
reason for refusal of evaluation,
¾
patient assessment, chief complaint and/or mechanism of injury,
¾
assessment of mental status and legal capacity to consent/refuse treatment,
¾
notification that EMS will return when requested should condition continue or worsen,
¾
patient or authorized family member’s signature indicating refusal of care / transport,
¾
printed name of any witnesses along with the witness signature (preferably PD, family or neighbor).
x
A signature on the hard copy or electronic version of the refusal form should be obtained from the party refusing along
with at least one non-EMS related witness (EMS should witness a refusal form only when there are no family, friends,
or police on scene who can).
x
All patient contacts must have a patient care record even if a refusal for transport is the end product.
x
Patients deemed incompetent should be transported to an appropriate facility for further evaluation.
x
BIOCARE MEDICAL CONTROL should be consulted before transporting any patient with questionable mental judgment
against their will.
INFORMED CONSENT
Consent to accept or refuse medical evaluation, treatment, and/or transport is based upon the concept that every
individual has the right to determine what is to be done with or to his/her own body. For every patient contact, the provider
should:
x
x
x
obtain verbal permission (when feasible) prior to patient contact, evaluation, or treatment,
determine the patient’s competency,
assess the patient’s ability to understand the medical condition and information including:
¾ risks of any procedures performed,
¾ medications administered,
¾ consequences of refusal of evaluation, treatment, and/or transportation,
¾ alternatives to evaluation, treatment and/or transportation by the EMS System.
REVISED: 12/18/2009
SOG-6
CONSENT FOR MEDICAL TREATMENT
Consent for medical treatment is also based upon the concept that every individual has the right to determine what is to
be done with or to his/her own body. For consent to be legally valid, it must be informed. A patient declared legally
incompetent by a court of law cannot consent to his or her treatment. The appointed guardian has the right to consent to,
or refuse, treatment.
Consent for emergency care of an individual is NOT required and is considered to be implied if:
x
x
x
The individual is:
¾ Unable to communicate because of an injury, accident, or illness or is unconscious; and,
¾ Suffering from what reasonably appears to be a life-threatening injury or illness;
a court of record orders the treatment of an individual who is in an imminent emergency to prevent the individual's
serious bodily injury or loss of life; or,
The individual is under age 18 and is suffering from what appears to be a life-threatening injury or illness and whose
parents, managing or possessory conservator *, or guardian is not present.
* A managing or possessory conservator is an individual appointed by the court to have custody of a minor, to make decisions
for the minor, and to make a home for the minor.
GEOGRAPHIC RESPONSE AREA
These suggested operating guidelines and patient care protocols are to be utilized by EMS providers and response
agencies functioning under Medical Direction of EMS Biocare and only within that agency’s primary 911, mutual aid or
transfer service area as defined by local statute, contract or any combination thereof.
DISASTER RESPONSE
Whether manmade, natural or terrorism related, a disaster is present when it overwhelms local, regional, or state
response capabilities. Because a disaster can severely disrupt resources across multiple agencies, providers under
Biocare may be requested for immediate mutual-aid assistance.
Because of the urgency of care needed during disasters, Biocare providers, as part of an organized response by the State
Operation Center (SOC), Texas DSHS, or Department agreements are allowed to function under EMS Biocare without
first obtaining written approval.
Only Nationally Registered personnel may cross a State line and function in other States. TDSHS certified or licensed
providers are allowed to function within the State of Texas as needed.
x
EMS providers who are not part of a State Operation Center (SOC) or being paid by the response agency (i.e. Fire
Department or Ambulance Service they work for) will be providing medical care on their own accord and will not be
covered under EMS Biocare protocols or medical director.
x
Any provider who responds on a mutual-aid call is still responsible for adhering to the same clinical standards
expected of them during day to day EMS operations.
REVISED: 12/18/2009
SOG-7
MEDICATION POLICY
The administration of any medication, including oxygen, may only be done under the authorization of a licensed physician.
This authorization is typically by means of established protocol or during direct contact with a physician. These protocols
do not allow EMS providers discretionary authority to administer a medication they are not approved or authorized to
carry or use. This includes the administration of a medication when requested by a patient (e.g., patient on DVT
precautions asking you to administer their Lovenox via injection).
Drug Adulteration
The Texas Food, Drug, and Cosmetic Act mandate that medications be properly stored according to manufacturer
specifications. This includes, but is not limited to, things like keeping medications out of direct sunlight, storing
medications in a climate recommended by the drug manufacturer, routinely checking medications for damage to storage
container, routinely checking for clarity of medication, and routinely checking for expiration date of medication.
Medication Administration
Because medication safety encompasses many areas, a standardized and intuitive process is needed to help ensure
patient safety. Medications include: oxygen, intravenous fluid or any drug administered by sublingual, oral, intranasal,
intramuscular, nebulized, subcutaneous, intravenous, endotracheal, or intraosseous route. This is best accomplished by
adhering to the “Five Rights of Medication Administration,” a basic principle to follow when administering any
medication to any patient.
“Right medication, Right Route, Right Patient, Right Amount, Right Time”
Any medication given via the IV route may instead be given via the IO route if an IO is established.
Pediatric doses should be calculated based on the patient’s ideal weight or Broselow tape, not actual weight. No single
pediatric dose shall exceed the adult dosage.
Tracheal tube medication administration should NOT be used in the adult patient, but can be used in pediatric patients
when IO is contraindicated ONLY. Any approved medications given via the tracheal tube should be at twice the IV dose.
All medications shall be thoroughly documented in the patient record to include: clinical need, patient presentation, dose,
route, vital signs, and clinical response observed after administration.
Expired medication:
Medication and IV fluid inventory which has been used, broken or near their expiration should be replaced as soon as
possible. Medications are dated with an expiration date on the outside of the box or on the medication itself in one of two
formats. The expiration date is either stated with the:
x Date expressed as mm/yyyy. This drug can be held until the last day of the respective month;
x Date expressed as I mm/yyyy. If you see a date with a I in front of the month, the drug expires on the first day of the
respective month and must be pulled no later than the first day of that month.
Lorazepam (Ativan®) storage:
Ativan may be stored at room temperature for a period not to exceed 60 days, after which time it loses its effectiveness
and should be disposed. When properly refrigerated, Ativan storage life is effective until the date of expiration printed on
the vial.
Packaging substitution:
Every effort should be made to maintain the quantity and packaging of a medication as outlined in the drug list. However,
should a medication not be available in the recommended and/or specified format, a suitably equivalent form and amount
may be substituted. Field crews are to be notified before a replacement is placed into service, as it may be packaged
differently or have a new dosage concentration or strength.
REVISED: 12/18/2009
SOG-8
INTERFACILITY TRANSFERS
All prehospital treatment occurring during transfer shall comply with established patient care protocols or have specific
written physician orders from the transporting or receiving facility. If a provider is unfamiliar with a medication, procedure
or medical device, they must first consult with transferring hospital staff prior to accepting the patient. If questions or
concerns still exist after consulting with hospital staff, BIOCARE MEDICAL CONTROL is to be contacted for further
consultation and transfer approval.
x
A written physician order (from current hospital chart or specific to EMS) must accompany the patient for any
medication and/or intervention not covered in this document or specific protocol.
x
The attending EMS crew and the transferring facility are both responsible for assuring that the EMS crew is
familiarized with infusion pumps or other devices prior to departure from the facility.
Interstate transfers:
Interstate transfers are permitted as long as protocols and staffing requirements are met and adhered to during patient
transfer.
Specialty care transports:
Specialty Care Transports are defined as the interfacility transfers of critically ill or injured patients requiring specialized
interventions, monitoring and/or staffing. This can include patients with blood or blood products and/or any other
parenteral pharmaceutical or device unique to the patient’s special health care needs.
The transferring facility should be requested to provide staff clinically capable of supporting any device or medication
beyond the scope, training, certification or licensure of EMS crews (unless paramedics who completed an approved
critical care course with proper training are available). Should the transferring facility be unwilling or unable to provide staff
during transport, EMS must contact BIOCARE MEDICAL CONTROL for consultation and guidance before they can accept the
patient for transport.
If the accompanying health care provider is an RN, he/she may assist with patient care within the scope of the Nursing
Practice Act while under written orders of the transferring physician. The transporting crew and accompanying staff are
both responsible for the management of the patient during transport. However, should the patient decompensate during
transport, EMS should assume all primary patient care responsibilities with assistance from accompanying staff.
Transport / transferring from a non-hospital facility (ECF, private home, etc.):
BLS transfer crews often are the first medical personnel to medically assess the patient with a critical illness or injury.
Rapid identification and early interventional care is often the key to a favorable patient outcome with early ALS
intervention in potentially life-threatening condition(s) when recognized.
EMS crews are to rapidly assess all patients to determine if any unstable criteria are present. Instability is said to exist
when an illness, injury or physiologic change places the patient in imminent danger of losing life or limb.
Assessment on non-emergency calls should, when possible, be completed quickly. Assessment should take into account
past medical history, medications and any diagnostic data obtained (BP, pulse, LOC and respiratory status), all of which
are needed to determine patient status.
If the patient is considered unstable, ALS backup should be requested to correct the problem or prevent further
deterioration of the patient's physiologic status. Exception: if the total packaging and transport time is less than the time it
would take for ALS to arrive, the BLS crew may transport to the closest facility.
REVISED: 12/18/2009
SOG-9
ADVANCED DIRECTIVES / DO NOT RESUSCITATE ORDERS
Competent and informed patients have a moral and legal right to consent to or refuse recommended medical procedures
or treatments, including CPR, advanced airway management, artificial ventilation, defibrillation and transcutaneous
pacing. An advance directive is any expression of a person’s thoughts, wishes, or preferences for end-of-life care. A
patient must be incompetent or otherwise incapable of communication before an advance directive is used to determine
treatment decisions.
Six valid reasons for withholding resuscitation in the prehospital environment:
1. Presence of a valid Out-of-Hospital Do Not Resuscitate Order, including a department-standardized
identification device such as a necklace or bracelet.
2. The presence of a valid written advance directive that has been signed by the patient - DNR orders of a
physician written onto a piece of plain paper or prescription pad is not sufficient.
3. A licensed physician directs EMS to withhold resuscitative efforts - This may occur either in person or via phone.
Providers must contact BIOCARE MEDICAL CONTROL if the physician is not a Biocare physician.
4. Attempts to perform CPR places the rescuer at risk of injury or death – this often will include grossly
contaminated patients (hazardous waste), a dangerous or volatile situation, or patient location.
5. Medical Power of Attorney form (MPOA) - In the event that EMS personnel know that the patient has executed a
valid medical power of attorney and the agent named in the medical power of attorney is physically present at the
scene, EMS personnel may withhold treatment, including life support, at the direction of the agent.
¾ Providers must contact BIOCARE MEDICAL CONTROL if a MPOA directs you to hold or stop resuscitation.
¾ Unless a limitation on the authority is contained in the MPOA form, the agent may make any medical decision on the
¾
¾
¾
¾
¾
¾
6.
patient’s behalf that the patient could make if the patient were competent.
Treatment may not be given to, or be withheld from the patient if the patient at anytime objects, regardless of whether,
at the time of the objection a MPOA is in effect; or the individual is competent.
EMS shall make reasonable efforts to inform the patient of any proposed treatment or of any proposal to withdraw or
withhold treatment before implementing an advance directive.
The MPOA is effective indefinitely unless it is revoked as provided by state law or the patient.
If the medical power of attorney has an expiration date and on that date the patient is incompetent, the MPOA continues
to be in effect until the patient becomes competent, unless it is revoked.
In the event that EMS personnel are informed of or provided with a revocation of a MPOA, they shall immediately record
the revocation in the patient care record and give notice of the revocation to the agent and any health care providers
responsible for the patient’s care.
A directive does not imply that a patient refuses palliative care initiated prior to cardiac or respiratory arrest for comfort
measures unless specified.
Obvious signs of death
TDSHS adopted rule §157.25 Out-of-Hospital Do Not Resuscitate (DNR) Order states; Records shall be
maintained on each incident in which an out-of-hospital DNR order or DNR identification device is
encountered by responding healthcare professionals, and the number of cases where there is an on-site
revocation of the DNR order shall be recorded. The data documented should include: an assessment of patient's
physical condition, whether an identification device or a DNR form was used to confirm DNR status and patient
identification number, any problems relating to the implementation of the DNR order, the name of the patient's
attending physician, and the full name, address, telephone number, and relationship to patient of any witness
used to identify the patient.
These records must be maintained and shall meet records retention requirements for each health care
profession. If the patient is transported, the original DNR order or a copy of the original order will be kept with
the patient. Copies of the original DNR order may be put on file with concerned parties, and the original order
shall remain in the possession of the patient, a legal guardian, or the healthcare facility responsible for the
patient's care.
REVISED: 12/18/2009
SOG-10
Identification devices (OOH – DNR Order)
1. TEXAS DEPARTMENT OF STATE HEALTH SERVICES STANDARD OUT-OF-HOSPITAL DO-NOTRESUSCITATE ORDER
2. As an optional means of identification, a patient may obtain, at patient's expense, an OOH DNR
device. An OOH DNR device, as approved by the Texas Department of State Health Services, must
meet the following requirements:
¾
An intact, unaltered, easily identifiable plastic identification OOH DNR bracelet, with the word "Texas" (or a
representation of the geographical shape of Texas and the word "STOP" imposed
over the shape) and the words "Do Not Resuscitate", shall be honored by
qualified EMS personnel in lieu of an original OOH DNR Order form.
¾
An intact, unaltered, easily identifiable metal bracelet or necklace inscribed with
the words, "Texas Do Not Resuscitate - OOH" shall be honored by qualified
EMS personnel in lieu of an OOH DNR Order form.
3. Valid Out-of-state DNR orders or device.
If there is any doubt to the validity, authenticity, or any dispute concerning a presented DNR,
contact BIOCARE MEDICAL CONTROL immediately for physician involvement and resolution.
An OOH DNR order is considered revoked and is not to be honored when:
1) The patient or person who executed the order:
¾
Destroys the form and removes the identification device: or,
¾
Directs someone in their presence to destroy the form and/or remove the ID device; or,
¾
Informs EMS that it is their intent to revoke the order (includes qualified patient less than 18),
2) The patient is known to be pregnant.
3) Unusual or suspicious circumstances are involved with the death (crime, suicide, etc.).
See Forms Section at back of book for a copy of Texas Department of State Health Services
Standard-out-of-Hospital Do-Not-Resuscitate order.
REVISED: 12/18/2009
SOG-11
DEAD ON SCENE (DOS) PATIENTS
DOS specifically refers to circumstances in which resuscitative efforts were attempted unsuccessfully, or in certain
circumstances, not at all due to an obvious death being present. In order to fulfill certain medical and legal obligations in
the determination of death at the scene of an emergency, EMS must, if at all possible, gain access and assess for signs of
life which may include: attaching a cardiac monitor, assessing for pulses, and observing for lividity or rigor mortis. Use
caution in situations of hypothermia, where the patient can appear clinically dead but may still be resuscitated.
Indications for withholding resuscitation:
Resuscitation attempts may be withheld for medical or trauma patients when any of the below described criteria are met.
However, resuscitation is required when no criteria are present, an exception is present or it is at anytime questionable.
x
A legal advanced directive or valid OOH-DNR is presented (non-trauma patients only):
x
Signs of obvious death are present as evidenced by:
¾
x
Decomposition; dependent lividity; decapitation or incineration; cold patient with rigor mortis (not hypothermic); obvious
mortal wounds with vital organ destruction (e.g., brain or thoracic contents extrusion) with no spontaneous pulse or
respiration.
Resuscitation efforts pose a danger to the health/safety of responders.
When it is deemed appropriate to pronounce a patient dead after unsuccessful cardiac resuscitation:
x
The patient has received a reasonable attempt at all indicated cardiac resuscitation measures (20 minutes) including
all of the following: an advanced airway, IV or IO access, medications, and/or defibrillation but failed to respond to any
therapies. Do not attempt to pronounce a patient who is not obviously deceased without first attempting cardiac
resuscitation measures.
x
Reevaluation of the patient reveals signs of an obvious death.
x
The patient does not have spontaneous respiration, eye opening, motor or other neurological activity at the time
stopping of resuscitation is contemplated.
x
VF/VT is not present; if either is present, resuscitation is to be continued and the patient transported.
x
Cardiac arrest reversible causes have been corrected.
x
Inadvertent initiation of CPR in the obviously deceased patient (by first responders, family etc.) or when resuscitative
efforts have been initiated prior to receiving a valid OOH DNR or MPOA document by an authorized agent. In these
instances you may discontinue care and obtain a pronouncement of death through consultation with BIOCARE
MEDICAL CONTROL.
Obtaining and documenting a pronouncement:
x
Only paramedic level personnel may obtain an in-field pronouncement.
x
It is not necessary to contact Medical Control if the above criteria have been met, however, if you need help with
pronouncements you can contact Biocare Medical Control via the recorded phone line at 214-947-8486.
¾
Once a Biocare physician is on line, clearly identify yourself, your certification level, and EMS affiliation.
¾
Be professional and provide a complete and accurate description of pertinent events, patient
presentation, and any response to care provided.
¾
Accurately document the official time of death, physician providing the time of death (if contacted) and
any other pertinent information about the death on the patient care record.
REVISED: 12/18/2009
SOG-12
Securing the scene and evidence after pronouncement:
When a patient is obviously dead or pronounced dead on scene, all access in and out of that scene should be limited until
law enforcement takes control of the scene. This is often accomplished by assigning personnel (First Responders, EMS or
Fire crews etc.) to limit and/or prevent unauthorized or repeated entry into the area.
When dealing with a potential crime scene:
x
Avoid cutting though bullet or knife holes on clothing. If the patient is hanging and resuscitation is indicated, avoid
cutting through knots unless there is no other way to remove the rope.
x
Cover the deceased after pronouncement only if they are:
¾ within direct view of the public or family (roadway, clubs, stores, living room etc.),
¾ totally nude (cover out of respect for the patient and family),
¾ have a potential for further debris contamination to occur (leaves, rain, dirt etc.).
x
When covering a body, the use of a disposable patient sheet (or a burn sheet if
disposable stretcher sheets unavailable) is preferred. Avoid using blankets, sheets or
any covers found at scene as these could be contaminated and later complicate forensic investigation.
Body Management - post resuscitation / pronouncement:
If pronounced in a public setting and there is any reason to believe that the situation may be a crime scene, any additional
movement of the body should occur only when it is deemed necessary to prevent the loss or destruction of the body
(move only if safe to do so).
Note: Movement of a body not in danger of destruction should occur only with law enforcement, Justice of the Peace
and/or Medical Examiner (ME) approval.
Under no circumstance is a deceased body to be left unsecured until local law enforcement, Justice of the Peace, Medical
Examiner or an authorized funeral home accepts responsibility. Security of the body (and scene) must be maintained at all
times until it is appropriately relinquished.
x
Chronically or terminally ill patients within a private setting placed on the floor for resuscitation purposes and
subsequently pronounced may be placed back in their original location only if a crime scene or abnormal death is not
suspected.
x
All decisions to move or cover the deceased should be made with the greatest possible respect for the dignity of the
patient, family, friends and the public.
x
If the patient was pronounced after resuscitative attempts and an unknown or suspicious factor is surrounding the
death you must:
¾ Leave and secure any IV or IO catheters for removal by the medical examiner (ME),
¾ Circle, using a pen or marker, all unsuccessful IV, IO or pleural decompression attempts for ME identification
(especially antecubital fossa IV/IO attempts to rule out an overdose),
¾ Leave all endotracheal tubes, surgical airways and/or pleural decompression catheters in place for removal by the
ME.
x
Anytime a body was moved to facilitate resuscitation or to help determine if resuscitation should occur, the following
information must be thoroughly documented in the patient care record:
¾ initial patient position when found,
¾ who was on scene when you arrived,
¾ position of any objects in relationship to the patient,
¾ position of any weapons and state of clothing (including knife or bullet holes etc).
REVISED: 12/18/2009
SOG-13
Important points to remember in DNR patients and pronouncements:
x
It is always appropriate to transport to the hospital if in the assessment of the on scene providers, the body location
would create a hazard or problem for the public (e.g., death in a public place such as a grocery store or movie
theater). This does not apply if the death is due to a criminally related act (e.g., shooting) and the patient is obviously
deceased.
x
Always rule out a non-traumatic etiology for what may be perceived as a traumatic arrest (e.g., patient going into
cardiac arrest from an MI causing a minor car crash).
x
Never leave a body in the possession of someone who is not a member of an authorized emergency services group
(EMS, Fire, Police) and never leave a body alone with family members.
x
An advanced directive does not imply that a patient refuses palliative and/or supportive care. Care intended for patient
comfort may not be withheld based on request of a MPOA; immediately contact BIOCARE MEDICAL CONTROL should
a MPOA request you withhold comfort measures.
x
When an EMS Provider honors an appropriately executed DNR order, the law provides protection against any
charges of aiding in suicide (Section 22.08 of the Penal Code -TAC 166.047).
x
When in doubt initiate resuscitation; termination can always be obtained later if appropriate.
x
Be aware that you may find or encounter evidence within or attached to a patient’s clothing. Be certain to check your
stretcher and ambulance for any potential evidence (such as bullets that may fall out of clothing) after each run. Any
items of evidence must be turned over to the Medical Examiner’s office or Law Enforcement agency. Clearly
document in your run report what was found and where it was found along with the name of the individual to whom
the article(s) were released.
PATIENT CARE RECORDS (PCR)
Documentation is a crucial component of patient care and effective communication of information is vital as improper
communication can result in confusion and complications in delivery of patient care. The Texas DSHS and Biocare require
EMS personnel to provide a written or computer generated run report to the receiving facility on all transports.
Failure to provide documentation allows TDSHS to suspend or decertify an EMS certificant or suspend or revoke a
licensed paramedic for, failing to make accurate, complete and/or clearly written patient care reports documenting a
patient's condition upon arrival at the scene, the prehospital care provided, and patient's status during transport, including
signs, symptoms, and responses during duration of transport. In the event EMS is in a response-pending status or was
called out prior to completion, the report shall be delivered to the emergency department at the next earliest opportunity.
All responding EMS units involved in patient care will provide patient care information for the receiving facility. Necessary
information includes vital signs, treatment and mechanism of injury. This information must be delivered to the receiving
facility within 24 hours of the call either from the specific agency or as provided to the transporting ambulance. It is the
responsibility of the transporting unit to gather all necessary information from the scene and ancillary personnel. First
responder and other information from participating EMS units should be included in the report left with the receiving
facility.
Basic guidelines for prehospital documentation:
x A PCR shall be completed on every patient with an injury, illness or medical complaint.
x A separate PCR shall be completed for each patient seen. Example: a mother and her newborn are transported
together or a delivery en route to the hospital. A separate PCR is needed on each.
x A PCR shall be completed for each encounter of the same patient on a new and separate call. Example: diabetic seen
and treated by EMS who refuses transport, but who requests EMS later for the same complaint or worsening of their
symptoms.
x JCAHO forbidden or “do not use” abbreviations are not to be used.
x ECGs obtained during the course of patient assessment or treatment must be attached (or captured if electronic
reporting is used) to EMS and hospital copies for permanent records.
x A receiving staff signature should be obtained on all transported patients.
REVISED: 12/18/2009
SOG-14
Regardless of the method of documenting information, patient care documentation should include, at minimum, the
following data (when available):
x
x
x
x
x
x
x
x
x
x
Patient name, age, and sex,
Weight in pounds or kg when a weight-based drug is given,
Chief complaint, nature of illness or mechanism of injury if trauma related,
Location of patient when first found, pre-arrival care by bystanders or other medical personnel,
Patient history, medications prescribed, medications taken and any drug hypersensitivities,
Physical assessment of the patient including at least two (2) complete sets of vital signs (including patient refusals
and traumatic arrest pronouncement), pertinent ECG findings or patient exam findings,
All care provided to the patient including any negative or positive responses to medical therapy,
Neurological assessments in stroke or head injured patients including a GCS score,
Acute changes in cardiac rate or rhythm,
Time an intervention was initiated or a medication was administered.
Abbreviations:
To avoid confusion, certain abbreviations, acronyms and symbols are no longer advocated for use in the health care
setting. To assure continued patient safety, the following abbreviations should not be used as outlined below.
Item
Prohibited Abbreviation
Potential Problem
Use Instead
1.
U or u (unit)
Mistaken for a “0” (zero), the number
“4” (four) or “cc”
Write "unit"
2.
IU (International Unit)
Mistaken as IV (intravenous) or the
number 10 (ten)
Write
"International Unit"
3.
Q.D., QD, or
q.d., qd
Mistaken for each other
Write "daily"
The period after the “Q” can be
mistaken for an "I" and the "O" can
be mistaken for an "I"
Write “every other day”
4.
5.
6.
7.
Q.O.D., QOD, or
q.o.d., qod
Trailing zero
(X.0 mg)*
Lack of leading zero (.Xmg)
Decimal point is missed
Decimal point is missed
Write “X mg”
(do not use a trailing zero)
Write “0.X mg”
(always use a leading
zero)
MS
8.
MSO4
9.
MgSO4
REVISED: 12/18/2009
Can mean morphine sulfate or
magnesium sulfate
Confused for one another
Write "morphine sulfate
Write "magnesium sulfate"
SOG-15
DOMESTIC VIOLENCE REPORTING
Family violence means an act by a member of a family or household against another member of the family or household
that is intended to result in a physical harm, bodily injury or assault or that is a threat that reasonably places the member
in fear of imminent physical harm, bodily injury or assault, but does not include defensive measures to protect oneself; or
is intended to inflict emotional harm, including an act of emotional abuse.
In accordance with information provided by Medical Professions of the Family Code of the Texas Criminal and Traffic
Law: medical professional who treats a person for injuries that the medical professional has reason to believe were
caused by family violence shall:
1. Immediately provide the person information regarding the nearest family violence shelter center:
2. Thoroughly document in the person's patient care record:
a. The fact the person received the information provided under subdivision (1);
b. The reasons why the provider believes the person's injuries were caused by family violence; and
c. Give the person a written notice including the following information completed with the required information, in
both English and Spanish.
"NOTICE TO ADULT VICTIMS OF FAMILY VIOLENCE"
It is a crime for any person to cause you any physical injury or harm even if that person is a member or former member of
your family or household. "You may report family violence to a law enforcement officer by calling the following telephone
numbers:__________________________.” "If you, your child, or any other household resident has been injured or if you
feel you are going to be in danger after a law enforcement officer investigating family violence leaves your residence or at
a later time, you have the right to: "Ask the local prosecutor to file a criminal complaint against the person committing
family violence; and "Apply to a court for an order to protect you.”
You may want to consult with a legal aid office, a prosecuting attorney, or private attorney. A court can enter an order that:
(1) prohibits the abuser from committing further acts of violence;
(2) prohibits the abuser from threatening, harassing, or contacting you at home;
(3) directs the abuser to leave your household; and
(4) establishes temporary custody of the children or any property.
"A VIOLATION OF CERTAIN PROVISIONS OF COURT-ORDERED PROTECTION MAY BE A FELONY. CALL THE FOLLOWING
VIOLENCE SHELTERS OR SOCIAL ORGANIZATIONS IF YOU NEED PROTECTION:__________________."
a) Except as provided by Subsection (b), a person who reports family violence or provides information under Section
91.003 is immune from civil liability that might otherwise be incurred or imposed.
b) A person who reports the person's own conduct or who otherwise reports family violence in bad faith is not protected
from liability under this section.
The NCTTRAC and BIOCARE MEDICAL CONTROL encourage each prehospital entity to direct the appropriate persons to
assistance groups within the area.
The EMS provider will make use of this information when the need arises and promptly notify law enforcement officials
when a family violence, domestic assault, or child abuse case is suspected. EMS providers are responsible for directly
reporting this information to law enforcement officials at the time of call.
REVISED: 12/18/2009
SOG-16
SUSPECTED ABUSE/NEGLECT OF A CHILD AND SUSPECTED ABUSE/NEGLECT OF THE ELDERLY
Under the Child Abuse Prevention and Treatment Act (CAPTA), child abuse and neglect means, at a minimum: “Any
recent act or failure to act on the part of a parent or caretaker, which results in death, serious physical or emotional harm,
sexual abuse or exploitation, or an act or failure to act, which presents an imminent risk of serious harm.”
Elder abuse comes in many forms: battering, verbal abuse, sexual abuse, neglect of physical, financial or emotional
needs or neglect of proper health care, hygiene and nutrition. Unintentional abuse often occurs because of ignorance,
inexperience or inability to provide good care.
“Abuse” includes the following acts or omissions by a person:
x
Mental or emotional injury that results in an observable and material impairment in the growth, development or
psychological well being;
x
Physical injury that results in substantial harm to a child or elder, or the genuine threat of substantial harm from
physical injury, including an injury that is at variance with the history or explanation given.
x
Verbal and psychological abuse.
x
Failure to make a reasonable effort to prevent an action by another person that results in physical injury or substantial
harm.
x
Sexual conduct harmful to a child’s or elders mental, emotional, physical welfare or compelling/encouraging one to
engage in sexual conduct defined by the Texas Penal Code;
x
The current use by a person of a controlled substance as defined by the Texas Health and Safety Code, in a manner
or to the extent that the use results in physical, mental, or emotional injury to a child or elder.
“Neglect” includes: the leaving of a child or elder in a situation where they would be exposed to a substantial risk of
physical or mental harm, without arranging for necessary care, or leaving oneself without the goods and services that are
necessary.
The following acts or omissions by a person may be seen as neglect:
x
Failing to seek, obtain, or follow through with medical care, with the failure resulting in or presenting a substantial risk
of death, disfigurement, or bodily injury or with the failure resulting in an observable and material impairment to the
growth and development.
x
The failure to provide a child or elder with food, clothing or shelter necessary to sustain life.
x
Placing or failing to remove a child or elder from a situation that would expose them to a substantial risk of sexual
conduct harmful to the child or elder.
Who must report:
By law, any person and all health care providers (including EMS) are obligated to report suspected child abuse/neglect or
elder abuse/neglect to either local law enforcement or the Texas Department of Family and Protective Services (DFPS).
When to report:
x When you have cause to believe that a child or elder’s physical or mental health or welfare has been adversely
affected by abuse or neglect;
x When a professional has cause to believe that a child or elder has been abused or neglected or may be abused or
neglected.
EMS reporting of suspected abuse is accomplished by one of three methods:
1. directly to law enforcement officer (not hospital security) either on scene or at the hospital,
2. via the 24 hour TDFPS Family Violence Hotline at 1-800-252-5400,
3. via secure website at https://www.txabusehotline.org/PublicMain.asp.
Reporting suspected abuse to a RN, Physician, or Social Worker does NOT satisfy your obligation to report under law as
you are required to report by one of three methods listed above.
REVISED: 12/18/2009
SOG-17
TREATING AND TRANSPORTING PRISONERS
It is an expectation that prisoners be treated with respect, informed of their rights as a patient to accept or decline EMS
assistance, and informed if it is the preference for EMS to provide care and transport if needed.
When dealing with an incarcerated individual or subject in law enforcement custody:
x
The role of EMS is to provide a thorough evaluation, any necessary medical care and needed transportation,
x
Individuals being detained, under arrest or classified as inmates in the custody of the law enforcement agency, still
have a right to receive and/or refuse medical care,
x
The arresting officer has the right to request a hospital destination for the person in his charge, as long as an officer
accompanies the patient in the ambulance or by close proximity vehicle escort. An attempt should be made to honor
the request of law enforcement for transport to a specific hospital as long as it does not conflict with required EMS
transport criteria (e.g., trauma facility criteria),
x
Law enforcement cannot refuse medical care for a subject in custody, and cannot legally sign a refusal of treatment
and/or transportation form for a subject in custody. However, based on your assessment, it is possible for a law
enforcement agency to transport the prisoner themselves instead of by ambulance,
x
It is the responsibility of law enforcement, prison or jail staff to search the prisoner for weapons, other dangerous
objects and contraband, and for assuming control of any property seized, before EMS care and transport is to occur,
x
The medic or officer in charge should communicate directly with the responsible officer to advise them on the
prisoner’s medical findings and treatment recommendations for the subject in custody.
MANDATORY MEDICAL DIRECTOR NOTIFICATION
Any incident which has or potentially has had an adverse impact on patient care or the Biocare EMS system as a whole
must be reported to EMS Biocare as soon as practical after call completion via phone 214-947-8444 during normal
business hours, or contact the hospital operator after hours at 214-947-8181 to have the on call person paged.
Notification must occur when:
x
Sudden and/or unanticipated cardiac arrest occurring after the use of:
¾
sedation (midazolam, lorazepam, etomidate),
¾
analgesia (morphine, fentanyl, nitrous oxide),
¾
neuromuscular blockade (vecuronium, succinylcholine),
¾
physical or chemical restraint,
¾
an electronic control device by law enforcement (e.g., Taser),
¾
an anti-arrhythmic or vasodilator in a previously hemodynamically stable patient.
x
Any attempt at a surgical airway (successful or not).
x
Observation of behavior that is considered unprofessional, involving a violation of a State Statute or Regulation, or
that could possibly lead to the injury or death of a patient.
x
Performance of actions outside the scope of credentials or qualifications.
x
Missing controlled substances or evidence of controlled medications being tampered with or abused
REVISED: 12/18/2009
SOG-18
TRANSPORT OF THE PATIENT RECEIVING BLOOD / BLOOD PRODUCTS
Blood and blood products are substances normally comprising the circulatory volume of the body. Blood and blood
products provide transport of nutrients and waste products and for correction of clotting disorders. Blood and blood
products include whole blood, packed red cells, platelets, and whole plasma.
Hemolytic transfusion reactions (HTR):
The hemolytic transfusion reaction is an adverse reaction that has symptoms of:
x Fever, chills, flushing,
x Nausea and vomiting,
x Burning at the IV site,
x Chest tightness, joint and/or back pain,
x Restlessness and apprehension.
The treatment of patients with an HTR focuses on the prevention of shock and maintaining renal perfusion to
prevent kidney failure. If a transfusion reaction is suspected, the transfusion must be terminated immediately. Contact
BIOCARE MEDICAL CONTROL for guidance (if needed).
Allergic reactions:
Another transfusion reaction is the allergic reaction. Immediate anaphylactic reactions are characterized by skin flushing,
hives, laryngeal edema, chills and hypotension. In the majority of cases reactions occurred before 10 mL of blood was
infused. When an immediate hypersensitivity reaction occurs, the transfusion is to be terminated and treatment for the
allergic response implemented.
General guidelines for the transport of patients receiving blood/blood products:
x These patients require continuous ECG monitoring and personnel who are capable of handling an acute reaction;
therefore only paramedics may transport a patient receiving blood or blood products.
x All blood products MUST be initiated by the transferring facility. Paramedics are not authorized to start, hang or initiate
any infusion of blood or blood products.
x Request a written order from the transferring facility as to the infusion rate and total amount to be infused during
transport. A copy of this order is to be attached to the EMS and facility charts.
x Record a complete set of vital signs (pulse, respirations, full BP etc.) prior to initiating transport and obtain a complete
set every ten minutes during transport.
x If the patient develops any signs of a transfusion or allergic reaction, immediately stop the infusion and
initiate a normal saline infusion (using new tubing) in its place. The blood or blood product is not to be thrown
away and must be turned over to the receiving facility for evaluation.
PROTOCOL PAGE
ADULT protocols are located on the left side of the protocol page.
PEDIATRIC protocols are located on the right side of the protocol page.
Medications, Intravenous fluids, and ALS treatments (e.g. TCP) are delineated by the BOLD font.
Each protocol outlines important patient care. Specific levels of care are not delineated within a protocol but are based on
the provider knowing his/her level of authorization for use of an intervention or medications as outlined on page APX-2,
Summary of approved medications and procedures by certification level. .
Each provider is authorized – at their approved level of care - to utilize any intervention, medication or therapy listed within
a guideline, protocol or appendices to assess, treat and/or stabilize a patient. Example: a patient in anaphylaxis requires a
definitive airway; however, intubation is not specifically listed within the protocol - the provider (intermediate or paramedic)
may intubate based on the Universal Patient Care protocol (UPC).
REVISED: 12/18/2009
SOG-19
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Universal Patient Care
•
•
Scene Size-Up: As you approach the scene, assure safety for yourself and the patient. Establish and follow Incident
Management System as needed.
Universal Precautions/Body Substance Isolation: Prior to patient assessment, employ precautions to prevent contact
with potentially infectious body fluids or hazardous materials. Wear appropriate protective gear to protect eyes, mucous
membranes and skin. Wear other appropriate specialized protective gear when the potential exists for contact with
biological and hazardous materials.
PATIENT ASSESSMENT:
• Initial Assessment: Perform this assessment on every patient to form a general impression of needs and priorities.
Determine if the patient has a life-threatening condition that warrants immediate intervention.
◊ Current AHA guidelines for BLS should be followed.
◊ For Foreign Body Airway Obstructions (FBAO) utilize BLS procedures for removal.
◊ Assess the patient’s mental status. Maintain spinal immobilization if indicated.
◊ Assess the patient’s airway status.
Responsive patient – assess for adequacy of breathing.
Unresponsive patient – check for and maintain an open airway.
For trauma patients, or those with unknown nature of illness, stabilize/immobilize the cervical spine and perform
the jaw-thrust maneuver if indicated.
◊ Assess the patient’s breathing.
Determine SpO2 when indicated and before administering oxygen if possible.
Oxygen may be indicated regardless of SpO2 reading. Non-evasive CO2 monitoring can be done as indicated (if
available).
If the respiratory rate is less than 12/min or greater than 24/min, provide high flow O2 or assist ventilations and
monitor EtCO2 (if available) as needed to maintain oxygenation.
If the patient is unresponsive and the breathing is adequate, provide high flow oxygen.
If the patient is apneic, ventilate using appropriate ventilatory adjuncts and high flow oxygen.
◊ Assess patient’s circulation.
Check for a pulse. If absent, begin resuscitation efforts.
If patient is pulseless and apneic, utilize AED/monitor and treat according to specific cardiac arrest protocol.
Check for major bleeding. If present, control the bleeding.
Check for perfusion by evaluating skin color and temperature.
Check capillary refill in pediatric patients.
Check for presence of carboxyhemoglobin (COHgb) using SpCO monitoring as needed (if available).
•
Focused history and physical examination:
◊ Utilize appropriate assessment and diagnostic-based processes to determine information and to conduct physical
examinations.
◊ Obtain a 12-lead ECG on any patient whom you suspect to have a cardiac cause for their complaint unless doing so
might cause a significant delay in emergent intervention (cardioversion, pacing, urgent airway or perfusion issues, etc.).
TREATMENT:
• Follow specific protocols and standing orders.
• Performing procedures should not delay transport in critical situations unless the intervention is necessary to correct a life
threat.
• Perform advanced airway management if indicated (tracheal intubation, single/multi-lumen lumen airway, cricothyrotomy).
Verification of successful placement must be determined by the following methods:
◊ Observation of chest movement
◊ Auscultation of breath sounds
◊ Absence of epigastric sounds
◊ Pulse oximetry in the perfusing patient
◊ End-tidal carbon dioxide monitoring
•
If two (2) intubation attempts have been unsuccessful, no further attempts should be made and a single or multi-lumen
airway should be placed (additional failed airway information on APX-11).
REVISED: 12/18/2009
UPC-1
Universal Patient Care
INTRAVENOUS/INTRAOSSEOUS VASCULAR ACCESS:
• Vascular access can be achieved using the following:
◊ Preexisting vascular access points may be used in patients who are unstable or in cardiac arrest.
◊ Saline Lock: only for patients who have stable vital signs and do not require volume replacement.
◊ Peripheral IV: for administration of fluids and as a medication route.
◊ Establish an IO route in adult/pediatric cardiac arrest patients, or whenever vascular access is critical and peripheral
venous sites are unavailable for patients that have a life-threatening condition, needing immediate vascular access to
administer a life-saving medication or to perform life-saving fluid resuscitation. These are clearly situations where the
patient will most likely go into cardiac arrest unless treatment is administered immediately.
• Fluid administration is at the following rates: (can be administered in ANY patient as needed)
◊ TKO – slow drip for patients who may need medication or fluid bolus
◊ Fluid Replacement – 20 mL/kg bolus may repeat once, then contact Biocare Medical Control or the receiving hospital
for further fluid replacement orders.
◊ Maintain IV flow rate as ordered by physician.
◊ A 10 to 20 mL bolus of fluid should follow the administration of drugs. When an extremity is used, it should be elevated
to enhance flow.
• Blood alcohol specimens may be drawn at the request of the police agency when, in the judgment of the attendant, patient
condition will not be compromised or transport significantly delayed.
• Prevention and control of severe nausea and/or vomiting for adult and pediatric patients:
Adult:
ondansetron 4 mg IV/IM/IO may repeat once in 10 minutes if needed.
Pediatric > 2 years:
ondansetron 0.1 mg/kg IV/IM/IO up to 4 mg may repeat once in 10 minutes if needed.
•
For General Anxiety or to help with patient compliance of positive pressure ventilation/CPAP:
Adult:
midazolam 2.5 mg IV/IO or 5 mg IM/IN may repeat once in 15 minutes.
OR
(optional) lorazepam 1-2 mg IV/IO may repeat in 15 minutes.
Pediatric:
Contact BIOCARE MEDICAL CONTROL
TRANSPORTATION:
• Immediate transport with treatment en route is recommended for patients with significant trauma or unstable airways.
Determining Hospital Destination:
• Patients can be transported to the hospital of their choice in the greater DFW area in most instances. Biocare EMS
providers reserve the right to create their own transport policies with Biocare approval.
• Transport destination for trauma patients should be determined according to the NCTTRAC Hospital bypass guidelines
(located in the appendix)
• Patients with major burns should be transported to the appropriate burn center (Parkland) unless life-saving measures are
needed.
◊ No patient will be transported to a hospital that is “out of service”.
◊ Unstable medical patients should be transported to the closest facility.
◊ “Unstable” is evidenced by, but not limited to, at least one of the following conditions:
Unable to establish or maintain an airway
Inability to ventilate
Unremitting shock
•
For patients with SpCO > 25% with loss of consciousness or neurological impairment, consider transport to a hospital with
a hyperbaric chamber.
•
For the patient in non-traumatic cardiac arrest, transport to the closest facility that is not out-of-service.
REVISED: 12/18/2009
UPC-2
Atrial Fibrillation/Flutter with Rapid Ventricular Response
ADULT
PEDIATRIC
Hemodynamically Stable
Monitor and transport to ED if necessary.
Hemodynamically Unstable
Sustained Rate > 150/min
(Child: Sustained Rate > 180/min)
(Infant: Sustained Rate > 220/min)
Synchronized cardioversion:
Monophasic:
100, 200, 300, 360 J.
Monophasic and Biphasic:
1 J/kg, 2 J/kg
Biphasic:
100, 120, 200 J.
Consider:
Consider:
Midazolam up to 2.5 mg slow IV/IO
and repeat once in 5 minutes as needed
Midazolam 0.1 mg/kg up to 2.5 mg slow IV/IO
OR,
OR,
Midazolam 5 mg IN and repeat once
in 5 minutes as needed.
Midazolam 0.2 mg/kg to 5 mg IN and repeat
once in 5 minutes as needed.
IF PATIENT IS UNSTABLE AND RHYTHM PERSISTS,
INITIATE TRANSPORT AND CONTACT BIOCARE
MEDICAL CONTROL FOR ORDERS.
IF PATIENT IS UNSTABLE AND RHYTHM PERSISTS,
INITIATE TRANSPORT AND CONTACT BIOCARE
MEDICAL CONTROL FOR ORDERS.
PEARLS:
•
•
•
•
Adenosine is contraindicated for atrial fibrillation and atrial flutter.
In the absence of hypovolemia, the priorities of care in tachydysrhythmias are rate control followed by volume loading.
NTG is contraindicated prior to rate control in patients with rapid rates due to potential reflex tachycardias.
The use of multiple defibrillations in short-lived or repetitive tachydysrhythmias is contraindicated.
•
It is not necessary to control Atrial Fibrillation/Flutter in stable patients. However, BIOCARE MEDICAL CONTROL can be
contacted for:
Adult: Amiodarone 150 mg IV/IO over 10 minutes.
REVISED: 12/18/2009
AR-1
Ventricular Tachycardia (VT)
ADULT
PEDIATRIC
Rate > 150/min, QRS > 0.12 ms
Rate > 150/min, QRS > 0.08 ms
Amiodarone 150 mg IV/IO over 10 minutes and
repeat once in 10 minutes as needed.
Amiodarone 5 mg/kg up to 150 mg IV/IO over
20 min and repeat once in 20 min at half the initial
dose as needed.
Sustained Rate > 150/min, QRS > 0.12 ms
Sustained Rate > 150/min, QRS > 0.08 ms
Monophasic:
100, 200, 300, 360 J.
Biphasic:
100, 120, 200 J.
1 J/kg, 2 J/kg
Consider:
Consider:
OR,
OR,
Midazolam 5 mg IN and repeat once in
5 minutes as needed.
Midazolam 0.2 mg/kg to 5 mg IN and
If no response to 4 shocks or VT recurs:
amiodarone 150 mg IV/IO over 10 min and repeat
at half the initial dose over 10 min as needed.
If no response to 4 shocks or VT recurs:
amiodarone 5 mg/kg up to 150 mg IV/IO over 10
min and repeat at half the initial dose over 10 min
as needed.
Continue synchronized cardioversion if needed.
For torsades de pointes: magnesium sulfate
2 grams IV/IO over 5 minutes.
PEARLS:
•
•
•
•
•
•
Nonsustained VT is less than 30 seconds in duration; over 30 seconds is considered sustained VT.
Stable VT patients are those who do not have hemodynamic decompenstation, ongoing chest pain, altered mental status,
shock, or CHF. Because stable VT will deteriorate into unstable VT, early treatment is required.
Amiodarone is contraindicated in VT from tricyclic antidepressant or fast-sodium channel blockers.
Magnesium is recommended in the treatment of Torsades, with or without cardiac arrest, but it has not been shown to be
effective in treating normal-QT-related VT.
Do not routinely give anti-arrhythmics. Treat new or reoccurring arrhythmias according to specific protocol.
REVISED: 12/18/2009
AR-2
Supraventricular Tachycardia (SVT)
ADULT
PEDIATRIC
Rate > 150/min
(Child: rate > 180/min) — (Infant: rate > 220/min)
Attempt valsalva maneuver.
Attempt valsalva maneuver.
Adenosine 6 mg rapid IV/IO.
Adenosine 0.1 mg/kg up to 6 mg rapid IV/IO.
If no response: adenosine 12 mg rapid IV/IO
and repeat once as needed.
If no response: adenosine 0.2 mg/kg rapid IV/IO
up to 12 mg and repeat once as needed.
Rate > 150/min
(Child: rate > 180/min) — (Infant: rate > 220/min)
Adenosine 12 mg rapid IV/IO and
repeat once if needed.
Adenosine 0.2 mg/kg up to 12 mg rapid IV/IO
Monophasic:
100, 200, 300, 360 J.
Biphasic:
100, 120, 200 J.
1 J/kg, 2 J/kg
Consider:
Consider:
OR
OR
Midazolam 5 mg IN and
Midazolam 0.2 mg/kg to 5 mg IN and
IF SVT PERSISTS FOLLOWING TREATMENT OF
STABLE OR UNSTABLE PATIENTS, CONTACT
BIOCARE MEDICAL CONTROL FOR ORDERS.
IF SVT PERSISTS FOLLOWING TREATMENT OF
STABLE OR UNSTABLE PATIENTS, CONTACT
BIOCARE MEDICAL CONTROL FOR ORDERS.
PEARLS:
•
•
•
•
Paroxysmal SVT (PSVT) generally begins and ends quickly. Many people experience short periods of PSVT without
symptoms and do not require treatment. However, SVT becomes a problem when it lasts for long periods of time and
patients become hemodynamically unstable.
Specific arrhythmias should be treated according to their presentation. If unable to identify a wide complex arrhythmia,
transmit the ECG to Biocare Medical Control for physician interpretation.
Adenosine works best if given IV in an AC or more proximal vein.
REVISED: 12/18/2009
AR-3
Bradycardia
ADULT
PEDIATRIC
Prepare for immediate transcutaneous pacing
(TCP) at a rate of 80/min.
For children < 1 year of age, BVM ventilation for
60 sec. If no change, begin CPR with a
compression rate of 100/min.
Consider atropine 0.5 mg IV/IO while awaiting
TCP and repeat every 3 to 5 min up to 3 mg as
needed. If ineffective, initiate TCP.
Epinephrine (1:10,000) 0.01 mg/kg up to 0.5 mg
IV/IO.
Repeat every 3 to 5 minutes as needed.
If no response: dopamine 5 to 20 mcg/kg/min
IV/IO titrated to effect.
Epinephrine (1:1000) 2 to 10 mcg/min IV/IO
titrated to effect.
If increased vagal tone or primary AV block:
atropine 0.02 mg/kg up to 1 mg (minimum dose
0.1 mg) IV/IO and repeat once as needed.
Consider:
Midazolam up to 2.5 mg slow IV/IO and repeat
IF NO RESPONSE, CONTACT BIOCARE MEDICAL
CONTROL FOR ORDERS.
OR
Midazolam 5 mg IN and repeat once in
Consider TCP at a rate of 100/min.
IF NO RESPONSE, CONTACT BIOCARE MEDICAL
CONTROL FOR ORDERS.
PEARLS:
•
•
•
•
•
Symptomatic/hemodynamically unstable bradycardia is defined as a heart rate less than 60/min with one or more of the
following symptoms: acute altered mental status, ongoing chest pain, hypotension, signs of poor perfusion, or other signs
of shock.
Atropine is the primary treatment for bradycardia due to increased vagal tone (e.g. tracheal intubation), or when a highdegree AV block is present. For pediatric patients, atropine is a secondary treatment [after epinephrine].
Use atropine with extreme caution in ACS as it can worsen ischemia or infarction. Parasympathetic blockade can allow
unopposed sympathetic stimulation to occur which can lead to tachycardia and HTN.
NTG administration in the presence of heart rates less than 50/min can cause increased vagal tone, which further reduces
heart rate.
An epinephrine infusion may be needed if profound hypotension or bradycardia fails to respond to standard measures. For
proper concentration, add epinephrine 2 mg (1:1000) to NS 500 mL to achieve 4 mcg/mL.
REVISED: 12/18/2009
AR-4
Cardiac Arrest—AED/No Monitor
ADULT
PEDIATRIC
Initiate current AHA CPR guidelines.
Initiate current AHA CPR guidelines.
Apply AED and follow prompts.
Apply AED and follow prompts.
Epinephrine 1 mg (1:10,000) IV/IO and repeat
every 3 to 5 minutes as needed.
Epinephrine 0.01 mg/kg (0.1 mL/kg) 1:10,000
IV/IO and repeat every 3 to 5 minutes as needed.
Transport patient or request monitor to identify
specific rhythm and treat accordingly.
Transport patient or request monitor to identify
specific rhythm and treat accordingly.
PEARLS:
•
•
•
•
•
Effective chest compressions are critical in any cardiac arrest situation. CPR should be performed around 2-minute cycles.
Pause for no more than 10 seconds to assess for ROSC and to utilize AED after each 2-minute cycle.
An AED should only be applied to all unresponsive patients.
An AED may be used in patients over 1 year of age. Pediatric-specific pads should be used to reduce the energy levels in
children. However, if pediatric pads are unavailable, adult pads may be used.
When an implanted device is located in an area where a defibrillation pad should be placed, position the pad at least 1 inch
away from the device.
If the patient is located in water, covered with water, or extremely diaphoretic, remove them from the water and/or wipe the
chest dry before applying electrodes or attempting defibrillation.
REVISED: 12/18/2009
CA-1
Cardiac Arrest—Asystole/PEA
ADULT
PEDIATRIC
If asystole or PEA rate < 60/min, administer
atropine 1 mg IV/IO and repeat every 3 to 5
minutes to a total of 3 mg as needed.
Look for and treat reversible causes.
Look for and treat reversible causes.
Upon Return of Spontaneous Circulation (ROSC),
treat patient according to Post-Resuscitation Care
protocol.
Upon Return of Spontaneous Circulation (ROSC),
treat patient according to Post-Resuscitation Care
protocol.
Any conversions or changes in cardiac rhythm
should be treated by the respective protocol.
Any conversions or changes in cardiac rhythm
should be treated by the respective protocol.
PEARLS:
•
•
•
High-dose epinephrine is contraindicated.
Confirm asystole in more than one lead to ensure that fine VF is not present.
Consider treatment for reversible causes identified during the arrest algorithm:
Hypoxia - manage airway and provide adequate ventilations
Hypothermia - warm patient in accordance with Heat and
Cold -Related Disorders protocol.
Tension pneumothorax - needle thoracostomy
Hypovolemia/tamponade NS 20 mL/kg bolus IV/IO
Acidosis (hydrogen ion) Sodium bicarbonate 1 mEq/kg IV/IO
Hypoglycemia Dextrose 50% up to 25 g IV/IO
Calcium Channel Blocker Overdose Calcium chloride 1g IV/IO
Opioid Overdose Naloxone 0.4 mg increments to 2 mg IV/IO
OR
Naloxone 1 mg increments to 4 mg IN/IM
REVISED: 1/6/2010
Cold-Related Disorders protocol.
Hypoglycemia Birth to 2 months: Dextrose 10% 5 mL/kg IV/IO
> 2 months to adult: Dextrose 25% 2 mL/kg IV/IO
Calcium Channel Blocker Overdose Calcium chloride 20 mg/kg IV/IO
Opioid Overdose Naloxone 0.1 mg/kg increments up to 2 mg IV/IO/IM
OR
Naloxone 0.02 mg/kg increments up to 1 mg IN
CA-2
Cardiac Arrest—Ventricular Fibrillation/Pulseless VT
ADULT
PEDIATRIC
Perform CPR while charging defibrillator.
Perform CPR while charging defibrillator.
Defibrillate once per manufacturers
recommendations or Monophasic at 360J
and Biphasic at 200J.
Defibrillate once at 2 J/kg.
Resume CPR immediately after this shock and all
subsequent shocks.
Resume CPR immediately after this shock and all
subsequent shocks.
After every 5 cycles of CPR, defibrillate once
according to manufacturers recommendations or
Monophasic at 360J and Biphasic at 200J.
After every 5 cycles of CPR, defibrillate once
at 4 J/kg.
Administer amiodarone 300 mg IV/IO and repeat
at half the dose in 10 minutes as needed.
Administer amiodarone 5 mg/kg IV/IO and repeat
For torsades de pointes, administer
magnesium sulfate 2 g IV/IO.
For torsades de pointes, administer
magnesium sulfate 50 mg/kg IV/IO
up to 2 grams.
PEARLS:
•
•
•
Amiodarone is the anti-arrhythmic of choice. Lidocaine is considered a Class Indeterminate and should not be used.
Precordial thumps are contraindicated.
Consider treatment for reversible causes identified during the arrest algorithm:
Cold -Related Disorders protocol.
Hypoglycemia Dextrose 50% up to 25 g IV/IO
Calcium Blocker Overdose Calcium chloride 1g IV/IO
Opioid Overdose Naloxone 0.4 mg increments to 2 mg IV/IO
OR
Naloxone 1 mg increments to 4 mg IN/IM
REVISED: 1/6/2010
Cold-Related Disorders protocol.
Hypoglycemia Birth to 2 months: Dextrose 10% 5 mL/kg IV/IO
Calcium Blocker Overdose Calcium chloride 20 mg/kg IV/IO
Opioid Overdose Naloxone 0.1 mg/kg increments up to 2 mg IV/IO/IM
OR
Naloxone 0.02 mg/kg increments up to 1 mg IN
CA-3
Cardiac Arrest—Post Resuscitation Care
ADULT
PEDIATRIC
Hypotension
Hypotension
Administer NS 20 mL/kg bolus IV/IO and repeat
once titrated to a SBP > 90 mm Hg.
Administer NS 20 mL/kg bolus IV/IO and repeat
once titrated to age-specific normal SBP levels.
If no response to fluids, administer
dopamine 5 to 20 mcg/kg/min IV/IO
titrated to a SBP > 90 mm Hg.
If no response to fluids, administer
dopamine 5 to 20 mcg/kg/min IV/IO titrated
to age-specific normal SBP levels.
Post-intubation Agitation
Post-intubation Agitation
Lorazepam 2 mg IV/IO over 1 to 2 minutes and
Lorazepam 0.1 mg/kg up to 2 mg IV/IO over
1 to 2 minutes and repeat once in 5 minutes
as needed.
OR
OR
Midazolam 2.5 mg IV/IO over 1 to 2 minutes and
repeat every 10 minutes as needed.
Total administration not to exceed 10 mg.
Midazolam 0.1 mg/kg IV up to 2.5 mg and
PEARLS:
•
•
Provide supportive care and treat any presenting conditions according to their respective protocols.
There is insufficient evidence to support the routine use of prophylactic administration of
anti-arrhythmic medications to cardiac arrest survivors. Therefore, post resuscitation anti-arrhythmic
drips are no longer recommended.
REVISED: 12/18/2009
CA-4
Acute Coronary Syndrome (ACS) / Chest Pain
ADULT
PEDIATRIC
ASA 324 mg PO (chewed)
Obtain 12-lead ECG ASAP and repeat if patient
condition changes.
If machine flags ACS or if provider suspects ACS,
immediately notify receiving hospital and transmit
ECG (if transmission-capable).
FOR THE TREATMENT OF SUSPECTED ACS IN THE
PEDIATRIC PATIENT, CONTACT BIOCARE
MEDICAL CONTROL.
Nitroglycerin 0.4 mg SL and repeat every
5 minutes if SBP > 90 mm Hg and ECG is negative
for inferior-wall ACS.
For pain after one NTG administration, administer
morphine 4 mg IV/IO over 1 to 2 minutes and
repeat in 2 mg increments up to 10 mg as needed.
Hypotension Due To Suspected
Right Ventricular Ischemia/Infarction
Acute myocardial ischemia and infarction is rare in
children and if present, usually occurs secondary to
congenital defects, acute inflammation or abnormal
location of the coronary arteries.
Because of the complex nature and relative rarity of
an acute coronary syndrome in a child, a physician
MUST be consulted before administration of any
medications.
NS 20 mL/kg IV/IO over 10 minutes and repeat as
needed until SBP > 90 mm Hg.
Transport the patient to a receiving facility
with 24-hour interventional cardiac
catheterization capabilities.
PEARLS:
•
•
•
•
•
•
•
•
Application of combination therapy electrodes (combo pads) is recommended.
All male and female patients must be assessed for phosphodiesterase inhibitor use. Nitrates are contraindicated if they
have taken sildenafil (Viagra), vardenafil (Levitra), tadalafil (Cialis), or other erectile dysfunction medications in the last 48
hours.
A 12-lead ECG and IV access should be performed before NTG is used. However, the inability to obtain vascular access
is not a reason for withholding NTG to a hemodynamically stable patient.
ST-segment Elevation MI (STEMI) is characterized by > 1 mm of elevation in at least 2 contiguous leads or any new LBBB.
When inferior-wall ACS is suspected, a right-sided ECG should be done to access for right ventricular ischemia/infarction.
Assess for ST-segment elevation using lead V4R.
In suspected right ventricular injury/infarction or posterior infarct (ST Depression in V1), the use of preload-reduction
medications such as captopril, enalapril, morphine, and NTG are to be avoided as profound hypotension can occur.
The initial therapy of RVI with hypotension and clear lungs is volume expansion to increase preload.
Before transmitting 12-lead ECG to hospital be sure to input patients name.
REVISED: 12/18/2009
MED-1
Allergic Reaction / Anaphylaxis
ADULT
PEDIATRIC
Minimal/Local Reaction
Minimal/Local Reaction
Diphenhydramine 50 mg IV/IM/IO.
Diphenhydramine 0.5 mg/kg IV/IM/IO up to 25 mg.
If symptoms persist:
If symptoms persist:
Epinephrine 0.5 mg (1:1000) IM
Epinephrine 0.01 mg/kg (1:1000) up to
0.5 mg IM and repeat once as needed.
If minor wheezing present:
If minor wheezing present:
Albuterol 2.5 mg mixed with ipratropium
0.5 mg nebulized and repeat as needed.
Albuterol 2.5 mg mixed with ipratropium
0.5 mg nebulized and repeat as needed.
Anaphylaxis with Hypotension
Anaphylaxis with Hypotension
Epinephrine 0.5 mg (1:10,000) IV/IO
and repeat every 5 minutes as needed.
up to 0.5 mg IV/IO over 3 minutes and repeat
every 5 minutes as needed.
Consider glucagon 1 mg IV/IO if patient is
currently taking beta blockers.
Consider glucagon 1 mg IV/IO if patient is
currently taking beta blockers.
NS 20 mL/kg IV/IO bolus and repeat once
NS 20 mL/kg IV/IO bolus and repeat once
If no response to fluids, administer dopamine 5 to
20 mcg/kg/min IV/IO titrated to SBP > 90 mm Hg.
FOR HYPOTENSION THAT DOES NOT RESPOND TO
FLUID REPLACEMENT, CONTACT BIOCARE MEDICAL
CONTROL AND CONSIDER DOPAMINE.
Acute Laryngeal Edema Refractory to Epinephrine
Acute Laryngeal Edema Refractory to Epinephrine
Epinephrine 0.3 mg (1:10,000) nebulized and
repeat once as needed.
Epinephrine 0.3 mg (1:10,000) nebulized and
repeat once as needed.
PEARLS:
•
•
•
•
•
•
Severe hypotension and/or cardiac arrest from anaphylaxis are often associated with a massive fluid shift and large volume
replacement is often needed. The primary medication for acute anaphylaxis is epinephrine. For severe cases, the primary
treatments are fluid replacement and epinephrine. All other drugs, including diphenhydramine, are considered adjunctive
treatments.
Epinephrine IM is the preferred route of administration unless the situation is serious/critical and requires IV administration.
In an allergic or anaphylactic reaction, symptoms, such as syncope or throat tightness, are very serious and can rapidly
progress to hemodynamic collapse and cardiac arrest.
Reassess lung sounds following a fluid bolus to assess for fluid overload and pulmonary edema.
Never administer epinephrine (1:1000) via IV/IO route.
Dystonic reactions are not allergic reactions, however they should be treated with:
Adult: Diphenhydramine 50 mg IV/IO over 1 to 2 min and repeat once at half the dose in 10 minutes
OR
Diphenhydramine 100 mg IM and repeat once at half the dose in 20 minutes as needed.
REVISED: 12/18/2009
MED-2
Behavioral / Patient Restraint
ADULT
PEDIATRIC
Chemical Restraint
Chemical Restraint
Midazolam 2.5 mg IV/IO or 5 mg IM/IN and repeat
once as needed.
CONTACT BIOCARE MEDICAL CONTROL.
OR
Optional treatment:
Haloperidol 5 mg IM/IV/IO and repeat once in 15
minutes as needed.
Use of chemical restraint in the adolescent and
preteen patient population is rarely indicated
because of the efficacy of additional restraint
options and overall patient size.
AND
Lorazepam 2 mg IV/IO or 4mg IM and repeat
once at half the dose in 15 minutes as needed.
Acute Dystonia
Acute Dystonia
Diphenhydramine 50 mg IV/IO over 1 to 2 min
and repeat once at half the dose in 10 minutes
OR
Diphenhydramine 100 mg IM and repeat once at
half the dose in 20 minutes as needed.
PEARLS:
•
•
•
•
•
•
A behavioral emergency is the sudden occurrence of behavior that presents with psychiatric symptoms such as delusions,
hallucinations, or depression.
Life-threatening conditions that can often present as agitation or delirium include cerebral hemorrhage, meningitis,
hypertension, heat stroke, hypoglycemia, and drug toxicity.
The onset of intravenous medications is generally within a few minutes. The onset of IM injections is generally between 15
to 25 minutes.
Patients who have attempted and/or expressed the desire to commit suicide are not permitted to refuse care or transport.
Involve law enforcement and consult with BIOCARE MEDICAL CONTROL.
Haldol and Lorazepam are both optional drugs and can be given together as an alternative to Midazolam. They should
NOT be giving in addition to Midazolam.
For detailed information regarding guidelines for proper use of patient restraint, see next page.
REVISED: 12/18/2009
MED-3
Behavioral / Patient Restraint
This protocol addresses the acceptable methods of restraining a patient when necessary to
protect patients, responders, and/or bystanders from harm.
GENERAL GUIDELINES FOR RESTRAINT OF PATIENTS:
• The safety of the patient and responders should be considered paramount to the decision to employ
restraint techniques. Responders are expected to identify and avoid potential threats to personal
safety prior to and during encounter with violent persons or remove themselves from a threatening
environment if a threat presents itself.
• Law enforcement should be involved in all cases when a patient poses a threat to EMS personnel or
others. If law enforcement is not immediately available, EMS personnel should retreat to a safe place
and await the arrival of law enforcement. If there is no option for retreat, EMS personnel may use
reasonable force to defend themselves against an attack.
• Restraint efforts should be individualized and should afford as much dignity to the patient as the
situation allows.
• The method of restraint should be the least restrictive necessary for the protection of the patient and
others.
• The use of restraints should be carefully documented. Such documentation should include the reasons
for and means of restraint and the periodic assessment findings of the restrained patient.
INDICATIONS FOR USE OF RESTRAINT:
• Patients who pose a threat to themselves or others due to hypoxia, hypoglycemia, alcohol or drug
intoxication, stroke, brain trauma, psychiatric emergency, mental health crisis, or other illness or injury.
• Continuation of restraint as previously established by a medical facility or law enforcement officer as
long as the method of restraint meets the guidelines found in this protocol.
TYPES OF RESTRAINT:
• Verbal
• The use of verbal techniques to calm and reassure a patient is usually the first method to be
utilized.
• Physical
• Use soft, padded wrist and ankle restraints that cannot collapse into narrow, restricting bands.
• Do not allow restriction of the respiratory structures (diaphragm, chest wall expansion, etc.). The
patient should be able to take full tidal breaths.
• Spinal immobilization straps can be used as adjunct restraints.
• Hard restraints such as handcuffs are not acceptable for EMS use but may be continued if
appropriately applied by law enforcement personnel. If the restraint device requires a key, the key
and/or officer should accompany the patient during transportation. In cases where the officer can
not accompany the patient, EMS must feel comfortable with having the officer follow close behind.
• Chemical
• See previous page.
REVISED: 12/18/2009
MED-4
Diabetic / Glucose Emergencies
ADULT
PEDIATRIC
Hypoglycemia (bG < 80 mg/dL and Symptomatic)
Hypoglycemia (bG < 60 mg/dL and Symptomatic)
Oral glucose up to 30 grams PO
Oral glucose up to 15 grams PO
Dextrose 50% up to 25 g IV/IO and repeat once in
Birth to 2 months: Dextrose 10% 5 mL/kg IV/IO
If no IV/IO access, glucagon 1 mg IM and repeat
If no IV/IO access:
< 20 kg: glucagon 0.1 mg/kg IM up to 0.5 mg IM.
> 20 kg: glucagon 1 mg IM.
Repeat once in 15 minutes as needed.
Hyperglycemia (bG > 250 mg/dL)
Hyperglycemia (bG > 250 mg/dL)
NS 500 mL over 30 minutes continued as a
maintenance infusion at 150 mL/hr.
NS 20 mL/kg bolus continued as a
maintenance infusion at 75 mL/hr.
PEARLS:
•
•
•
•
•
IO access should only be used when vascular access cannot be obtained, IM glucagon failed to work and patient is
presenting with profound hypoglycemia as evidenced by decreased LOC, seizures or shock.
Signs and symptoms of pediatric dehydration include sunken fontanel, poor turgor, hypoperfusion, delayed capillary refill
and tachycardia.
Insulin pumps should be turned off or removed for patients experiencing hypoglycemia.
Patients who receive dextrose or glucagon may refuse ambulance transport and have their IV discontinued only if the
following criteria are met :
1) Glucose is above 80 mg/dl and patient is without further complaints or symptoms
2) Patient is A&O x 4 and has been instructed to withhold insulin until contacting their primary healthcare
practitioner.
3) A responsible adult is present to monitor the patient.
For Patients who do not meet the criteria but wish to refuse care/transport, contact BIOCARE MEDICAL CONTROL.
for approval.
•
D25% Preparation: Remove 25 mL (12.5g) of Dextrose from a pre-filled D50 syringe and add 25 mL NS.
•
D10% Preparation: Waste 40 mL (20g) D50%, and dilute remaining 10 mL (5g) in original 50 mL syringe with 40 mL NS.
REVISED: 12/18/2009
MED-5
Drowning / Submersion Injury
ADULT
PEDIATRIC
Airway management up to and including
CPAP and tracheal intubation.
Airway management up to and including
CPAP and tracheal intubation.
Bronchospasm/Wheezing
Bronchospasm/Wheezing
Albuterol 2.5 mg mixed with ipratropium 0.5 mg
nebulized and repeat as needed.
PEARLS:
•
•
•
•
•
•
Drowning is defined as death from asphyxia within 24 hours of submersion in water.
The term submersion injury, formerly known as “near-drowning,” refers to survival beyond 24 hours after a submersion
episode. The principal physiological consequences of submersion injuries are prolonged hypoxemia and acidosis.
Victims of submersion injuries should be convinced to be evaluated at an Emergency Department due to secondary
infections that could occur in the hours following the event.
Management of hypoxia is crucial in submersion injuries. Early use of CPAP, intubation, or positive-pressure ventilation
with PEEP is warranted in any patient who remains hypoxic or dyspenic after receiving 100% oxygen.
Non-cardiogenic pulmonary edema should be treated with positive-pressure ventilations, not medications.
Consider spinal trauma in any submersion injury or injuries associated with recreational equipment. If the patient is unable
to give a clear history of events, has evidence of facial or head injury, or is found unresponsive in a pool or other body of
water, immobilize the cervical spine until injury can be excluded.
REVISED: 12/18/2009
MED-6
Heat and Cold Related Disorders
ADULT & PEDIATRIC
Heat-Related Disorders
Move patient to cool environment, remove heavy clothing, and begin external cooling
Do not allow patient to shiver
Prehospital cooling measures should not delay patient transport.
Heat Cramps and Exhaustion
Fluids PO unless the patient is nauseated or exhibits decreased level of consciousness.
Do not massage muscle cramps.
Heat Stroke
Aggressive evaporative cooling.
Cold-Related Disorders
Move patient to a warm environment, remove wet clothing, and begin external rewarming.
Frostbite
Carefully remove clothing from the affected area and begin
rewarming. Do not allow the area to refreeze.
Cover the area with a loose light dressing. Do not tape or use tight bandages.
The patient may experience severe pain when frostbitten area begins to thaw.
PEARLS:
•
•
•
Use extreme caution when administering sympathomimetic and chronotropic agents.
Cardiac arrest may occur as a result of hypothermia when body temperatures are below 90°F (32.2°C). In these situations,
drug and electrical therapy may be of little, if any, use until the body temperature is increased and acidosis is corrected.
For this reason, only 1 defibrillation should be attempted when indicated before hospital contact is made. CPR, advanced
airways, oxygen, and rapid transport to begin core rewarming are essential to effectively treat these patients. Even normal
stimuli can trigger ventricular fibrillation in hypothermia with core temperatures between 85°F and 89°F (29.4°C and 31.1°
C). Maintain a calm environment with minimal external stimuli.
Treat pain associated with frostbite according to pain management principles on the next page.
REVISED: 12/18/2009
MED-7
Pain Management
ADULT
PEDIATRIC
Abdominal Pain
Abdominal Pain
Allow the patient to assume a comfortable position,
Allow the patient to assume a comfortable position,
unless contraindicated. Flexion of the knees may help unless contraindicated. Flexion of the knees may help
reduce pain.
reduce pain.
Obtain 12-lead ECG if suspected cardiac origin.
Obtain 12-lead ECG if suspected cardiac origin.
Fentanyl up to 1.5 mcg/kg IV/IO/IM* over 1 to 2 min
and repeat as needed in 5 to 10 minutes.
Total administration not to exceed 300 mcg.
Fentanyl up to 1.5 mcg/kg IV/IO/IN/IM* over
1 to 2 min and repeat as needed in 5 to 10 minutes.
Musculoskeletal, Soft-Tissue or Joint Pain
Musculoskeletal, Soft-Tissue or Joint Pain
Fentanyl up to 1.5 mcg/kg IV/IO/IM* over 1 to 2 min
and repeat as needed in 5 to 10 minutes .
Fentanyl up to 1.5 mcg/kg IV/IO/IN/IM* over
1 to 2 min and repeat as needed in 5 to 10 minutes.
(Optional)
If fentanyl is ineffective, Lorazepam 2 mg IV/IO.
Burns
Burns
Morphine 4 mg IV/IO/IM* over 1 to 2 min and
repeat every 5 min as needed.
Morphine 0.1 mg/kg IV/IO/IM* over 1 to 2 min up to
4 mg and repeat every 5 min as needed.
All Other Etiologies of Pain
All Other Etiologies of Pain
* IN/IM administration is not over 1-2 minutes
* IN/IM administration is not over 1-2 minutes
PEARLS:
•
•
•
•
•
•
•
For all patients experiencing pain, documentation should include frequent numerical pain scale assessments.
Use non-pharmacological interventions such as positioning, splinting and cold therapy in addition to analgesia.
Contraindications include no complaint of pain/discomfort, aortic dissection, poisoning or OD, ETOH intoxication, head
trauma, hypotension, altered mental state, respiratory depression, bronchospasm, or significant trauma to chest/abdomen.
Analgesia use requires the regular and ongoing monitoring of SpO2, BP, ECG and respiratory status.
Rapid administration of morphine will cause nausea/vomiting. Always administer slowly. Consider Zofran as needed.
The onset of intravenous medications is generally within a few minutes. The onset of IM injections is generally between 1525 minutes.
For patients experiencing a sickle-cell crisis, in addition to fentanyl, administer:
NS 1,000 mL over 10 to 15 minutes and repeat once as needed
• Adult:
• Pediatric: NS 20 mL/kg up to 500 mL over 10 to 15 minutes as needed.
REVISED: 12/18/2009
MED-8
Pharmacologically Assisted Intubation (PAI)
ADULT
PEDIATRIC
Head Injury Patients Pre-medication Phase
Head Injury Patients Pre-medication Phase
Lidocaine 1.5 mg/kg IV/IO up to 150 mg
over 1 minute.
over 1 minute.
Wait 3 minutes before proceeding.
Rapid Sedation Phase
Rapid Sedation Phase
< 10 yrs: Atropine 0.02 mg/kg rapid IV/IO.
Total dose not to exceed 0.5 mg.
Etomidate 0.3 mg/kg rapid IV/IO.
Wait 1 minute before attempting intubation.
Continuous Sedation/Post-Intubation
Continuous Sedation/Post-Intubation
Midazolam 2.5 mg IV/IO over 1 to 2 minutes and
Midazolam 0.1 mg/kg IV/IO up to 2.5 mg and
FOR ADDITIONAL SEDATION INTERVENTIONS,
FOR ADDITIONAL SEDATION INTERVENTIONS,
PEARLS:
•
•
•
•
•
•
Oxygen levels in obese patients tend to rapidly decrease due to a reduced functional reserve capacity, the weight of the
viscera upon the diaphragm, compliance changes, and weight of chest wall in respect to accessory muscle usage during
labored respiration. Use PAI with extreme caution in obese patients.
If intubation attempts are difficult or unsuccessful, manage airway using BLS interventions. BLS airway management is
preferable to multiple failed intubation attempts.
Etomidate is contraindicated when sepsis is either present or suspected.
If unable to intubate after PAI, continue cricoid pressure and begin BVM ventilations. Consider King airway and BVM prior
to cricothyrotomy.
Cricothyrotomy is a last resort. It is used only after all other interventions have been attempted and have failed.
All patients shall receive constant and ongoing monitoring of their SpO2, BP, ECG, EtCO2, and respiratory status.
REVISED: 12/18/2009
MED-9
Rapid Sequence Intubation (RSI) - Optional
ADULT
PEDIATRIC
Pre-Medication Phase
Pre-Medication Phase
over 1 minute.
over 1 minute.
Atropine 0.5 mg rapid IV/IO if HR < 60/min.
< 10 yrs: Atropine 0.02 mg/kg rapid IV/IO.
Total dose not to exceed 0.5 mg.
Neuromuscular Blockade Phase
Neuromuscular Blockade Phase
Succinylcholine 1.5 mg/kg IV/IO up to 150 mg.
Succinylcholine 1.5 mg/kg IV/IO up to 100 mg.
Continuous Sedation/Post-intubation
Continuous Sedation/Post-intubation
SBP < 90 mm Hg: midazolam 1 to 5 mg IV/IO.
Repeat every 20 minutes up to 15 mg/hr.
SBP < 90 mm Hg: midazolam 1 to 2 mg IV/IO.
Repeat every 20 minutes up to 5 mg/hr.
SBP >90 mm Hg: fentanyl 25 to 50 mcg IV/IO.
Repeat every 20 minutes up to 150 mcg/hr.
SBP > 90 mm Hg: fentanyl 2 mcg/kg IV/IO up to
25 mcg. Repeat every 20 min up to 75 mcg/hr.
Vecuronium 0.1 mg/kg IV/IO every 20 minutes.
Vecuronium 0.1 mg/kg IV/IO every 20 minutes.
Medications may be given earlier if patient exhibits
signs of reduction in sedation.
Medications may be given earlier if patient exhibits
signs of reduction in sedation.
PEARLS:
•
•
•
•
•
•
•
•
RSI requires that two RSI-trained providers be present before an attempt is made.
RSI is contraindicated in patients with upper airway obstructions (e.g. croup, epiglottitis, edema, etc.) as paralysis relaxes
the pharyngeal muscles which can make BVM ventilation impossible. In those circumstances, PAI should be considered.
If unable to intubate after RSI, continue cricoid pressure and begin BVM ventilations. Consider King airway and BVM prior
to cricothyrotomy.
Succinylcholine is contraindicated in the presence of severe burns or suspected/confirmed renal failure.
Cricothyrotomy is a last resort. It is used only after all other interventions have been attempted and have failed.
Atropine is contraindicated in the presence of tachydysrhythmias such as SVT, VT, or AF with RVR.
Lidocaine is contraindicated in the presence of a HR < 60/min, 2nd- or 3rd-degree AV blocks, or idioventricular rhythms.
All RSI patients shall receive the constant and ongoing monitoring of their SpO2, BP, ECG, EtCO2, and respiratory status.
REVISED: 12/18/2009
MED-10
Respiratory Distress
ADULT
PEDIATRIC
Allergic Reaction
Allergic Reaction
Treat in accordance with Allergic Reaction protocol.
Treat in accordance with Allergic Reaction protocol.
Asthma/Bronchoconstriction
Asthma/Bronchoconstriction
Epinephrine 0.5 mg IM (1:1000)
and repeat twice as needed.
Epinephrine 0.01 mg/kg (1:1000) IM up to 0.5 mg
and repeat twice as needed.
Tension Pneumothorax
Tension Pneumothorax
Perform needle decompression for the rapidly
deteriorating patient.
Perform needle decompression for the rapidly
deteriorating patient.
Foreign Body Airway Obstruction (FBAO)
Foreign Body Airway Obstruction (FBAO)
Direct laryngoscopy and removal of obstruction.
Direct laryngoscopy and removal of obstruction.
Cricothyrotomy.
Cricothyrotomy.
CHF (Pulmonary Edema)
CHF (Pulmonary Edema)
Apply CPAP (if available).
Nitroglycerin 0.4 mg SL if SBP > 90 mm Hg and
FOR PEDIATRIC PATIENTS PRESENTING WITH
CHF, CONTACT BIOCARE MEDICAL CONTROL.
Captopril 25 mg SL if SBP > 90 mm Hg. (Optional)
Epiglottitis / Croup
OR
Enalaprilat 1.25 mg IV/IO if SBP > 90 mm Hg.
Morphine 2 mg IV/IO and repeat every 5 minutes
to a total of 10 mg.
Chronic Obstructive Pulmonary Disease (COPD)
Encourage coughing and purse-lipped breathing.
Establish IV only if doing so will not aggravate
the patient’s respiratory condition.
Consider: Epinephrine 0.3 mg (1:10,000)
nebulized and repeat once as needed.
Laryngoscopy and advanced airways are only
indicated if positive pressure ventilation is ineffective
or unsuccessful.
PEARLS:
•
•
•
•
•
Epinephrine is contraindicated in the presence of CHF.
Consider CPAP for patients with pulmonary edema, asthma, COPD, or pneumonia who show signs of respiratory failure.
A 12-lead ECG and IV access should be performed before NTG is used. However, the inability to obtain vascular access
is not a reason for withholding NTG to a hemodynamically stable patient.
Hyperventilating patients may require coaching and rebreathing of expired air when presenting with symptoms such as
hyperesthesia or carpal/pedal spasms. Be certain hyperventilation is the cause of the medical problem and not a symptom.
Treatment priorities for severe CHF are to maintain ventilation and perfusion, reduce cardiac workload, and transport
rapidly. Securing an IV and obtaining an ECG should be considered secondary priorities and should not delay transport.
REVISED: 12/18/2009
MED-11
Seizures
ADULT
PEDIATRIC
Grand Mal Seizure
Grand Mal Seizure
Midazolam 0.1 mg/kg IM/IN up to 10 mg.
Midazolam 0.1 mg/kg IV/IO/IM/IN up to 5 mg.
OR
OR
Midazolam 2.5 mg IV/IO and repeat once as
needed.
OR
Lorazepam (Optional) 0.1 mg/kg IV/IO up to 2 mg
over 2 minutes and repeat twice in
5-minute increments as needed.
Lorazepam (Optional) 2 mg IV/IO over 2 minutes
and repeat three times in 5-minute increments as
needed.
Eclampsia
Eclampsia
Magnesium sulfate 5 grams IV/IO. Mix in
NS 100 mL and infuse over 15 to 20 minutes.
If seizure persists:
Midazolam 0.1 mg/kg IM/IN up to 10 mg.
OR
Midazolam 2.5 mg IV/IO and repeat once as
needed.
Magnesium sulfate 1 gram IV/IO infused
over 10 to 15 minutes.
OR
Lorazepam (Optional) 2 mg IV/IO over 2 minutes
and repeat three times in 5 minute increments as
needed.
FOR PERSISTENT STATUS EPILEPTICUS,
PEARLS:
•
•
Status epilepticus has many effects including massive release of catecholamines resulting in hypertension, tachycardia,
dysrhythmias, hyperglycemia, hyperthermia, and acidosis from muscle rigidity and poor ventilation.
Assess blood glucose prior to administration of lorazepam or midazolam in order to rule out hypoglycemia as the cause of
the seizure.
Use caution administering benzodiazepines in patients showing signs of ETOH intoxication, patients older then 60 years of
age, and debilitated or chronically ill patients as respiratory depression and renal problems may develop.
Intravenous administration of medication is the preferred route. However, if no vascular access is available, intramuscular
or intranasal midazolam may be given. Once IV access has been established, the IV route should be used for any
subsequent administrations.
For magnesium overdose, contact BIOCARE MEDICAL CONTROL for Calcium Chloride 1g IV/IO slow push.
•
Eclampsia has been known to occur up to 30 days post-delivery.
•
•
•
REVISED: 12/18/2009
MED-12
Stroke (CVA)
ADULT
PEDIATRIC
General Treatment
General Treatment
Key priorities for CVA patients are efficient scene
times and transport to tertiary care.
Key priorities for CVA patients are efficient scene
times and transport to tertiary care.
Assessment should include the patients ability to:
Smile to identify facial drooping or paralysis,
Repeat a sentence to identify slurred speech or
aphasia, and
• Equally extend both arms together without
wavering to determine coordination.
•
•
Assessment should include the patients ability to:
Smile to identify facial drooping or paralysis,
Repeat a sentence to identify slurred speech or
aphasia, and
• Equally extend both arms together without
wavering to determine coordination.
•
•
Place the patient in a position of comfort or on the
affected side to control upper airway secretions.
Place the patient in a position of comfort or on the
affected side to control upper airway secretions.
Elevate the head 30 degrees to promote cerebral
drainage when indicated.
Elevate the head 30 degrees to promote cerebral
drainage when indicated.
Assess blood glucose levels to determine if
hypoglycemia is present.
Assess blood glucose levels to determine if
hypoglycemia is present.
Hypotension or Hypovolemia
Hypotension or Hypovolemia
NS 20 mL/kg fluid bolus IV/IO.
NS 20 mL/kg fluid bolus IV/IO.
Dopamine 5 to 20 mcg/kg/min IV/IO
titrated to effect.
FOR HYPOTENSION THAT DOES NOT RESPOND TO
FLUID REPLACEMENT, CONTACT BIOCARE MEDICAL
CONTROL AND CONSIDER DOPAMINE.
PEARLS:
•
In the hypertensive stroke patient, antihypertensive therapy often leads to worsening of cerebral perfusion. However, when
ACS, acute heart failure or known aortic dissection are present, prehospital treatment of hypertension may be considered
only after approval from BIOCARE MEDICAL CONTROL.
•
Glucose and dextrose administration are contraindicated in absence of hypoglycemia as its use can increase anaerobic
metabolism and lactic acid production in ischemic brain tissue, thereby worsening neurological outcomes.
•
Aspirin is now indicated in the first 24 to 48 hours after stroke onset symptoms and is now included in the CVA treatment.
REVISED: 12/18/2009
MED-13
REVISED: 12/18/2009
MED-14
Obstetric Emergencies (1/2)
ADULT
General Treatment
Monitor contractions to include time, frequency, duration, and strength.
Check perineum for bleeding, evidence of prolapsed cord, crowning, or other presenting parts.
Any bleeding associated with pregnancy may be life-threatening to mother and/or fetus. Third-trimester
bleeding should be considered a life threatening condition. Initiate rapid transport when a life threatening
condition exists.
If patient becomes hypotensive or needs fluid replacement, administer
NS 20 mL/kg fluid bolus IV/IO and repeat once as needed.
Uncomplicated Childbirth
Prepare the patient and equipment for delivery.
Follow procedures for normal cephalic delivery.
Initiate suctioning of the nose and mouth when the fetal head is delivered.
Facilitate delivery of the remaining portion of the fetus as necessary.
Immediately after delivery, vigorously dry the newly-born patient and maintain body warmth.
Determine APGAR within the first minute after delivery and five minutes after.
Clamp and cut umbilical cord and anticipate delivery of the placenta.
Place newly-born patient and mother in position of comfort, preferably with newly-born
patient on mother’s chest to maintain warmth.
Abruptio Placenta and Placenta Previa
Place patient in shock position. If patient becomes hypotensive or needs fluid replacement,
administer NS 20 mL/kg IV/IO bolus and repeat once as needed.
Breech Presentation
Place the mother in position for delivery.
Assist breech delivery as indicated. If head is delayed, insert two fingers into the vagina and maintain the
baby’s airway. Initiate rapid transport.
Prolapsed Cord
Treat the depressed/meconium-stained newly-born patient according to Neonatal Resuscitation protocol.
Position the mother on her left side with her knees towards her chest and her head down.
Check cord for pulsation and rate being cautious not to occlude blood flow. Apply gentle pressure to the
presenting part to relieve pressure on the cord. Recheck cord for pulsation and rate and assess fetal
status. Keep moist with NS and initiate rapid transport.
REVISED: 12/18/2009
OB-1
Obstetric Emergencies (2/2)
ADULT
Postpartum Hemorrhage
Observe and assess for significant blood loss of > 500 mL (3-4 blood soaked pads) and signs and
symptoms of shock. Massage fundus after placental delivery.
If patient becomes hypotensive or needs fluid replacement, Administer NS 20 mL/kg fluid bolus IV/IO.
May repeat once as needed.
Pre-eclampsia and Eclampsia
Magnesium sulfate 5 grams IV/IO. Mix in NS 100 mL
and infuse over 15 to 20 minutes.
If seizure persists:
Midazolam 0.1 mg/kg IM/IN up to 10 mg
OR
Midazolam 2.5 mg IV/IO and repeat once as needed.
OR
Lorazepam (Optional) 2 mg IV/IO over 2 minutes and repeat
three times in 5 minute increments as needed.
FOR PERSISTENT STATUS EPILEPTICUS,
PEARLS:
•
•
•
•
•
•
•
Initiate rapid transport when mother or fetus present with or develop a life-threatening condition.
Breech births carry a much higher risk of infant mortality. Make every effort to ensure that delivery occurs in the hospital.
Immediately after delivery, place infant at same level as mother’s abdomen until the cord has been clamped and cut. This
will prevent blood from flowing to the placenta or excessive blood from flowing to the infant.
Keep infant warm after delivery.
Suctioning of meconium before full body delivery is no longer recommended in infants born to mothers with meconium
staining. Small amounts of meconium often only discolor the fluid without obvious particles being visible. Management
with deep suctioning is not necessary in these patients.
Remember the APGAR score aids in determining whether the patient is viable on its own or if resuscitation is required.
If signs and symptoms of Magnesium sulfate toxicity exist (depressed reflexes, hypotension, respiratory depression),
Contact BIOCARE MEDICAL CONTROL for Calcium Chloride 1 gram IV/IO over 5 minutes.
•
APGAR scoring must be documented at 1 and 5 minutes following delivery.
Sign
Heart Rate
Respiratory Effort
Muscle Tone
Reflex Irritability
Color
REVISED: 12/18/2009
0
1
2
Absent
Absent
Limp
No Response
Blue, Pale
<100
Slow, Irregular
Some Extremity Movement
Grimace
Body Pink, Extremities Blue
>100
Good, Crying
Active Motion
Cough or Sneeze
Completely Pink
OB-2
Neonatal Resuscitation
PEDIATRIC
Depressed Newly-Born
•
•
•
•
•
•
•
•
Avoid hypothermia.
Position and suction the patient as necessary, dry vigorously and provide tactile stimulation.
Initiate blow-by oxygen therapy if respirations are present.
Initiate BVM ventilation at 40 to 60 breaths per minute if patient is apneic or if the heart rate is less
than 100/min.
Initiate cardiac compressions for pulse rates < 60/min using a 3:1 compression-to-ventilation ratio.
Intubate with endotracheal tube and ventilate with 100% oxygen.
Epinephrine 0.01 mg/kg (1:10,000) IV/IO. May repeat every 3 to 5 minutes as needed.
Administer NS 20 mL/kg bolus IV/IO and repeat once as needed.
Meconium Staining Present
•
•
•
If the infant has absent or depressed respirations, decreased muscle tone, or HR < 100/min, perform
direct laryngoscopy, tracheal intubation, and suctioning before providing positive pressure ventilation
or stimulation.
Repeat suctioning until little additional meconium is recovered or the HR indicates that resuscitation
should proceed without delay.
It may be necessary to initiate positive-pressure ventilation despite the presence of meconium in the
airway if HR or respirations are severely depressed.
Hypoglycemia (bG < 60 mg/dL)
Dextrose 10% 5 mL/kg IV/IO
Suspected or Confirmed Narcotic-Related Depression
Naloxone 0.1 mg/kg increments up to 2 mg IV/IM/IO
PEARLS:
•
•
•
Always keep and maintain warmth in all newborns. All newborns have difficulty tolerating cold and depressed infants are
especially at high-risk for complications of cold stress.
Suctioning of meconium before full body delivery is not indicated for patients with small amount of meconium staining if
obvious particles are not visible. Management with deep suctioning is not necessary in these patients. Deep suctioning is
only indicated in meconium-stained newborns when large particles are observed and the newborn is depressed. There is
no evidence that endotracheal suctioning of a vigorous newborn provides any benefit.
Acidosis in children is a primarily a problem of ventilation and oxygenation. When other therapies are ineffective,
Contact BIOCARE MEDICAL CONTROL to request Sodium bicarbonate 4.2% 1 to 2 mEq/kg IV/IO. To obtain the proper
admixture, dilute the supplied 8.4% solution with equal parts of NS.
REVISED: 12/18/2009
OB-3
REVISED: 12/18/2009
OB-4
Toxicological Emergencies (1/2)
ADULT
PEDIATRIC
Suspected or Confirmed Beta Blocker
or Calcium Channel Blocker Overdose
Suspected or Confirmed Beta Blocker
or Calcium Channel Blocker Overdose
Prepare for transcutaneous pacing at a rate of
80/min if no response to atropine.
Prepare for transcutaneous pacing at a rate of
80/min if no response to atropine.
Glucagon 1 mg IV/IO.
Glucagon 1 mg IV/IO.
Calcium chloride 1 gram IV/IO over 5 minutes.
Calcium chloride 20 mg/kg IV/IO over 5 minutes.
NS 20 mL/kg bolus IV/IO and repeat once.
If no response to fluids, administer dopamine
5 to 20 mcg/kg/min IV/IO titrated to effect.
Epinephrine 2 to 10 mcg/min IV/IO.
Epinephrine 2 to 10 mcg/min IV/IO.
Suspected or Confirmed
Tricyclic Antidepressant Overdose
Tricyclic Antidepressant Overdose
Sodium Bicarbonate 1 mEq/kg IV/IO.
Sodium Bicarbonate 1 mEq/kg IV/IO.
Organophosphate Poisoning
Organophosphate Poisoning
Atropine 2 mg IV/IM/IO and repeat
Atropine 0.02 mg/kg IV/IM/IO and repeat
Minimum dose 0.1 mg
Narcotic (Opioid) Overdose
Narcotic (Opioid) Overdose
Naloxone 0.4 mg to 2 mg IV/IO and repeat as
needed.
Naloxone 0.1 mg/kg increments, maximum single
dose 2 mg IV/IO/IM
OR
OR
Naloxone 1 mg IM/IN and repeat as needed.
Naloxone 0.02 mg/kg increments, maximum single
dose 1 mg IN
REVISED: 12/18/2009
TOX-1
Toxicological Emergencies (2/2)
PEARLS:
•
•
In cases of suspected or confirmed Carbon Monoxide Exposure, assess SpCO levels if equipment is available.
Use caution administering Calcium Chloride as it carries a high risk of sclerosis and infiltration.
Beta-Blockers
• Most, but not all, generic names end with "-olol"). Commonly-prescribed examples include:
◊ metoprolol (Lopressor, Toprol XL)
◊ propranolol (Inderal)
◊ carvedilol (Coreg)
◊ atenolol (Tenormin, Tenoretic)
◊ bisoprolol (Bisoprolol)
Calcium-Channel Blockers
• Many generic names end with "-dipine". Commonly-prescribed examples include:
◊ diltiazem (Cardizem)
◊ verapamil (Calan, Isoptin)
◊ amlodipine (Norvasc)
◊ felodipine (Plendil)
◊ nifedipine (Procardia)
Tricyclic Antidepressants (TCA’s)
• TCA’s are used to treat depression, neuropathic pain and ADHD. Commonly-prescribed examples include:
◊ amitriptyline (Elavil)
◊ imipramine (Imipril, Tofranil)
◊ desipramine (Norpramin)
◊ nortriptyline (Pamelor)
Opioids (Narcotics)
• Opioids are found in prescription form, in combination with other drugs, or as illicit “street drugs.”
• The desired treatment outcome for an opioid overdose patient is adequacy of respirations as measured by SpO2.
• Commonly-prescribed examples of natural and semi-synthetic opioids include:
◊ codeine (Tylenol #3)
◊ hydrocodone (Vicodin, Lortab, Norco)
◊ hydromorphone (Dilaudid)
◊ meperidine (Demerol)
◊ morphine (MS-Contin)
◊ oxycodone (Oxycontin, Percocet, Percodan)
◊ tramadol (Ultram)
•
Higher doses of naloxone may be required to achieve the desired outcome for patients with excessive amounts of synthetic
opioids in their bloodstream. Contact BIOCARE MEDICAL CONTROL to discuss treatment options. Commonly-prescribed
examples include:
◊ fentanyl (Duragesic, Sublimaze)
◊ propoxyphene-N (Darvocet),
◊ methadone (Methadose)
Organophosphates
• Ensure your safety at all times.
• For patients with inhaled organophosphate poisoning, their expired air may be toxic. Protect yourself accordingly.
• Verify that the patient has been adequately decontaminated prior to being loaded onto the cot, into the ambulance and/or
being transported to an ED.
• Higher doses of atropine may be required for patients with significant organophosphate poisoning. Contact
BIOCARE MEDICAL CONTROL to discuss treatment options.
REVISED: 12/18/2009
TOX-2
Trauma - General Management (1/3)
ADULT & PEDIATRIC
Do not prolong scene times or transport time to perform procedures in the critical trauma patient when
they can be performed during transport. The survival of trauma patients is dependent upon transport for
surgical consultation and intervention.
Treat signs and symptoms according to their respective protocols (e.g. seizures, pain management, etc.).
For any patient needing fluid as a result of trauma:
Administer NS 20 mL/kg fluid bolus IV/IO and repeat once titrated to SBP > 90 mm Hg.
FOR HYPOTENSION REFRACTORY TO FLUID
ADMINISTRATION, CONTACT BIOCARE MEDICAL
CONTROL FOR ORDERS.
Spinal Immobilization
Spinal immobilization is indicated in trauma patients who sustain a mechanism of injury sufficient to cause
a spinal cord injury and who display at least one of the following criteria:
• Altered mental status,
• Evidence of intoxication,
• A distracting painful injury,
• Neurological deficit, and/or
• Spinal pain or tenderness.
Stabilize head and neck in neutral position unless movement causes pain, deformity, or resistance. If so,
immobilize the head and neck in the position found.
Apply a cervical collar before moving the patient. Immobilize the entire spine with the appropriate devices
and techniques. Use rapid extrication techniques for critical patients only.
Spinal immobilization for athletes and motorcycle helmets:
• The face mask should be removed prior to transport.
• Helmets and shoulder pads should be left in place if the patient can be adequately immobilized.
• The helmet & shoulder pads should be removed as a unit if:
• The helmet and chin strap do not hold the head securely,
• Immobilization of the helmet does not also immobilize the head,
• The airway can not be controlled or ventilation provided even after removal of the face mask,
• The face mask can not be removed after a reasonable period of time, and/or
• The helmet prevents immobilization for transportation in an appropriate position.
REVISED: 12/18/2009
TR-1
ADULT & PEDIATRIC
Amputations
•
•
•
•
Rinse with NS to remove loose debris.
Wrap in gauze moistened with NS or sterile water and place part into bag or container.
Place container into another container with ice to keep cool.
Transport parts with patient whenever possible.
Abdominal Trauma
•
•
Stabilize impaled objects and cover eviscerations with large saline-soaked dressings.
Assess for fetal movement, vaginal bleeding, and contractions in the pregnant trauma patient.
Chest Trauma
Chest Wall Trauma:
• Stabilize fractures and flail segments.
• Seal open chest wounds with occlusive dressings.
• Monitor patient for signs of tension pneumothorax.
• Provide positive pressure ventilation as needed.
Myocardial Contusion:
• Obtain 12 Lead ECG
• Treat dysrhythmias as needed.
Pneumothorax:
• Place patient in a position of comfort unless suspected or obvious injuries prohibit.
• Chest decompression as indicated by signs and symptoms or clinical status.
Pericardial tamponade:
• Administer NS 20 mL/kg fluid bolus IV/IO and repeat once.
Soft-Tissue Trauma
•
Control hemorrhage by direct pressure, elevation, pressure points and pressure dressings. Utilize
tourniquets to control excessive bleeding as needed.
Animal/Human Bites:
• Wash wounds thoroughly with soap and water (ideal) or irrigate with sterile water or NS.
• Remove constricting bands
• For snake bites, contact receiving facility for verification of anti-venom stock.
• Treat soft tissue injuries appropriately
Eye Injuries:
• Irrigate with NS or sterile water to remove foreign objects.
• Stabilize impaled objects as found
• Apply eye patch to the affected eye and cover both eyes with bulky dressing.
REVISED: 12/18/2009
TR-2
ADULT & PEDIATRIC
Head Trauma
•
•
Elevate the patients head 15-30 degrees if not contraindicated.
If patient exhibits signs of impending brainstem herniation or increased ICP with altered mental status,
hyperventilate to maintain an EtCO2 of 30-35 mm Hg. Otherwise, avoid hyperventilation to reduce the
chance of cerebral ischemia.
Extremity Trauma
•
•
•
Stabilize all fractures prior to moving the patient and immobilize all joints above and below the injury
where indicated unless rapid extrication is necessary or doing so would delay the transport of a critical
patient.
Irrigate gross contaminants from open fracture sites with NS before applying dressings.
Immobilize angulated joint injuries in the position found unless manipulation is needed to reestablish
distal pulses.
Sexual Assault
•
•
•
Do not examine the genitalia unless active bleeding is present and a dressing is required to control the
bleeding.
Whenever possible, transport the patient to a hospital in the County where the assault occurred. If this
is not possible, transport the patient to Parkland Hospital.
Treat pain and other obvious injuries as needed while preserving level of consciousness.
Tasered Patients
•
•
•
•
To remove barbs: stretch the skin near the area of the puncture site, apply counter pressure with one
hand, grasp the blunt end of the probe with gloved fingers of your other hand, and remove quickly.
Cleanse all puncture sites with alcohol and bandage as needed.
Do not remove barbs from the face, neck, nipple, umbilicus, groin, or imbedded in bone.
Oxygen and ECG monitoring should be provided for patients with one or more of the following
conditions: Illicit/illegal drug use, Pregnancy, Cardiac history or disease, Implanted cardiac stimulation
device (AICD/Pacemaker)
REVISED: 12/18/2009
TR-3
Trauma - Burns
ADULT & PEDIATRIC
•
•
•
•
•
•
Stop the burning process. Remove the patient from the source of the injury. Remove the patient’s
clothes and ensure the clothes are transported with the patient.
Monitor the airway closely for laryngeal edema and intubate if the airway becomes compromised.
Physical examination should include an assessment of the extent of the injury estimating depth and
percentage of total body surface area burned (TBSA)
Remove rings, bracelets, and other constricting items.
Treat pain in accordance with Pain Management protocol.
Any patient with major burns should be transported to Parkland Hospital unless immediate life-saving
procedures are needed.
Partial-thickness or full-thickness burns < 10 % TBSA
Cover with cool wet sterile dressings
Partial thickness or full thickness burns > 10 % TBSA
Cover with dry sterile dressings, administer bolus NS (4 mL/kg multiplied by TBSA percentage)
Chemical Burns and Electrical Burns
Chemical:
• Consult appropriate HAZMAT resources and decontaminate the patient.
• Brush away as much chemical as possible before irrigating with copious amounts of NS or water for at
least 20 minutes.
• Apply dry sterile dressing after irrigation is complete.
Electrical:
• Ensure the safety of all personnel and avoid electrical hazards. Assess for associated injuries to
cardiovascular, musculoskeletal, hepatic, renal, and neurological systems.
• Initiate cardiac monitoring, 12-lead ECG, and treat dysrhythmias as needed.
PEARLS:
•
•
•
A major burn is defined by the presence of one or more of the following criteria:
◊ Partial thickness burns > 10% TBSA
◊ Significant burns involving the hands, face, feet, genitalia, or major joints
◊ Full thickness burns
◊ Electrical burns including lightning injuries
◊ Chemical burns and/or inhalation injuries
Utilize the Rule of 9’s for estimating TBSA percentage.
With major burns, hypothermia is a primary concern. Keep the patient warm and
do not allow the patient to shiver.
REVISED: 12/18/2009
TR-4
EMS Biocare Drug Formulary
Table of Contents:
Adenosine hydrochloride
Albuterol sulfate
Amiodarone hydrochloride
Aspirin
Atropine sulfate
Calcium chloride
Captopril
Dextrose/instaglucose
Diphenhydramine hydrochloride
Dopamine hydrochloride
Enalaprilat
Epinephrine hydrochloride
Etomidate
Fentanyl citrate
Glucagon
Haloperidol lactate
Ipratropium bromide
Lidocaine hydrochloride
Lorazepam hydrochloride
Midazolam hydrochloride
Morphine sulfate
Naloxone hydrochloride
Nitroglycerin
Ondansetron hydrochloride
Oxygen
Sodium bicarbonate
Sodium chloride
Succinylcholine chloride
Vecuronium bromide
REVISED: 12/18/2009
2010 EMS Biocare Drug Formulary
FORM-1
ADENOSINE
Adenocard®
CLASS:
Adenosine is an endogenous nucleoside present in all cells of the body
ACTIONS:
Slows conduction through the AV node.
INDICATIONS:
• Supraventricular tachycardia
ADMINISTRATION:
• Adult: Follow each dose of adenosine with a 20 mL bolus of normal saline
• Pediatric: Follow each dose of adenosine with a 10 mL bolus of normal saline
SIDE EFFECTS:
• Transient flushing, dyspnea
• Transient asystole and varying degrees of AV block often occur, resolving within seconds
CONTRAINDICATIONS:
• Atrial fibrillation/flutter
• Second- or third-degree heart block or sinus node disease (e.g. sick sinus syndrome or symptomatic bradycardia)
PRECAUTIONS:
• The short duration of action (<10 seconds) requires a rapid flush using the port closest to the vascular access site
to be certain the solution reaches the systemic circulation
• Drug Interactions:
• Methylxanthines, such as caffeine and theophylline, inhibit the effects of adenosine.
• Concurrent use with calcium channel blockers may cause VF. Monitor ECG closely.
• Dipryidamole (persantine) may increase the effects of adenosine
• Concurrent use with carbamazepine may produce higher degree of AV block.,
PROTOCOL REFERENCE:
• Supraventricular Tachycardia
REVISED: 12/18/2009
FORM-2
ALBUTEROL
Proventil®, Ventolin®
CLASS:
Sympathomimetic, Beta 2 agonist
ACTIONS:
Relaxes smooth muscle of the bronchioles and reverses bronchospasm
Inhibits the release of mediators of immediate hypersensitivity (histamine), especially from mast cells
INDICATIONS:
• Bronchoconstriction
• Dyspnea
ADMINISTRATION:
• The EMT should assist in the self-administration of other physician-prescribed, patient-use Beta-2 agonists. Do not
assist in administering steroidal or non-Beta-2 agonist inhalers.
SIDE EFFECTS:
• Tremors, headache, hyperactivity
• Tachycardia, palpitations, hypokalemia
• Nausea, vomiting
• Bronchospasm, increased sputum
CONTRAINDICATIONS:
• Known hypersensitivity
PRECAUTIONS:
• Should be used with caution in patients with cardiovascular disease, especially coronary insufficiency, cardiac arrhythmias, and hypertension convulsive disorders and hyperthyroidism or patients being treated with tricyclic antidepressants.
• Beta blockers and albuterol inhibit the effect of each other.
• May be mixed in the medication nebulizer chamber with ipratropium bromide.
PROTOCOL REFERENCE:
• Allergic Reaction/Anaphylaxis
• Drowning/Submersion Injury
• Respiratory Distress
REVISED: 12/18/2009
FORM-3
AMIODARONE HYDROCHLORIDE
Cordarone®
CLASS:
Potassium channel blocker and Class III antiarrhythmic that exhibits properties of each of the four anti-arrhythmic classes.
ACTIONS:
Effects result from a blockade of potassium chloride leading to a prolongation of action potential
duration.
INDICATIONS:
• Ventricular tachycardia
• Ventricular fibrillation
• Post-Resuscitation
SIDE EFFECTS:
• Tremors, malaise, fatigue,
• Bradycardia, hypotension, arrhythmias, heart failure, heart block, sinus arrest
• Acute respiratory distress syndrome, severe pulmonary toxicity
CONTRAINDICATIONS:
• Second- or third-degree heart block or sinus node disease (e.g. sick sinus syndrome or symptomatic bradycardia)
• Cardiogenic shock
PRECAUTIONS:
• QT prolongation may be exaggerated in patients with hypokalemia or hypomagnesemia, increasing the potential for
the development of torsades de pointes
• Drug Interactions:
• Use with beta blockers and calcium channel blockers may increase risk of hypotension and bradycardia
• Use with fentanyl may cause hypotension, bradycardia, and decreased cardiac output.
• Use with antihypertensives may increase the hypotensive effect
PROTOCOL REFERENCE:
• Ventricular Tachycardia
• Cardiac Arrest - VF/Pulseless VT
• Cardiac Arrest - Post-Resuscitation Care
Adult Infusion (150 mg in 100cc over 10 min)
DOSE
150mg OVER 10min Run 10 drop tubing @:
150mg/100cc
100 gtts/min
REVISED: 12/18/2009
Pediatric Infusion (5 mg/kg)
Inject 5mg/kg
5 mg/kg OVER
(150mg Max)
10min - Run 10
Patient Weight
Amiodarone into
drop tubing @:
100cc NS
5 kg / 11 lbs
10 kg / 22 lbs
15 kg / 33 lbs
20 kg / 44 lbs
25 kg / 55 lbs
30 kg / 66 lbs
25mg
50mg
75mg
100mg
125mg
150mg
100 gtts/min
100 gtts/min
100 gtts/min
100 gtts/min
100 gtts/min
100 gtts/min
FORM-4
ASPIRIN
CLASS:
• Platelet aggregate inhibitor
ACTIONS:
• Blocks formation of thromboxane A2 thereby inhibiting platelet aggregation arterial
constriction.
INDICATIONS:
• Suspected ACS
• Chest Pain
• Stroke/CVA
SIDE EFFECTS:
• None pertinent to EMS
CONTRAINDICATIONS:
• Allergies to aspirin
PRECAUTIONS:
PROTOCOL REFERENCE:
• ACS/Chest Pain
• Stroke/CVA
REVISED: 12/18/2009
FORM-5
ATROPINE SULFATE
CLASS:
Anticholinergic, parasympatholytic
ACTIONS:
Inhibits action of acetylcholine at postganglionic parasympathetic neuroeffector sites, blocks normal vagal inhibition
of the heart, positive chronotropic effect, increasing SA node automaticity, increases AV node conduction.
INDICATIONS:
• Cardiac Arrest - Asystole/PEA
• RSI
• Symptomatic Bradycardia
• Organophosphate Poisoning
ADMINISTRATION:
• Should be given over at least one minute to patients with pulses.
SIDE EFFECTS:
• Headache, restlessness, dizziness, bradycardia or tachycardia
CONTRAINDICATIONS:
• None in cardiac arrest
• Relatively contraindicated in patients with angle-closure glaucoma, tachycardia, myocardial ischemia, asthma, or
myasthenia gravis.
• Use cautiously in patients with Down syndrome as they may be more sensitive to its effects.
PRECAUTIONS:
• Do not use doses < 0.5 mg in the adult due to possible paradoxical bradycardia
PROTOCOL REFERENCE:
• Bradycardia
• Rapid Sequence Intubation
• Toxicological Emergencies
REVISED: 12/18/2009
FORM-6
CALCIUM CHLORIDE
CLASS:
Electrolyte
ACTIONS:
Replaces calcium and maintains calcium level.
INDICATIONS:
• Suspected or confirmed hypocalcemia
• Suspected or confirmed Magnesium toxicity/overdose
SIDE EFFECTS:
• Bradycardia, arrhythmias
• Cardiac arrest can ensue if given too fast
• Local reactions including but not limited to burning, necrosis, or cellulitis.
CONTRAINDICATIONS:
• Cancer patients with bone metastases
• Ventricular fibrillation, hypercalcemia, or renal calculi
PRECAUTIONS:
• Use very cautiously in patients taking digitalis
• Administer slowly to decrease the chances of vein irritation
• Use cautiously in pregnancy
PROTOCOL REFERENCE:
• Obstetric Emergencies
REVISED: 12/18/2009
FORM-7
CAPTOPRIL
Capoten®
CLASS:
Angiotensin Converting Enzyme (ACE) Inhibitor
ACTIONS:
Prevents conversion of angiotensin I to angiotensin II.
INDICATIONS:
• CHF
SIDE EFFECTS:
• Dizziness, fainting, headache, fatigue, fever, angioedema
• Tachycardia, hypotension, angina
• Abdominal pain, dry mouth, nausea, vomiting, dry cough
CONTRAINDICATIONS:
• Pregnancy
• Hypersensitivity to drug or other ACE inhibitors
PRECAUTIONS:
• Concurrent administration with diuretics may cause excessive hypotension. Monitor blood pressure and heart rate
closely.
• Use cautiously in patients with impaired renal function or serious autoimmune disease.
• Assess for signs of angioedema.
PROTOCOL REFERENCE:
REVISED: 12/18/2009
FORM-8
DEXTROSE/INSTAGLUCOSE
CLASS:
Carbohydrate
ACTIONS:
Restores blood sugar to normal levels. Transient osmotic diuretic.
INDICATIONS:
• Suspected or confirmed hypoglycemia
SIDE EFFECTS:
• Worsened hypertension and heart failure with fluid overload in susceptible patients, phlebitis, venous sclerosis
• Pulmonary edema, and unconsciousness (if given to patients with HHNC)
• May precipitate severe neurological symptoms in alcoholics
CONTRAINDICATIONS:
• None pertinent
PRECAUTIONS:
• Dextrose is very irritating - use a large vein, make sure it's patent and flush well after administration
• Dextrose is a hypotonic solution. Use cautiously in patients with renal insufficiency, urinary obstruction, or hypovolemia.
• Use caution in the patient with suspected intracranial bleeding as the presence of glucose in the hematoma would
draw fluid into the site increasing its size
PROTOCOL REFERENCE:
• Diabetic/Glucose Emergencies
• Neonatal Resuscitation
REVISED: 12/18/2009
FORM-9
DIPHENHYDRAMINE HYDROCHLORIDE
Benadryl®
CLASS:
Antihistamine
ACTIONS:
Competes with histamine for H1-receptor sites and prevents but doesn’t reverse, histamine-mediated responses.
INDICATIONS:
• Isolated or minimal allergic reaction
SIDE EFFECTS:
• Sedation, sleepiness, dizziness, seizures
• Nausea, dry mouth, epigastric discomfort
• Thickening of bronchial secretions
CONTRAINDICATIONS:
• Use cautiously to treat patients with asthma, COPD, CV disease, or hypertension.
PRECAUTIONS:
• Use cautiously in patients who have recently taken sedatives and anticholinergics as it
potentiates their effects.
PROTOCOL REFERENCE:
REVISED: 12/18/2009
FORM-10
DOPAMINE HYDROCHLORIDE
Intropin®
CLASS:
Sympathomimetic with dose dependent Alpha and Beta agonist properties
ACTIONS:
Dose-dependent stimulation of alpha, beta-1, and dopaminergic receptors of the CNS.
• Low dose (< 2 mcg/kg/min) causes mainly dopaminergic stimulation.
• Medium dose (2-10 mcg/kg/min) causes mainly beta-1 stimulation.
• Large dose causes mainly alpha stimulation.
INDICATIONS:
• Hypotension refractory to fluid replacement
SIDE EFFECTS:
• Increased myocardial oxygen demand
• Asthmatic episodes, hypotension, and anaphylaxis.
CONTRAINDICATIONS:
• Uncorrected tachyarrhythmias
• Pheochromocytoma
PRECAUTIONS:
• If DBP rises disproportionately (creating a significant narrowing of the pulse pressure), decrease the infusion rate
and monitor blood pressure very closely.
• Use cautiously in patients with cold injuries, pregnant patients, patients with a history of sulfite sensitivity, and in
those taking MAO inhibitors.
• With trauma, hypovolemia should be corrected with fluids prior to dopamine administration
• If drug is stopped, watch closely for a sudden drop in blood pressure.
PROTOCOL REFERENCE:
• Bradycardia
• Cardiac Arrest - Post-Resuscitation
• Stroke (CVA)
400mg / 250 cc = 1600 mcg/cc -OR– 800 mg / 500 cc = 1600 mcg/cc
Use 60 drop (gtt)/ml tubing
Patient Weight
10 kg / 22 lbs
20 kg / 44 lbs
30 kg / 66 lbs
40 kg / 88 lbs
50 kg / 110 lbs
60 kg / 132 lbs
70 kg / 154 lbs
80 kg / 176 lbs
90 kg / 198 lbs
100 kg / 220 lbs
110 kg / 242 lbs
120 kg / 264 lbs
130 kg / 286 lbs
REVISED: 12/18/2009
5 mcg/kg/min
2 gtts/min
4 gtts/min
6 gtts/min
8 gtts/min
9 gtts/min
11 gtts/min
13 gtts/min
15 gtts/min
17 gtts/min
19 gtts/min
21 gtts/min
23 gtts/min
24 gtts/min
10 mcg/kg/min
4 gtts/min
8 gtts/min
11 gtts/min
15 gtts/min
19 gtts/min
22 gtts/min
26 gtts/min
30 gtts/min
34 gtts/min
38 gtts/min
41 gtts/min
45 gtts/min
49 gtts/min
15 mcg/kg/min
6 gtts/min
11 gtts/min
17 gtts/min
23 gtts/min
28 gtts/min
34 gtts/min
39 gtts/min
45 gtts/min
51 gtts/min
56 gtts/min
62 gtts/min
68 gtts/min
73 gtts/min
20 mcg/kg/min
8 gtts/min
15 gtts/min
23 gtts/min
30 gtts/min
38 gtts/min
45 gtts/min
53 gtts/min
60 gtts/min
68 gtts/min
75 gtts/min
83 gtts/min
90 gtts/min
98 gtts/min
FORM-11
ENALAPRILAT
CLASS:
Angiotensin Converting Enzyme (ACE) Inhibitor
ACTIONS:
Prevents conversion of angiotensin I to angiotensin II.
INDICATIONS:
• CHF
SIDE EFFECTS:
• Anaphylaxis
• Dizziness, fainting, headache, fatigue, fever, angioedema
• Tachycardia, hypotension, hyperkalemia, angina
• Abdominal pain, dry mouth, nausea, vomiting, dry cough
CONTRAINDICATIONS:
• Pregnancy
• Hypersensitivity to drug or other ACE inhibitors
PRECAUTIONS:
• Concurrent administration with diuretics may cause excessive hypotension. Monitor blood pressure and heart rate
closely.
• Use cautiously in patients with impaired renal function or serious autoimmune disease.
• Assess for signs of angioedema.
PROTOCOL REFERENCE:
REVISED: 12/18/2009
FORM-12
EPINEPHRINE HYDROCHLORIDE
CLASS:
Endogenous catecholamine
ACTIONS:
Stimulates alpha and beta-2 receptors in the sympathetic nervous system, resulting in relaxation of bronchial
smooth muscle. Also inhibits histamine release and antagonizes it’s effects on the organs.
INDICATIONS:
• Symptomatic bradycardia
• Cardiac Arrest
• Anaphylaxis
• Bronchoconstriction
SIDE EFFECTS:
• Nervousness, tremor, headache, drowsiness, cerebral hemorrhage, CVA
• Palpitations, VF, shock
CONTRAINDICATIONS:
• None relevant to EMS.
PRECAUTIONS:
• If epinephrine is being used to treat a reaction caused by another drug given IM or SQ, inject epinephrine into the
site where the other drug was given to minimize further absorption.
• Use with caution when administering to:
• Patients with narrow angle glaucoma.
• Adult patients with shock symptoms (with exception of anaphylactic shock)
• Perfusing patients over 50 years of age
• Pregnant patients
• Asthma patients with a history of severe hypotension or CAD
• Hypotension or circulatory collapse resulting from a phenothiazine overdose
PROTOCOL REFERENCES:
• Bradycardia
• Cardiac Arrest - AED/No Monitor
REVISED: 12/18/2009
FORM-13
ETOMIDATE
Amidate®
CLASS:
Hypnotic
ACTIONS:
A carboxylated imidazole which produces a rapid induction of anesthesia with minimal cardiovascular effects and
steroid suppression.
INDICATIONS:
• Sedation
ADMINISTRATION:
• Should be given via rapid IV/IO push
SIDE EFFECTS:
• Transient venous pain, skeletal muscle movement
CONTRAINDICATIONS:
• Hypersensitivity
PRECAUTIONS:
• Etomidate has sedative and hypnotic properties but no analgesic properties.
PROTOCOL REFERENCE:
• PAI
• RSI
REVISED: 12/18/2009
FORM-14
FENTANYL CITRATE
Fentanyl®
CLASS:
Opioid analgesic
ACTIONS:
Inhibits ascending pain pathways in CNS
Inhibits pain threshold and perception by binding to opiate receptors
INDICATIONS:
• Pain
• Sedation maintenance
SIDE EFFECTS:
• Sedation, somnolence, confusion, seizures
• Arrhythmias, respiratory depression, apnea, diaphoresis
CONTRAINDICATIONS:
• Hypersensitivity to opioids
• Pregnancy or in nursing women
PRECAUTIONS:
• Unlike morphine sulfate, fentanyl citrate does not cause a histamine release and, therefore, will not typically result
in decreased blood pressure.
• Use with caution in patients with head injury, increased CSF pressure, COPD, respiratory depression, or bradydysrhythmias.
• Effects may be increased with concomitant use of other CNS depressants, alcohol, sedatives, antipsychotics,
skeletal muscle relaxants
• Pulse oximetry and cardiac monitoring must be in place as well as continuous monitoring of respiratory status
• Pain Management
• RSI
REVISED: 12/18/2009
FORM-15
GLUCAGON
CLASS:
Hormone
ACTIONS:
Raises glucose level by promoting catalytic depolymerization of hepatic glycogen to
glucose. Relaxes the smooth muscle of the stomach, duodenum, small bowel, and colon.
INDICATIONS:
• Hypoglycemia
• Beta-blocker overdose/reversal
SIDE EFFECT:
• Bronchospasm, respiratory distress
CONTRAINDICATION:
• Pheochromocytoma
PRECAUTIONS:
• Supplemental carbohydrates should be given to prevent secondary hypoglycemia as soon as the patient is conscious and able to tolerate oral administration
REVISED: 12/18/2009
FORM-16
HALOPERIDOL
Haldol®
CLASS:
Antipsychotic
ACTIONS:
Blocks postsynaptic dopamine receptors in the brain
INDICATIONS:
• Behavioral emergency
SIDE EFFECTS:
• Dystonic and/or extrapyramidal reactions
• Tardive dyskinesia
• TDP
• Sedation
CONTRAINDICATIONS:
• Hypersensitivity to drug
• Parkinson’s Disease, coma, and CNS depression
PRECAUTIONS:
• Use cautiously in elderly and/or debilitated patients, and patients with history of seizures, CV dysfunction, or glaucoma.
• Behavioral/Patient Restraint
REVISED: 12/18/2009
FORM-17
IPRATROPIUM BROMIDE
Atrovent®
CLASS:
Anticholinergic (parasympatholytic) bronchodilator chemically related to atropine
ACTIONS:
Inhibits vagally-mediated reflexes by antagonizing acetylcholine at muscarinic receptors on bronchial smooth muscle.
INDICATIONS:
• Dyspnea
• Allergic reaction/anaphylaxis
SIDE EFFECTS:
• URI, bronchitis, bronchospasm
CONTRAINDICATIONS:
• Hypersensitivity to atropine or its derivatives
• Hypersensitivity to peanut or soy products
PRECAUTIONS:
• Use with caution in patients with angle-closure glaucoma.
• If a face mask is being used for administration, take care to prevent leakage around the mask because eye pain or
temporary blurred vision may occur.
• May be mixed in the medication nebulizer chamber with albuterol sulfate.
• Drowning/Submersion Injury
REVISED: 12/18/2009
FORM-18
LIDOCAINE HYDROCHLORIDE
Xylocaine®
CLASS:
Aminoacyl amide
ACTIONS:
A class 1B antiarrhythmic that decreases the depolarization, automaticity, and excitability in the ventricles during the
diastolic phase by direct action on the tissues, especially the Purkinje network.
INDICATIONS:
• RSI/PAI preparation
SIDE EFFECTS:
• Lidocaine is a CNS depressant that produces sedative, analgesic, and anticonvulsant effects (in therapeutic
ranges)
• Clinical indicators of toxicity include: drowsiness, altered LOC, agitation, slurred speech, tinnitus, paresthesias, visual
disturbances, hallucinations, muscle twitching, and seizures.
• CV: (higher doses) hypotension, bradycardia, and cardiovascular collapse
CONTRAINDICATIONS:
• Hypersensitivity to lidocaine or other amides
PRECAUTIONS:
• None
PROTOCOL REFERENCE:
• PAI
• RSI
REVISED: 12/18/2009
FORM-19
LORAZEPAM
Ativan®
CLASS:
Benzodiazepine
ACTIONS:
Potentiates the effects of GABA and depresses CNS at the limbic and subcortical levels
INDICATIONS:
• Anxiety/acute agitation
• Seizure
SIDE EFFECTS:
• Respiratory depression
• Sedation, disorientation, headache
• Hypotension, nausea, abdominal pain
CONTRAINDICATIONS:
• Hypersensitivity to benzodiazepines
PRECAUTIONS:
• Use cautiously in patients with pulmonary renal or hepatic impairment.
PROTOCOL REFERENCE:
• Pain Management
• Seizure
• OB
• UPC
REVISED: 12/18/2009
FORM-20
MAGNESIUM SULFATE
CLASS:
Electrolyte
ACTIONS:
Replaces magnesium and maintains magnesium level.
Interferes with release of acetylcholine at myoneural junction.
INDICATIONS:
• Torsades de Pointes (TDP)
• Seizures related to eclampsia/pre-eclampsia
SIDE EFFECTS:
• Depressed reflexes
• Hypotension, flushing, bradycardia, circulatory collapse
• Respiratory paralysis
CONTRAINDICATION:
• Heart block or myocardial damage
PRECAUTIONS:
• Use with caution in patients with impaired renal function
• Use with caution in pregnant women during labor or within two hours preceding delivery
PROTOCOL REFERENCE:
• Ventricular Tachycardia (TDP)
• Seizure
• OB
REVISED: 12/18/2009
FORM-21
MIDAZOLAM HYDROCHLORIDE
Versed®
CLASS:
Benzodiazepine
ACTIONS:
Potentiates the effects of GABA, depresses the CNS, and suppresses the spread of seizure activity.
INDICATIONS:
• Sedation related to cardioversion or intubation
• Behavioral emergency
• Seizure
SIDE EFFECTS:
• Sedation, drowsiness, amnesia
• Nausea
• Apnea, respiratory depression, hiccups, pain at the injection site
CONTRAINDICATIONS:
• Hypersensitivity to benzodiazepines
• Shock
PRECAUTIONS:
• Lower doses should be give to patients at or over 60 years of age, patients who are chronically ill, debilitated, or
patients displaying symptoms of acute alcohol intoxication.
• Pulse oximetry and cardiac monitoring must be in place as well as continuous monitoring of respiratory status
PROTOCOL REFERENCE:
• Atrial Fibrillation/Flutter with RVR
• Ventricular Tachycardia
• Supraventricular Tachycardia
• Bradycardia
• PAI
• RSI
• Seizure
• UPC
REVISED: 12/18/2009
FORM-22
MORPHINE SULFATE
CLASS:
Opioid analgesic
ACTIONS:
Binds with opiate receptors in the CNS, altering perception of and emotional response to pain, depresses the vasomotor center therefore increasing venous capacitance and decreasing peripheral vascular resistance and
depresses the respiratory and cough centers in the brain
INDICATIONS:
• ACS/Chest pain
• Pain
• CHF
SIDE EFFECTS:
• Sedation, somnolence, seizures, dizziness
• Hypotension, bradycardia, shock, cardiac arrest
• Nausea, vomiting, constipation
• Thrombocytopenia
• Respiratory depression, apnea, respiratory arrest.
CONTRAINDICATIONS:
• Hypersensitivity to opioids
• Acute bronchial asthma or upper airway obstruction
• Hypotension
• SBP < 90 mm Hg
PRECAUTIONS:
• Unlike fentanyl, morphine sulfate causes a histamine release and will result in a drop in blood pressure.
• Do not administer unless naloxone and definitive airway control are readily available
• Use with caution in any patient with a decreased LOC (i.e. head injury, CVA, increased ICP) as morphine may
mask these conditions
PROTOCOL REFERENCE:
• ACS/Chest Pain
• Pain Management
REVISED: 12/18/2009
FORM-23
NALOXONE HYDROCHLORIDE
Narcan®
CLASS:
Narcotic (opiate receptor) antagonist
ACTIONS:
Exact mechanism of action is unknown. Thought to displace opioids analgesics from their receptors through competitive antagonism; drug has no pharmacologic activity of it’s own.
INDICATIONS:
• Patients suspected of narcotic overdose
SIDE EFFECTS:
• Seizures
• VF
CONTRAINDICATION:
• Hypersensitivity
PRECAUTION:
• Withdrawal symptoms (nausea, vomiting, sweating, tachycardiac, hypertension, anxiety) are possible in opioiddependent patients.
• Titrate carefully and be prepared to treat withdrawal symptoms
PROTOCOL REFERENCE:
• Toxicological Emergency
REVISED: 12/18/2009
FORM-24
NITROGLYCERIN
Nitrolingual Spray®
CLASS:
Antianginal
ACTIONS:
Reduces cardiac oxygen demand by decreasing preload and, to a lesser extent, afterload. Also increases blood
flow through the collateral coronary vessels.
INDICATIONS:
• ACS
• Chest Pain
• CHF
ADMINISTRATION:
• Nitroglycerin spray may be administered either supralingual or sublingual
SIDE EFFECTS:
• Headache, dizziness
• Orthostatic hypotension, tachycardia, flushing, palpitations
CONTRAINDICATIONS:
• Hypersensitivity to nitrates
• SBP < 90 mm Hg
• Increased intracranial pressure
• Phosphodiesterase inhibitor or other erectile dysfunction agent use within the past 48 hours
PRECAUTIONS:
• Do not shake the aerosol container before administration as bubbling within the canister impairs release of the drug
• Blood pressure must be monitored before and after administration; hypotensive episodes during ACS can enlarge
the infarct and thereby worsen the patient’s condition.
PROTOCOL REFERENCE:
• ACS/Chest Pain
REVISED: 12/18/2009
FORM-25
ONDANSETRON HYDROCHLORIDE
Zofran®
CLASS:
Antiemetic
ACTION:
Selective antagonist of 5-HT3 receptors located in the CNS at the chemoreceptor trigger zone and in the peripheral
nervous system on the nerve terminals of the vagus nerve.
INDICATION:
• Nausea and/or vomiting
SIDE EFFECTS:
• Headache, malaise, fatigue, dizziness, sedation
• Cardiac arrhythmias
• Diarrhea, constipation
• Musculoskeletal pain
CONTRAINDICATIONS:
• Pediatrics less than 2 years of age
PRECAUTIONS:
• Use cautiously in patients with impaired renal function
PROTOCOL REFERENCE:
• UPC
REVISED: 12/18/2009
FORM-26
OXYGEN
CLASS:
An element, medicinal gas
ACTIONS:
• Oxygen is required to enable cells to break down glucose into a usable energy form
• Supplemental oxygen increases alveolar concentrations of oxygen and therefore arterial oxygen tension is increased
• Supplemental oxygen reduces both the magnitude and the extent of ST-segment changes on the EKG in patients
with acute MI
• Increased myocardial contractility, increased PVR
INDICATIONS:
• Suspected hypoxemia of any etiology
• Oxygen saturation of < 95% indicates need for supplemental oxygen
SIDE EFFECT:
• None relevant to EMS.
CONTRAINDICATION:
• None relevant to EMS
PRECAUTIONS:
• COPD patients (whose primary breathing stimulus is the hypoxic drive) must be monitored very closely for decreased respiratory drive when oxygen is being administered.
• The tank containing oxygen is under great pressure - make sure the tank is secure at all times. Failure to do so
may result in fire and explosion.
PROTOCOL REFERENCE:
• UPC
REVISED: 12/18/2009
FORM-27
SODIUM BICARBONATE
CLASS:
Electrolyte
ACTIONS:
Restores buffering capacity of the body and neutralizes excess acid.
INDICATIONS:
• Acidosis
SIDE EFFECTS:
• Metabolic alkalosis
CONTRAINDICATIONS:
• Metabolic or respiratory alkalosis
PRECAUTIONS:
• Shifts the oxyhemoglobin curve to the left, inhibiting the release of oxygen
• In the presence of respiratory and metabolic acidosis, bicarbonate administration without hyperventilation increases
intracellular acidosis. The excess carbon dioxide produced crosses cell membranes into the cells quickly if it is not
excreted through the lungs
• The sodium load given may cause hypernatremia and actually increase intravascular volume, especially in those
patients with renal insufficiency
• Do not mix with other drugs as it inactivates catecholamines
PROTOCOL REFERENCE:
REVISED: 12/18/2009
FORM-28
SODIUM CHLORIDE (0.9%)
Normal Saline, NS
CLASS:
Crystalloid salt solution
ACTION:
Isotonic solution that supplements intravascular volume
INDICATIONS:
• Maintain patent vascular access route
• Flush medications through vascular lines
• To dilute medications for administration
• Fluid challenge/infusion
• Fluid replacement for burn patients
• Saline lock flush
SIDE EFFECTS:
CONTRAINDICATIONS:
PRECAUTIONS:
PROTOCOL REFERENCE:
• ACS/Chest Pain
• Stroke (CVA)
• OB
• Trauma
• UPC
REVISED: 12/18/2009
FORM-29
SUCCINYLCHOLINE
Anectine®
CLASS:
Depolarizing Neuromuscular Blocker
ACTIONS:
Acts on cholinergic receptor sites at neuromuscular junctions. Following the repeated contraction of skeletal
muscles, the membrane is unable to repolarize provided that Succinylcholine remains abound to the receptor.
INDICATIONS:
• RSI
ADMINISTRATION:
• May only be given three minutes after the use of etomidate.
• After administration, wait one minute before attempting intubation.
SIDE EFFECTS:
• Muscle weakness and muscle spasms followed by skeletal muscle paralysis.
• Bradycardia and respiratory paralysis are expected adverse effects.
CONTRAINDICATIONS:
• Severe Burns
• Neuromuscular Disease
• History of Malignant Hyperthermia
• Hepatic or Renal Failure
• Suspected or Confirmed Hyperkalemia
PRECAUTIONS:
• Additional skeletal muscle blockade occurs if given concurrently with lidocaine.
• Effects are decreased when given with diazepam.
• Patients receiving both succinylcholine and narcotics are at increased risk for bradycardia and sinus arrest.
PROTOCOL REFERENCE:
• RSI
REVISED: 12/18/2009
FORM-30
VECURONIUM BROMIDE
Norcuron®
CLASS:
Non-depolarizing Neuromuscular Blocker
ACTIONS:
Prevents acetylcholine from binding to receptors on the motor end plate
INDICATIONS:
• Maintenance of neuromuscular blockade
ADMINISTRATION:
• Administer over 1 to 2 minutes
• Administer every 20 minutes to maintain neuromuscular blockade
SIDE EFFECTS:
• Skeletal muscle weakness/paralysis
CONTRAINDICATIONS:
• Hypersensitivity to drug or to bromides
PRECAUTIONS:
• Prior use of Succinylcholine enhances neuromuscular blockade
• Opioid analgesics enhance neuromuscular blockade
PROTOCOL REFERENCE:
• RSI
REVISED: 12/18/2009
FORM-31
SOURCES:
Mosby’s Nursing Drug Reference, 2009
Advanced Cardiac Life Support Provider Manual, American Heart Association, 2006.
Pediatric Advanced Life Support Provider Manual, American Heart Association & American Academy of Pediatrics, 2006.
U.S. Food and Drug Administration (FDA). (2008). Retrieved from www.fda.gov
REVISED: 12/18/2009
FORM-32
Appendix
AGE SPECIFIC DEFINITIONS
AHA CPR Guidelines:
x Newborn CPR guidelines apply from birth until 5 days.
x Infant CPR guidelines apply to patients 5 days until 1 year of age.
x Child CPR guidelines apply to patients from 1 year of age to the onset of adolescence or puberty (about 13 years of
age). Puberty may be defined as the presence of secondary sex characteristics (development of breasts or pubic hair
in females and pubic, armpit or facial hair in boys).
Age Group Parameters:
x
Patients age 13 or greater or a total body weight of greater than 40 kg (88 lbs) should be treated as an adult using
adult protocol therapies (unless specifically contraindicated by a protocol).
Legal age for medical consent or signing a refusal form:
x
The legal age for medical consent, to refuse treatment, or refuse transport is 18 years of age unless legally
considered emancipated (refer to section on consent for more detailed information).
AIRWAY MANAGEMENT
Authorized Airway Procedures
ECA
EMT-B
EMT- I
EMT- P
x
Manual airway maneuvers (chin lift, jaw thrust, etc.)
9
9
9
9
x
NPA and OPA airway insertion
9
9
9
9
x
Bag-valve-mask ventilation
9
9
9
9
x
Use of cricoid pressure during ventilation
9
9
9
9
x
Oropharyngeal suctioning (includes trach, stoma)
9
9
9
9
x
Deep tracheal suctioning via ET or trach tube
9
9
x
Nasal & orotracheal intubation (includes BAAM use)
9
9
x
Stomal intubation
9
9
x
Meconium aspiration via ET tube
9
9
x
End tidal C02 detection
9
9
x
Continuous Positive Airway Pressure (CPAP)
x
Gum elastic bougie
9
9
x
Magill forceps
9
9
x
King Airway Device (EMT may use only if NO higher certified
personnel on scene)
9
9
REVISED: 12/18/2009
9
9
APX-1
Appendix
SUMMARY OF APPROVED MEDICATIONS AND PROCEDURES BY CERTIFICATION LEVEL
Procedure/Intervention
Automated External Defibrillator use (AED)
Airway management (see APX-1 for details)
Alternate vascular access (central line)
Blood glucose assessment
Cardioversion / manual defibrillation
ECG Interpretation (includes 12-lead)
Endotracheal drug administration
External jugular vein cannulation
Medication Administration IM, SQ, IV/IO, IN
Exception: epinephrine auto-injector
Intraosseous access
Nebulizer: setup and use
Nebulizer: administration of epinephrine
Peripheral IV access with NS administration
Pharmaceutically Assisted Intubation (PAI)
Pleural decompression
Pulse oximetry
Rapid sequence intubation
(trained /approved)
Spinal restriction / immobilization
Transport Ventilators
Transcutaneous pacing
Medication
Adenosine
Albuterol
Amiodarone
Aspirin
Atropine Sulfate
Calcium Chloride
Captopril
Dextrose
Diphenhydramine
Dopamine
Enalaprilat
Epinephrine (1:1000) & (1:10,000)
Epinephrine auto-injector (If trained)
Etomidate
Fentanyl
Glucagon
Haloperidol
Ipratropium Bromide
Lorazepam
Lidocaine
Magnesium Sulfate
Midazolam
Morphine
Naloxone
Nitroglycerin
Nitrous Oxide
Ondansetron
Oral Glucose
Sodium Bicarbonate
Succinylcholine
Vecuronium
REVISED: 12/18/2009
ECA
9
EMT- Basic
Intermediate
Paramedic
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
ECA
EMT- Basic
Intermediate
Paramedic
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
APX-2
Appendix
TRACHEOSTOMY TUBES AND STOMAS
A patient with a partial laryngectomy has only part of the larynx removed, often breathes through the nose and mouth,
and has some change in speech quality. Surgery can affect the functioning of their epiglottis, so care must be taken to
prevent aspiration. A patient with a total or complete laryngectomy has their larynx completely removed and the trachea
brought to the front of the neck, creating a stoma through which the patient breathes. In a complete laryngectomy there
is no longer any connection between the upper and lower airways.
BVM ventilation of the laryngectomy patient:
x Use appropriate BSI practices.
x Ascertain if the patient has a total or partial laryngectomy or a tracheoesophageal puncture (TEP) as each requires a different approach for initial
ventilation:
o Total laryngectomies require mask-to-stoma ventilation (round pedi
mask provides the best fit).
o Patients with TEPs and partial laryngectomies often must have
their noses and mouths securely sealed to prevent air leakage
during mask-to-stoma ventilation.
o If ventilating a stoma and air escapes from the mouth/nose, close
the mouth and pinch the nostrils.
o Partial laryngectomies and patients with TEPs may ultimately
require stomal intubation to achieve adequately sealed airways for
ventilation.
x Clear any mucous plugs or secretions from the stoma.
x Leave the head and neck in a neutral position. Do not allow excessive
forward flexion to occur which may cause the chin to occlude the stoma
opening.
x Use a round infant mask to establish a seal over the stoma if the absence
of a patent artificial airway.
x If unable to ventilate through the stoma, consider sealing the stoma and
attempt to ventilate through the mouth and nose (may only be effective in
partial or TEP patients).
x Connect the BVM to oxygen as soon as possible.
BVM ventilation via tracheostomy tube:
x Use appropriate BSI practices.
x Clear any mucous plugs or secretions from the tube.
x If the patient has a double cannula tracheostomy tube, the inner cannula
must be in place (inner cannulas are uncommon in infants due to the size of
their airway).
x Remove the mask from a bag-valve device and attach it to the tracheostomy
tube
x Follow normal procedures for assisted ventilation.
x Connect the BVM to oxygen as soon as possible.
REVISED: 12/18/2009
APX-3
Appendix
OCCLUDED OR DISLODGED TRACHEOSTOMY TUBE
If breathing is still inadequate or ineffective after BVM ventilation the tracheostomy tube may be occluded or dislodged,
requiring its removal and replacement. Dislodged tubes should be immediately inspected and reinserted, as long as the
cannula and stoma are open or can be cleared. Most parents or home care providers are trained in this procedure; ask
them to help when possible.
x
x
x
x
x
x
x
x
x
x
x
x
Use appropriate BSI practices.
Try suctioning the tube first (see suctioning section for more
information). If suctioning fails to clear the occlusion, remove the
tube and replace.
Connect a syringe (6 cc) to the pilot balloon and remove all air until
the balloon is flat.
Cut the ties and remove old trach tube with one hand using an upand-out motion (follow angle of tube). Suction as needed.
Gently insert the new tube with the curved end pointed downward.
In double cannula tubes, remove the inner cannula, clean and
reinsert, or remove and replace it.
If replacing the inner cannula fails to clear the airway, remove the
outer cannula as well, and then replace the inner and outer tubes.
If the tube cannot be easily inserted, withdraw and try again (a
suction catheter may be used as a guide). Try a smaller tube if still
unsuccessful.
If the smaller tube fails, try to insert an endotracheal tube (ETT) of
appropriate size (ALS).
{
If an ETT is used the tip is aimed downward after
entering the stoma,
{
Do not insert the tube more than 2 inches into the
opening,
{
Select a tube with an inner diameter equal to or
smaller than the inner diameter of the last tube
attempted,
{
Do not cut the tube to shorten it.
Always verify for proper placement after replacing a trach tube or inserting an ETT:
{
Proper placement - equal chest rise and breath sounds on both sides of the chest.
{
Improper placement - resistance during insertion, bleeding at the insertion site, bleeding through the
tube, lack of chest rise, unusual resistance during assisted ventilation, or signs of subcutaneous air in the
tissues.
Secure the tube once it is correctly in place. Do not secure ties too tight (you should be able to easily slide a single
finger under the tie).
After changing a trach tube, it is common for an increase in secretions to occur over several hours and for the tube
change to cause slight irritation to the airway with pinkish secretions commonly seen.
Do not force the tube. The airway can be worsened by tubes being forced or inserted into the wrong space. If you cannot
insert a tube or catheter into the stoma, and the patient is adequately breathing, initiate transport to the closest ED and
contact a Biocare physician for further guidance.
If the patient is ineffectively breathing or hypoxia is present they will need to be ventilated through the stoma. In this case,
you should attempt assisted ventilation by placing either a stoma mask or a newborn facemask (round) directly over the
stoma and ventilating.
REVISED: 12/18/2009
APX-4
Appendix
CIRCULATORY SUPPORT
Adequate perfusion depends on the ability of the circulatory system to function properly due to a rate problem, a pump
problem or a volume problem. Regardless of the cause it is important that all hypoperfused patients be placed in a
position that best supports central circulation without compromising respiratory status.
They key indicator of patient status is usually the vital signs and a commonly made mistake is assuming that a patient
who is upright and talking cannot be critically ill or injured. Resuscitation is more than just performing CPR or
administering medications; it is about recognizing seriously abnormal vital signs and taking action to correct them.
Normal vital signs:
Group
Age
Pulse
Respirations
Blood Pressure
Newborn
< 28 days
80 – 200
40 - 60
60 - 80 systolic
Infant
29 days to 1 year
80 – 140
30 - 40
70 - 90 systolic
Toddler
1 – 2 years
80 – 130
20 - 30
80 - 90 systolic
Preschool
2 – 6 years
60 – 140
20 - 30
70 + (2 x age in yrs)
School Age
6 – 12 years
60 – 100
16 - 24
70 + (2 x age in yrs)
Adolescent
12 – 16 years
60 – 100
12 - 20
90 - 120
Adult
> 16 years
60 – 100
12 - 20
90 - 140
Abnormal vitals signs (may or may not present with hypoperfusion or shock):
Group
Age
Pulse
Respirations
Systolic BP
Newborn
< 28 days
< 80 or > 200
40 - 60
< 60
Infant
29 days to 1 year
< 100 or > 180
30 - 40
< 65
Toddler
1 – 2 years
< 80 or > 130
20 - 30
< 70
Preschool
2 – 6 years
< 60 or > 140
20 - 30
< 80
School Age
6 – 12 years
< 60 or > 100
16 - 24
< 80
Adolescent
12 – 16 years
< 60 or > 150
< 10 or > 29
< 90
Adult
> 16 years
< 60 or > 150
< 10 or > 29
< 90
Additional clinical information:
x
Puberty often begins between ages 8 -13 in girls and between ages 10 -15 in boys; it typically
presents first with the development of armpit / facial hair in boys and breasts in girls. These
patients are often treated as adults once the onset of puberty has begun.
x
Shock is not just defined by a low BP, but also by evidence of impaired perfusion.
x
A drop in blood pressure is considered a LATE sign of shock in an infant or child.
REVISED: 12/18/2009
APX-5
Appendix
Evidence of hypoperfusion
Evidence of hypovolemia or dehydration
Abnormal vital signs combined
with any of the following;
Hypoperfusion combined
with any of the following;
x
Anxiety, restlessness, decreased LOC,
x
SaO2 readings < 94% despite oxygenation,
x
Fast, slow, weak, or absent peripheral (radial,
brachial) or central (femoral, carotid) pulses,
x
Decreased urine output that is less than 1
mL/kg/hr in infants, less than 0.5 mL/kg/hr in
children, and less than 400 mL/d in adults,
x
Abnormal breathing patterns (deep, rapid,
shallow, slow, erratic etc.), dyspnea, or
cyanosis
x
Abnormal body temperature,
x
Pale, cool, mottled or clammy skin
(neurogenic shock skin is often warm, dry
and pink),
x
Delayed capillary refill, or
x
Pulmonary congestion / edema.
x
Cracked, furrowed, or dry mucous
membranes,
x
Diminished urine output as hypoperfusion,
infants often have dry diapers, and urine may
be dark or concentrated,
x
Inability to produce tears or tenting of the
skin,
x
Depressed or sunken anterior fontanel (if
less than 1 year of age – assess seated
upright if possible).
END-TIDAL CO2 DETECTION AND MONITORING
The amount of CO2 that is eliminated from the lungs can be measured by placement of a CO2 sensor at the patient’s
airway, The amount of C02 detected at the end of exhalation is referred to as end-tidal CO2, or EtCO2. A normal EtCO2
value is between 35 - 45 mmHg; elevations above 45 mmHg (hypercarbia) are indicative of CO2 retention and those
below 35 mmHg often indicate low perfusion or hyperventilation.
Electronic EtCO2 monitoring:
A capnometer to used measure carbon dioxide and display a waveform
called a capnogram. The shape of the capnogram and the values obtained
from it are useful guides for providing therapy. Capnographs are useful for
ensuring ET tube placement and monitoring of patient ventilatory status.
REVISED: 12/18/2009
APX-6
Appendix
Description
Sustained low EtC02
without alveolar plateau
(shark fin appearance)
Sudden decrease in EtC02 to low,
non-zero value
Elevated EtC02 with good
alveolar plateau
Exponential decrease
in EtC02
Gradually increasing
level of EtC02
Sustained low EtC02 with good
alveolar plateau
REVISED: 12/18/2009
Common Waveform
Possible Causes
x
Bronchospasm from asthma or COPD
x
Partially obstructed or kinked ET tube
x
Incomplete exhalation
x
Mucous plugging
x
Leak in the airway system
x
ET tube in hypopharynx
x
Partial airway obstruction
x
Partial disconnect from vent circuit
x
Hypoventilation
x
Hyperthermia
x
Respiratory depressant drugs
x
Shivering
x
Inadequate minute ventilation
x
Cardiopulmonary arrest occurring
x
Pulmonary embolism
x
Sudden hypotension
x
Massive blood loss
x
Hypoventilation or sedation
x
Elevated body temperature
x
Increased metabolism
x
Partial airway obstruction
x
Absorption of C02 from outside source
x
Hyperventilation
x
Hypothermia
x
Dead space ventilation
APX-7
Appendix
BASIC LIFE SUPPORT AND CPR GUIDELINES
Adult
(> 8 years/puberty)
Maneuver
Child
(1 - 8 yrs.)
Infant (5 days - 1 yr.)
Same; but avoid
overextension
of the neck
Head tilt, chin lift if no trauma. If trauma suspected use jaw thrust
maneuver
Airway
Breathing Initial
Ventilation with
compressions
2 breaths at
1 second per breath
Newborn
(birth - 5 days)
2 effective breaths at 1 second per breath
40 to 60 bpm
12 to 20 breaths/min (approximate)
30 bpm
10 to 12 breaths/min
(approximate)
Note: Manual chest compression is contraindicated in any patient
with an implanted Heart Mate or any other ventricular assist device
that requires a hand-operated pump to propel blood.
CPR ventilation:
Pt. intubated
8 to 10 breaths per min
(approximate)
Foreign body airway
obstruction
Abdominal thrusts
Pulse check site
Carotid
Compression
landmarks
Compression method:
hard and fast allowing
for complete recoil
Compression
rate
Alternated back blows
and chest thrusts
Brachial or femoral
Just below
nipple line
(lower 1/2
sternum)
Lower half of sternum,
between nipples
Heel of one hand,
other hand on top
30 bpm
of
Brachial, femoral
or umbilical cord
Just below
nipple line
(lower 1/3 of sternum)
2 or 3 fingers or
2 thumbs and hands
encircling the chest (2 rescuers)
Heel of one hand
or as for adults
Approximately 100/min.
Do not exceed 90 strokes per minute if using a hand pump for a ventricular assist device
Compression depth
1.5 to 2 inches
Compressionventilation ratio
30:2
(1 or 2 rescuers)
AED
Adult pads. Do not
use child pads
Approximately one third
to one half the depth of the chest
Approximately one
third the depth of the
chest
1 rescuer: 30:2
3:1
2 rescuers: 15:2
Use AED after 5 cycles
of CPR
Use pediatric AED
system for children
1 to 8 years,
if available
Not recommended for
Infants
<
1 year of age
x
Consider changing compressor/ventilator roles every few minutes to prevent deterioration of compression rate/depth
which can occur when tired (attempt to keep the switch to < 5 seconds).
x
Once intubated use 100 compressions per minute with no pauses for ventilations; ventilate at 8 to 10 bpm.
x
An increase in the heart rate is a sign of effective ventilation during newborn resuscitation. Other signs include;
improving color, spontaneous breathing and improving muscle tone. Always check for these signs of improvement
after 30 seconds of PPV (requires the assistance of another person).
REVISED: 12/18/2009
APX-8
Appendix
THE VENTRICULAR ASSIST DEVICE PATIENT
The VAD is a mechanical device implanted in the chest to partially or completely replace the function of a failing heart.
VADs are designed to assist either the right or left ventricle, or both. The typical VAD setup consists of a pump, a
controller and an energy supply. The most common VAD is the Heart Mate I; a "pulsatile" pump that pumps blood in a
cycle of pump/relax, pump/relax, giving the patient a palpable pulse. Compressions in the patient with a Heart Mate I are
contraindicated and are replaced by a manual hand pump as an emergency means for powering the pump pneumatically.
A newer VAD is the Heart Mate II which uses a rotary action to create a constant blood flow instead of the pumping action
seen with the HeartMate I. Because of this you will not be able to palpate a “pulse wave” in these patients.
Hand Pumping Instructions (applies to the Heart Mate I only)
1. Disconnect system controller from power source. Note: ALWAYS disconnect
from power source before pumping.
2. Remove Vent Filter from Vent Port.
3. Connect Hand Pump to Vent Port.
4. Press and hold down white purge valve on Hand Pump.
5. Collapse and hold bulb using your thumb.
6. Release white purge valve and then release bulb.
7. Wait about 10 seconds then press the white purge valve again and let the
bulb fully inflate.
8. Separate and swing around handles.
9. Begin hand pumping by bringing together handles and releasing them at a
rate of 60 - 90 pumps a minute.
a. Note: Ensure the bulb inflates completely after each squeeze and do
NOT exceed 90 pumps per minute.
Controller Malfunction (Heart Mate I only)
1. If the pump is not working, reassess all connections and power sources
between patient, controller, and power source. A caregiver should be
available to assist you with this.
2. If connections are okay, change the batteries. You must use the hand pump
while changing batteries.
3. If pump function returns after changing batteries, immediately stop hand
pumping. OR
4. If pump is non-operational after checking connections and changing
batteries, initiate hand pumping.
5. Disconnect patient from Batteries or PBU Cable.
6. Attach pump to vent port, prime pump, and begin pumping.
7. Continue hand pumping during patient transport.
Defibrillation/Cardioversion
x Note: a carotid pulse may be felt even if the patient is in arrest from VF or VT.
x Disconnect system controller from power, and then disconnect system controller from patient.
x Follow hand pumping instructions (Heart Mate I) as above while preparing for shock.
x Defibrillate or cardiovert patient. Avoid placing pads or paddles directly over device.
x Reconnect system controller to patient, and then connect system controller to power.
The Heart Mate II (Rotary VAD)
The Heart Mate II is a VAD consisting of an internal pump, controller, batteries, power base unit
(PBU) and cables. A critical difference between the Heart Mate II and the Heart Mate I is that
the Heart Mate II does not utilize a hand pump and it will not produce a pulse wave (a physical
pulse). The Heart Mate II is a continuous flow pump and therefore, you will not be able to
hear a BP or feel a pulse. It is not necessary to remove the control device prior to
defibrillation when required.
REVISED: 12/18/2009
APX-9
Appendix
Use indications for EtC02 by device type
Colorimetric
Quantitative
Verification of ET tube placement following intubation
(mandatory)
9
9
Monitoring of ET tube placement during movement / transport
9
9
Assessment of forward blood flow in PEA or ROSC during CPR
9
Evaluating severity of hypercarbia in
asthma/CHF/COPD/shock/PE
9
During and after any drug which can cause hypoventilation or
apnea
9
To monitor the ventilatory status in a non-intubated breathing
patient
9
To monitor the ventilatory status in the intubated and breathing
patient
9
9
Ventilation of the traumatic brain injury patient
9
Monitoring for signs of reduction in sedation
9
Colorimetric EtCO2 Detector:
The colorimetric CO2 detector uses a disc coated with a material that combines with CO2 to form hydrogen ions. When the
pH decreases, disc color changes from purple to tan. Detectors are normally purple in the absence of CO2 and change to
tan or yellow in the presence of elevated concentrations of CO2. The best known devices are the Easy Cap II and PediCap, but they may be found in certain BVM devices also.
The color of the detector will fall into 1 of 3 ranges depending on the C02 concentration; colors and their
associated ranges of C02 are as follows:
Color Range A (PURPLE): EtCO2 level is < 4 mmHg.
x A continued color of purple after 6 breaths in the patient with adequate blood flow typically
indicates an esophageal intubation has occurred.
x A continuous color of purple may also be seen during cardiac arrest without CPR or during
ineffective ventilations, even if correctly intubated.
Color Range B (TAN): EtCO2 level is from 4 to < 15 mmHg.
x When blood flow to the lungs is decreased or CO2 production is reduced the detector may
change to tan at the end of exhalation.
x The tan color may also initially appear within the first six breaths if CO2 is still present in the stomach, but this should
clear up once six breaths have been delivered as CO2 is washed out.
x If the color still remains purple after 6 breaths, then the endotracheal tube is either in the esophagus or is actually in
the trachea, but a very low flow state exists which is not producing CO2.
Color Range C (YELLOW): EtCO2 level is from > 15 to 38 mmHg.
x If the trachea is intubated and blood flow to the lungs is adequate, the CO2 detector will change to a yellow during
exhalation. This indicates that the lungs are being ventilated.
x During cardiac arrest, a sudden improvement in color (from purple or tan to yellow) indicates a large increase in
ETCO2. This usually signals the return of spontaneous circulation (ROSC) and a pulse.
REVISED: 12/18/2009
APX-10
Appendix
Clinical Information:
x
End Tidal CO2 detectors MUST be used to verify and monitor all tracheal tube placements throughout EMS
patient care and transport.
x
Any loss of CO2 detection or sudden color change must be documented along with all procedures used to verify or
correct the problem.
x
When using a colorimetric device, gastric distention with air prior to attempted intubation may introduce CO2 into the
detector even if the endotracheal tube is misplaced in the esophagus. Because of this you MUST ventilate with at
least 6 breaths before attaching a detector.
x
The Easy Cap II is indicated for patients > 15 kgs; the Pedi-Cap – in patients from 1 kg to 15 kg.
x
A colorimetric detector may be used for up to two hours, after that it must be replaced.
x
Tube placement should be verified frequently and always after each patient move.
x
Reflux of stomach contents, edema, fluid, the or administration of a medication into or through a colorimetric detector
will cause a persistent color change which does not vary with the respiratory cycle; contamination of this type can
greatly increase airway resistance and affect ventilation, when contamination is present you should discard the device
and attach a new detector.
x
The effectiveness of fluid resuscitation can be monitored by EtCO2 monitoring. When a patient becomes hypovolemic
the EtCO2 is lower than normal due to reduced cardiac output and perfusion.
x
The measurement of EtCO2 is a valuable tool during arrest management. In several studies, patients with a persistent
EtCO2 of less than 10 mmHg had a near zero chance of ROSC.
x
Dead space is relatively high for neonates when using a colorimetric device; prolonged use is not recommended in
those patients.
FAILED AIRWAY PROCEDURE
Indications:
Unconscious patients who are apneic or hypoventilating without a gag reflex
Oral or nasal intubation attempts have been unsuccessful after two attempts.
Contraindications:
None
•
If first intubation attempt fails, make adjustments and try again once.
Consider:
¾
¾
¾
Use a Bougie, endotracheal tube size, change cricoid pressure, apply the BURP (Back Up Right Posterior)
maneuver, change intubators, or if there are no contraindications, change patient’s head position.
Make a maximum of two attempts per patient.
Placement of King Airway.
•
Transport any patient with an unstable airway to the closest receiving facility. A King Airway with oxygen saturation
greater than 90% is not considered an unstable airway.
•
Maintaining SaO2 > 90% is the key. The two main questions to ask yourself are:
¾ “Am I able to bag?”
¾ “Am I going to be able to intubate?”
•
Because “can’t intubate” and “can’t ventilate” = 100% mortality. If you cannot intubate or ventilate, proceed to a King
airway or surgical airway.
•
As soon as possible after intubation, attach waveform capnography.
•
Confirm tube placement after initial intubation and every time patient is moved using as many of the following as
possible:
¾ Visualizing the tube passing through the vocal cords.
¾ Observation of rise and fall of the chest.
¾ Auscultation of the lungs and epigastrium.
¾ Misting on the interior of the endotracheal tube.
¾ Capnometer measurements.
¾ Capnography waveform strip printed and attached to the patient report.
REVISED: 12/18/2009
APX-11
Appendix
KING LTS-D AIRWAY
Indications:
Cardiac or respiratory arrest.
Unresponsive patient with potential for aspiration or airway obstruction without a gag reflex.
When oral or nasal intubations have been unsuccessful after 2 attempts.
Contraindications:
Patient with esophageal disease (esophageal cancer, varices, surgery, etc.).
Patients who have ingested a caustic substance.
Patient with suspected narcotic overdose prior to Narcan administration.
1. Choose the correct size airway, based on patient height:
o Size 3 (yellow) 4-5 feet tall.
o Size 4 (red) 5-6 feet tall.
o Size 5 (purple) over 6 feet tall.
2. Test the cuff inflation system by injecting the
maximum recommended volume of air
(marked on syringe included in kit) into the cuff.
3. Remove all air from cuff prior to insertion.
o Size 3: 45-60 mL
o Size 4: 60-80 mL
o Size 5: 70-90 mL
4. Lubricate the proximal distal end of the tube with a water soluble jelly such as KY Jelly.
5. Position the head. The ideal position is the “sniffing position”. (unless trauma indicated)
6. Hold the airway at the connector with the dominant hand. With non-dominant hand, hold mouth open and apply chin
lift.
7. Place the flat edge of the airways tip against the hard palate. The tube should be in the corner of the mouth with the
tube rotated laterally (outward), when the tip passes under the tongue, rotate it medially to midline. Continue until the
base of the connector is aligned with teeth or gums. (Never use force when positioning the airway).
8. Inflate the cuff as directed by pre-packaged syringe with air in cuff volume is dependant on size of King tube utilized.
9. Attach BVM to connector. While bagging patient, assess ventilations while simultaneously withdrawing the airway until
ventilation is easy and free flowing. (Large tidal volume with minimal airway pressure).
10. Secure the King tube.
Clinical Notes:
x
The King LTS-D will enter the esophagus the majority of the time, however, if tracheal intubation is suspected, then
pull back on airway and reassess.
x
An intubation attempt should take no longer than 30 seconds
x
If removal of the King airway is necessary, do so with the patient on his/her side and suction should be immediately
available
x
If resistance is met when advancing the tube, discontinue the attempt
x
Patients with a King airway successfully placed are considered to be successfully intubated.
REVISED: 12/18/2009
APX-12
North Central Texas Trauma Regional Advisory Council
Trauma Triage Protocol
INTRODUCTION
A systems approach requires a
regional triage system with identified
Trauma Centers capable of providing
trauma care to major trauma patients.
Patients must be identified and transported
to the appropriate level of care in a timely
fashion based on clinical need.
Triage is the classification of
patients according to medical need. Since
the majority of trauma deaths occur either
before reaching the hospital or within four
hours of arrival, prehospital and
emergency department personnel must
make rapid triage decisions based on preestablished system standards.
Trauma Service Area-E (TSA-E) is
diverse with urban, suburban, and rural
areas. Persons injured in each of these
areas may need to be triaged differently
but with the intention of providing optimal
care in spite of the area where the injury
occurred. TSA-E has many different
prehospital providers ranging from
volunteer units to advanced aircraft
agencies. Similarly, the hospitals in the
region are variable in their ability and
desire to care for injured patients.
that is designated by the Texas Department
of Health. A facility that is actively
pursuing designation can receive trauma
patients appropriate to the level of
designation to which the facility is
pursuing until December 1, 1999 if they
demonstrate their commitment to trauma
by informing the Department of Health or
the NCTTRAC of their intentions or by
having applied for designation or
consultation to either the Department of
Health or the American College of
Surgeons.
The North Central Texas Regional
Advisory Council has developed these
triage guidelines to provide prehospital,
hospital, and trauma facilities with
assistance in triaging injured patients to
appropriate levels of care. These guidelines
may need to be modified to accommodate
local conditions and will be continuously
monitored by the NCTTRAC Quality
Improvement Program.
Some hospitals in TSA-E are
designated as trauma facilities. Other
hospitals are actively working towards
achieving designation. Other hospitals are
not pursuing any level of designation. For
the purposes of this document, a trauma
facility is defined as a health care facility
Approved NCTTRAC: 4/14/98; Amended: 7/14/98
Approved TDH: 5/4/98
INCLUSIVE SYSTEM
Major trauma patients are those
with either a severe injury or a risk for
severe injury. A severe injury is one that
could result in morbidity or mortality and
is classically defined as an injury with an
Injury Severity Score (ISS) of 16 or
greater. On initial evaluation, these
patients typically have abnormal vital signs
or a significant anatomical injury.
However, triage is often inexact due to
patients’ variable physiological responses
to trauma. In some patients, minor injuries
can result in morbidity or mortality due to
the patient’s age and/or co-morbid factors,
and some patients may have a delayed
physiological response to trauma.
Patients involved in a high-energy
event are at risk for severe injury. Five to
fifteen percent of these patients, despite
normal vital signs and no apparent
anatomical injury on initial evaluation, will
have a severe injury discovered after full
trauma evaluation with serial observations.
A continuum of services must be
developed to provide preventive programs,
prehospital care, acute care, and
rehabilitation to all injured patients and to
match resources with individual patient
needs.
Current systems often rely on over-triage
to Trauma Centers and often an
exaggerated and unnecessary response
from trauma professionals. Such systems
may cause over-treatment of certain
patients, unnecessary expenses, burnout of
participants, and under-utilization of
certain health resources, including
personnel. In spite of these excesses, such
systems may still run the risk of not
treating all injured patients, including not
appropriately treating all major trauma
patients. Under-triage runs the obvious
risk of excluding some major trauma
patients from receiving appropriate care.
An inclusive system uses a tiered response
to provide appropriate delivery,
evaluation, and care for all patients,
including the major trauma patient, in a
cost-effective manner.
PATIENT IDENTIFICATION
One characteristic of an inclusive
trauma system is patient triage designed to
care for major trauma patients by matching
patient severity to facility in a timely
manner. A systems approach will consider
injury severity, injury severity risk, time
and distance from site of injury to
definitive care, interhospital transfers
considering guidelines for immediate
versus post-intervention transports, and
factors that activate the regional system
(see Table 1).
Table 1
Definition of Major Trauma-Adult
! Multisystem Blunt or Penetrating Trauma
With Unstable Vital Signs (BP<90, HR>120,
RTS<11, GCS<14)
! Penetrating Injury of head, neck, torso, groin
! Burns > 20% TBSA (2nd or 3rd degree) or
involving face, airway, hands, feet, or genitalia
! Amputation (with reimplantation potential)
! Paralysis or other signs of spinal cord injury
! Flail chest
! Open or suspected depressed skull fracture
! Unstable pelvis or suspected pelvic fracture
!Two or more long bone fractures
! High energy event, such as
! Ejection from vehicle
! Significant fall (> 20 feet)
! Rollover mechanism
! Bent steering wheel
! Auto-pedestrian impact
! Motorcycle or bicycle involvement
! Significant assault
Major trauma patient triage criteria
should consider categories such as:
- Patients with multisystem blunt or
penetrating trauma and unstable vital
signs.
- Patients with known or suspected
anatomical injuries and stable or
normal vital signs.
- Patients who are involved in a “highenergy” event with a risk for severe
injury despite stable or normal vital
signs.
PREHOSPITAL TRAUMA TRIAGE
Prehospital triage should consider
time and distance and identify patients
needing transport to the most appropriate
designated Trauma Center rather than the
nearest acute care facility. In addition,
prehospital triage criteria should allow for
the activation of the trauma system from
the field including an appropriate response
from the designated Trauma Center.
(NOTE: Field personnel should always
seek guidance from physicians providing
on-line medical direction if there is any
doubt regarding destination decisions or
system activation.) Figure 1 is the model
prehospital algorithm for TSA-E.
After the trauma patient is
identified, the first priority of management
is the recognition of possible serious
airway compromise. If this potential is
identified, control of the airway is
essential. If the field personnel are not
capable of controlling the airway, then the
patient should be transported to the
nearest facility capable of managing airway
or respiratory compromise.
The
prehospital providers should be familiar
with the facilities in their area that are
capable of managing airway problems
rapidly.
Once identified, these patients should
activate an appropriate systems response.
Triage occurs at both the prehospital and
hospital level.
Pediatric patients (<13 years old) require a
separate definition of major trauma due to
their different physiologic response to
injury:
Table 2
Definition of Major Trauma- Pediatric
With Unstable Vital Signs:
BP:
Neonate:
<60 mmHg
Infant (<2yr): <65 mmHg
Child (2-5 yr): <70 mmHg
Respiratory rate: <10 or >60
PTS<9
GCS<14
! Flail chest
If no airway problems are present
or the airway has been controlled, the next
determination is the presence of
hypotension that indicates the possibility of
active hemorrhage. These patients may
need blood transfusions rapidly to prevent
irreversible shock and death and should be
transported to the nearest facility that can
Page
3
initiate rapid stabilization and transfusions.
In rural areas, this “facility” may include a
higher level EMS agency or an air
evacuation site. Air evacuation services
can initiate transfusions during transport to
a Level I or II Trauma Center. For ground
transport, the patient should be
transported to the highest level facility
within 15 minutes. Prehospital providers
should not wait longer than 15 minutes
after the patient is ready for transport for
aircraft evacuation; the patient should
either be directed to a landing site closer to
the Level I/II Trauma Center or to a local
facility for stabilization.
If no hypotension is present, the
patient should be taken to the most
appropriate level Trauma Center within 15
minutes. Since Level I and Level II
Trauma Centers are capable of providing
the same level of care, they should be
considered equal for triage purposes. If no
Trauma Center is present within 15
minutes, the patient should be transported
to the nearest Trauma Center, regardless
of level of designation. Stabilization and
transport can then be initiated at that
facility prior to transport to a higher level
facility.
For pediatric patients, the priorities
are the same, but the definition of major
trauma is different. Figure 2 is the model
pediatric prehospital algorithm for TSA-E.
and rapid transfer to a more
comprehensive Trauma Center) and those
patients that could be safely managed in
the Level III/IV facility for further
evaluation and serial observations. Level
III facilities are expected to have the
capability to manage most injuries and
transfer those injuries that they do not
have the capability to manage to the
nearest Level I or II facility. Level IV
facilities are expected to be stabilization
and transfer facilities and are expected to
transfer most patients to higher level
facilities. Both Level III and Level IV
facilities should develop protocols
identifying which patients should be
transferred, and these protocols should be
widely disseminated throughout the
Emergency Department. All Emergency
Department personnel should be familiar
with these protocols. Each Level III/IV
Trauma Center should have a three-tiered
response. The Level 1 Response identifies
those patients that require a Trauma Team
Activation. In many of these cases, the
treatment requirements are not available at
the Level III/IV facility and stabilization
and transport to a Level I/II Trauma
Center is necessary.
The Level 2
Response identifies those patients that can
initially be evaluated by a designated
member of the trauma team with
subsequent evaluation by a trauma
surgeon. The Level III Response identifies
those patients that can initially be
evaluated by the Emergency Department
Team with subsequent evaluation by a
trauma surgeon or appropriate
subspecialist, if necessary. Figure 3 is the
model Level III/IV algorithm for TSA-E.
LEVEL III/IV TRAUMA CENTER
Level III/IV Trauma Center triage
criteria should identify those patients
needing immediate post-intervention
transport (i.e., requiring initial stabilization
Page
4
LEVEL I/II TRAUMA CENTER
Level I/II Trauma Center triage
criteria should provide for the
comprehensive evaluation and treatment of
major trauma patients. The Level I
Response identifies those patients that
require a Trauma Team Activation. The
Level 2 Response identifies those patients
that can initially be evaluated by a
designated member of the trauma team
with subsequent evaluation by a trauma
surgeon. The Level 3 Response identifies
those patients that can initially be
evaluated by the Emergency Department
Team with subsequent evaluation by a
trauma surgeon or appropriate
subspecialist, if necessary. (NOTE: The
Trauma Center triage criteria should also
consider changes that might occur during
evaluation and observation.) Figure 4 is
the model Level I/II algorithm for TSA-E.
Page
5
North Central Texas Trauma Advisory Council
Trauma Triage Algorithm
Prehospital - Adult
Major Trauma
No
→
Transport to
appropriate facility
Yes
↓
Serious Airway
Compromise
→
Transport to closest
facility capable of
managing airway
→
Continue to transport to Highest
Level Trauma Center ¹. If
transport is greater than 15
minutes - Transport to nearest
facility to provide stabilization
& transfer
Yes
No
↓
BP less than 90mmHg
Or
Pulse>120/min
Or
Other signs of shock
refractory to fluids
Yes
No
↓
Transport to
appropriate Level 1 or
Level 2 Trauma
Center
¹Level 1 and Level 2 facilities should be treated as having equal capabilities.
Figure 1
Prehospital - Pediatric
Major Trauma
No
→
Transport to
appropriate facility
Yes
↓
Serious airway or
respiratory compromise
that cannot be managed?
→
Yes
No
↓
Hypotension present?
Neonate: <60
Infant (<2yr): <65
Child (2-5yr): <70
Child (6-12yr): <80
→
Yes
Transport to nearest
facility capable of
managing
airway/respiratory
compromise
Transport to nearest facility¹
that can rapidly initiate blood
and provide initial
stabilization² and transfer out
to higher level of care.
No
↓
Transport to Pediatric
Trauma Center, if
within 15 minutes²
¹Nearest facility might include higher level of EMS agency or air evacuation landing site.
²If multiple levels of designation present within 15 minutes of each other, go to highest level facility. Level
I and II Trauma Centers should be considered equal.
Figure 2
Level III/IV Trauma Center
Level 1 Response
CMultisystem Blunt Trauma with Unstable Vital
Signs (BP<90, RTS<11, GSC<14)
CPenetrating Injury of head, neck, chest, abdomen
CBurns >20% TBSA (2nd or 3rd degree) or
CAmputations (with reimplantation potential)
CParalysis or other signs of spinal cord injury
CFlail chest
COpen or suspected depressed skull fracture
CUnstable pelvis or open pelvic fracture
CInitiate Trauma Team Activation
CConsider early transport to Level I/II
Trauma Center
CCoordinate transport with Level I/II
Trauma Center
Level 2 Response
CTwo or more longbone fractures
CSuspected pelvis fracture
CSignificant spinal column injury
CInitiate Trauma Treatment Protocol
CInitiate Transfer Protocol to Level I/II
Center, if appropriate
Level 3 Response
High Energy Event, such as
CFall >20 ft
CEjection from vehicle
CDeath of occupant in same vehicle
CRollover mechanism
CBent steering wheel
CAuto-pedestrian impact
CMotorcycle or bicycle involvement
CSignificant assault
CPerform complete trauma evaluation
and appropriate serial examinations
9
CDeterioration in patient condition with
decrease in GCS, vital signs, or other
significant findings then initiate either
Trauma Team Activation or Trauma
Treatment Protocol
Figure 3
Level I/II Trauma Center
Level 1 Response
CMultisystem Blunt Trauma with Unstable Vital
Signs (BP<90, RTS<11, GSC<14)
CPenetrating Injury of head, neck, chest, abdomen
CBurns >20% TBSA (2nd or 3rd degree) or
CAmputations (with reimplantation potential)
CParalysis or other signs of spinal cord injury
CFlail chest
COpen or suspected depressed skull fracture
CUnstable pelvis or open pelvic fracture
CInitiate Trauma Team Activation
Level 2 Response
CTwo or more longbone fractures
CSuspected pelvis fracture
CSignificant spinal column injury
CInitiate Trauma Treatment Protocol
Level 3 Response
High Energy Event, such as
CFall >20 ft
CEjection from vehicle
CDeath of occupant in same vehicle
CRollover mechanism
CBent steering wheel
CAuto-pedestrian impact
CMotorcycle or bicycle involvement
CSignificant assault
CPerform complete trauma evaluation
and appropriate serial examinations
9
CDeterioration in patient condition with
decrease in GCS, vital signs, or other
significant findings then initiate either
Trauma Team Activation or Trauma
Treatment Protocol
Figure 4
Hospital Bypass Protocol
1. Purpose
This protocol is designed to provide guidelines to pre-hospital providers for the bypass of
closer facilities when the patient=s condition warrants transport to a facility capable of providing higher
level trauma care. Transport decisions should also account for distance and time. If there should be
any questions, Medical Control should be consulted. Trauma patients who are medically unstable,
unconscious, or at high risk of multiple and/or severe injuries will be quickly identified and transported
to an appropriate trauma system hospital.
The major trauma patient as defined in the NCTTRAC Trauma Triage Protocol is given below:
Definition of Major Trauma-Adult
With Unstable Vital Signs (BP<90, HR>120,
RTS<11, GCS<14)
! Flail chest
! Bent steering wheel
! Prolonged extrication
Definition of Major Trauma- Pediatric
With Unstable Vital Signs:
BP:
Neonate:
<60 mmHg
Infant (<2yr) : <65 mmHg
Reviewed by NCTTRAC: 8/21/07
Respiratory rate: <10 or >60
PTS<9
GCS<14
! Flail chest
2. Guidelines
I.
Closest receiving hospital as primary destination:
A. All blunt trauma victims receiving CPR should be taken to nearest facility capable of
providing Advanced Life Support.
B. All penetrating trauma victims receiving CPR should be taken to the nearest trauma
facility capable of providing the necessary interventions.
C. Major trauma patients without hypotension or airway problems should be transported to
the closest receiving hospital if transport to a designated trauma facility will require
transport times greater than 15 minutes. If air evacuation is necessary, the patient should
be transported to the closest trauma facility or landing zone if a helicopter cannot be
available in 15 minutes or less.
II. Level IV (Basic) Trauma Facility as primary destination:
A Level IV Trauma Facility is appropriate for immediate stabilization of a major trauma patient
if the expected transport time to a Level I/II facility is greater than 15 minutes. Air
transport to the nearest Level I/II facility should be considered (see local Air Transport
Protocol).
II. Level III (General) Trauma Facility as primary destination:
A Level III Trauma Facility is appropriate for immediate stabilization of a major trauma patient
if the expected transport time to a Level I/II facility is greater than 15 minutes. Air
transport to the nearest Level I/II facility should be considered (see local Air Transport
Protocol).
A Level IV Trauma Facility is appropriate when the only evidence of injury is a suspicion
based on the mechanism of injury. These mechanisms of injury are: fall>20 ft, ejection
from vehicle, death of occupant in same vehicle, rollover mechanism, bent steering wheel,
auto-pedestrian impact, motorcycle or bicycle involvement, or significant assault.
A Level III Trauma Facility has the capability to evaluate and manage most trauma patients.
Major trauma patients with evidence of severe injury (multisystem blunt or penetrating
trauma with unstable vital signs [BP<90 mm Hg, HR>120 bpm, or GCS<14], penetrating
injury of head, neck, torso, or groin, burns>20% TBSA or involving face, airway, hands,
feet, or genitalia, amputation with reimplantation potential, paralysis or other signs of
spinal cord injury, flail chest, open or suspected depressed skull fracture, or unstable or
suspected pelvis fracture) should be taken to a Level I/II facility if it is within 15 minutes
transport time. Certain Level III facilities can manage some of these patients. If there is a
question about the appropriate destination, Medical Control should be contacted.
III.
Level I or II Trauma Center as primary destination:
All major trauma patients injured within 15 minutes transport time with one of the following:
A. Multisystem blunt trauma with unstable vital signs (BP<90 mm Hg, RTS<11,
GCS<14)
B. All patients with a penetrating injury of head, neck, chest, or abdomen
C. All patients with limb amputations that have the possibility of reimplantation
D. All patients with paralysis or other signs of spinal cord injury
E. All patients with open or suspected depressed skull fracture
E. All patients with an unstable or open pelvic fracture
III.
Regional Burn Center as primary destination:
Patients with second and third degree burns greater than 20% total body surface area or
burns involving the face, airway, hands, feet, or genitalia
III.
Pediatric Trauma Center as primary destination:
All major traumas in pediatric patients injured within 15 minutes.
8111 form
Date: _______________
Time:__________________
Department: _____________________________________
Reason for 8111:__________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________
Signature:________________________________________
Printed Name:____________________________________
Please fax to Biocare at 214-947-8416 when form is complete.
Figure: 25 TAC §157.25 (h)(2)
STOP
DO NOT
RESUSCITATE
Page 1 of 2
TEXAS DEPARTMENT OF STATE HEALTH SERVICES
STANDARD OUT-OF-HOSPITAL DO-NOT-RESUSCITATE ORDER
This document becomes effective immediately on the date of execution. It remains in effect until the patient is pronounced dead by
authorized medical or legal authority or the document is revoked. Comfort measures will be given as needed.
All persons who sign the form must sign again under number 3.
1.
Date of Birth:
Male/Female (Circle One)
Patient’s full legal name — printed or typed
2.
COMPLETE ONE OF THE FOUR BOXES: A, B, C, or D. If using Box A, B, or C, Witnesses and Physician’s Statement must be completed.
A.
Patient’s Statement: I, the undersigned, am an adult capable of making an informed decision regarding the withholding or withdrawing of
CPR, including the treatments listed below, and I direct that none of the following resuscitation measures be initiated or continued:
Cardiopulmonary Resuscitation (CPR), Transcutaneous Cardiac Pacing, Defibrillation, Advanced Airway Management,
Artificial Ventilation.
Signature
B.
Date
Printed or Typed Name
Only use this box if the order is being completed by a person acting on behalf of an adult patient who is incompetent or
otherwise unable to make his or her wishes known.
I am the patient’s: c legal guardian; c agent under Medical Power of Attorney; c or Qualified Relative (see back); AND:
c I attest to issuance of an Out-of-Hospital DNR by the patient by nonwritten means of communication; O R
c I am acting under the guidance of a prior Directive to Physicians; O R
c I am acting upon the known values and desires of the patient; O R
c I am acting in the patient’s best interest based upon the guidance given by the patient’s physician.
I direct that none of the following resuscitation measures be initiated or continued on behalf of the patient: Cardiopulmonary Resuscitation (CPR), Transcutaneous Cardiac Pacing, Defibrillation, Advanced Airway Management, Artificial
Ventilation.
Signature
C.
Date
Only use this box if the order is being completed by a person acting on behalf of a minor patient who has been diagnosed
with a terminal or irreversible condition.
I am the minor patient’s: c Parent; c legal guardian; or c managing conservator.
I direct that none of the following resuscitation measures be initiated or continued on behalf of the patient: Cardiopulmonary Resuscitation (CPR), Transcutaneous Cardiac Pacing, Defibrillation, Advanced Airway Management, Artificial Ventilation.
Signature
Date
WITNESSES: (see qualifications on reverse) We have witnessed all of the above signatures.
Witness 1 Signature
Date
Witness Printed or Typed Name
Witness 2 Signature
Date
Witness Printed or Typed Name
PHYSICIAN’S STATEMENT: I, the undersigned, am the attending physician of the patient named above. I have noted the existence of this order in
the patient’s medical records, and I direct out-of-hospital health care professionals to comply with this order as presented.
Date
D.
Physician’s signature
Printed name
License number
Only use this box if the order is being completed by two physicians acting on behalf of an adult who is incompetent or
otherwise unable to make his or her wishes known, and who is without a legal guardian, agent, or qualified relative .
c I attest to issuance of an Out-of Hospital DNR by the patient by nonwritten communication; O R:
c The patient’s specific wishes are unknown, but resuscitation measures are, in reasonable medical judgement, considered ineffective in
these circumstances or are otherwise not in the best interest of the patient.
I direct that none of the following resuscitation measures be initiated or continued on behalf of the patient: Cardiopulmonary Resuscitation (CPR), Transcutaneous Cardiac Pacing, Defibrillation, Advanced Airway Management, Artificial Ventilation.
Signature
Treating Physician
Signature Second Physician who is not involved in treating the patient
3.
Date
Date
ALL PERSONS WHO SIGNED MUST SIGN HERE (Pursuant to H&SC 166.083(b)(13). This document has been properly completed.
Signature of Patient, Agent or Relative (A, B, or C)
Signature of Second Physician (D)
Signature of Witness
Signature of Witness
Signature of Attending Physician
Date
SHOULD TRANSPORT OCCUR, THIS DOCUMENT OR A COPY MUST ACCOMPANY THE PATIENT.
Figure: 25 TAC §157.25 (h)(2)
OUT-OF-HOSPITAL DNR INSTRUCTIONS
Page 2 of 2
PURPOSE:
This form was designed to comply with the requirements as set forth in Chapter 166 of the Health and Safety Code (H&SC) relating to the issuance of
Out-of-Hospital Do-Not-Resuscitate (DNR) orders for the purpose of instructing Emergency Medical Personnel and other health care professionals to
forgo resuscitation attempts and to permit the patient to have a natural death with peace and dignity. This order does NOT affect the provision of other
emergency care including comfort care.
APPLICABILITY:
This form applies to all health care professionals operating in any out-of-hospital setting to include hospital outpatient or emergency departments and
physician’s offices.
IMPLEMENTATION:
A competent adult may execute or issue an Out-of-Hospital DNR Order. The patient’s attending physician will document the existence of the
directive in the patient’s permanent medical record.
If an adult patient is capable of providing informed consent for the order, he/she will sign and date the out-of-hospital DNR order on the front of this
sheet in Box A. In the event that an adult patient is unable to provide informed consent, his/her Legal Guardian, agent under Medical Power of
Attorney, or Qualified Relative may execute the order by signing and dating the form in Box B. If an adult patient is unable to provide informed
consent and none of the persons listed in Box B are available, the treating physician may execute the order using Box D with the consent of a second
physician who is not treating the patient and/or is a member of the health care facility ethics committee or other medical committee.
The following persons may execute an out-of-hospital DNR order on behalf of a minor: the minor’s parents, the minor’s legal guardian or the minor’s
managing conservator. A person executing a DNR order on behalf of a minor may execute the order by signing and dating the form in Box C. An outof-hospital DNR order may not be executed unless the minor has been diagnosed by a physician as suffering from a terminal or
irreversible condition.
The form must be signed and dated by two witnesses except when executed by two physicians only (Box D).
The original standard Texas Out-of-Hospital DNR form must be completed and properly executed. Duplicates may be made by the patient, health care
provider organization or attending physician as necessary. Copies of this completed document may be used for any purpose that the original
may be used and shall be honored by responding health care professionals.
The presence of a Texas DNR identification device on a person is sufficient evidence that the individual has a valid Out-of-Hospital DNR Order.
Therefore, either the original standard form, a copy of the completed standard form, or the device is sufficient evidence of the existence of the order.
For information on ordering identification devices or additional forms, contact the Texas Department of State Health Services at (512) 834-6700.
REVOCATION:
The Out-of-Hospital Do-Not-Resuscitate Order may be revoked at ANY time by the patient OR the patient’s Legal Guardian/Agent/Managing Conservator/Qualified Relative, Parent (if a minor), or physician who executed the order. The revocation may involve the communication of wishes to
responding health care professionals, destruction of the form, or removal of all or any Do-Not-Resuscitate identification devices the patient may possess.
AUTOMATIC REVOCATION: This Out-of-Hospital DNR order is automatically revoked if the patient is known to be pregnant or in the case of
unnatural or suspicious circumstances.
DEFINITIONS:
Attending Physician: The physician who is selected by or assigned to a patient who has primary responsibility for a person’s treatment and care and
is licensed by the Texas State Board of Medical Examiners or who is properly credentialed and holds a commission in the uniformed services of the United
States and who is serving on active duty in this state. (H&SC 166.002 (3) & (12))
Qualified Relatives: Those persons authorized to execute or issue an out-of-hospital DNR order on behalf of a person who is comatose, incompetent,
or otherwise mentally or physically incapable of communication under Section 166.088 H&SC Section 166.088 refers to 166.039; “One person, if
available, from one of the following categories, in the following priority...: (1) The patient’s spouse; (2) the patient’s reasonably available adult children;
(3) the patient’s parents; or (4) the patient’s nearest living relative.”
Health Care Professional: Means physicians, nurses, physician assistants and emergency medical services personnel, and, unless the context requires
otherwise, includes hospital emergency department personnel. (H&SC 166.081 (5))
Witnesses: Two competent adult witnesses must sign the form acknowledging the signature of the patient or the person(s) acting on the patient’s behalf
(except when signed by two physicians in Section C). Witness One must meet the qualifications listed below. Witness Two may be any competent adult.
Witness One (the “qualified” witness) may not be: (1) person designated to make a treatment decision for the patient; (2) related to the patient by blood
or marriage; (3) entitled to any part of the estate; (4) be a person who has a claim against the estate of the patient; (5) the attending physician or an
employee of the attending physician; (6) an employee of a health care facility in which the patient is being cared for, if he or she is involved in providing
direct patient care to the patient; or (7) an officer, director, partner, or business office employee of a health care facility in which the patient is being
cared for or any parent organization of the health care facility.
Please report any problems with this form to the Texas Department of State Health Services at (512) 834-6700.
Revised July 19, 2005
Texas Department of State Health Services
Page 2 of 2
Publications No. EF01-11421

2010 EMS Biocare Emergency Medical Services Clinical Protocols

Transcription

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