Trauma Team EMS PROTOCOLS

Prehospital Medical Protocols & Standing Orders

Protocols / Standing Orders
Quick Drug Reference
Definitions
Application of These Protocols
Communication Problems
General Guidelines for Protocol Usage
Special Considerations
Resuscitation Considerations
Scene Responses/On-Scene Physicians
Critical Care Transport Medication List
Routine Care
Appendix
1. Use of Paralytic Agents
2. Procedure: Rapid Sequence Induction (RSI)
3. Needle Cricothyroidotomy
4. Surgical Cricothyroidotomy
5. Needle Decompression
6. Intraosseous Line Placement

PROTOCOLS / STANDING ORDERS

Abdominal Trauma	Environmental Emergencies (Hyperthermia)
Alcohol Emergencies	Environmental Emergencies (Hypothermia)
Altered Mental Status/Coma	Eye Injuries
Amputations	Fractures (General)
Anaphylaxis/Allergic Reactions	Fractures (Femur)
Aortic Aneurysm/Dissection	Fractures (Pelvis)
Asthma	Head Injury/Spinal Trauma
Burns	Hypertensive Crisis
Cardiogenic Shock	Intra-Aortic Balloon Pump
Chest Pain	Motion Sickness
Chest Trauma	Multiple Trauma
Childbirth	Nausea and Vomiting
Congestive Heart Failure/Pulmonary Edema	Near-Drowning
CVA/Stroke	Pediatric Emergencies
Dehydration	Cardiac Arrest (Medical)
Diabetic Emergencies/Hypoglycemia	Cardiac Arrest (Trauma)
Diabetic Emergencies/Hyperglycemia (Ketoacidosis)	Croup (Laryngotracheobronchitis)
Diving Emergencies (Decompression Sickness)	Epiglottitis
Dyspnea	Sudden Infant Death Syndrome (SIDS)
Dysrhythmias (Guidelines)	Poisoning/Overdose
Asystole	Preeclampsia/Pregnancy-Induced Hypertension
Bradycardia-Symptomatic	Pre-Term Labor
Narrow Complex Tachycardia-Symptomatic	Psychiatric Emergencies
Premature Ventricular Contractions	Pulmonary Embolism
Pulseless Electrical Activity (PEA)	Seizures
Ventricular Fibrillation	Sexual Assault
Ventricular Tachycardia-With Pulse	Snakebite
Ventricular Tachycardia-Without Pulse	Syncope
Eclampsia	Weak and Dizzy
Environmental Emergencies (Frostbite)

Adenosine	Dimenhydrinate	Isoetharine	Nitroglycerin paste
Albuterol	Diphenhydramine	Ketorolac	Norepinephrine
Aminophylline	Dobutamine	Labetalol	Oxygen
Amrinone	Dopamine	Lidocaine	Phenytoin
Aspirin	Epinephrine 1:10,000	Magnesium sulfate	Procainamide
Atropine sulfate	Epinephrine 1:1,000	Mannitol	Prochlorperazine
Bretylium tosylate	Flumazenil	Methylprednisolone	Promethazine
Calcium chloride	Furosemide	Midazolam	Racemic Epinephrine
Activated Charcoal	Glucagon	Morphine	Succinylcholine
Dextrose, 50%	Haloperidol	Sodium bicarbonate	Terbutaline
Dexamethasone	Heparin	Nalbuphine	Thiamine
Diazepam	Hydroxyzine	Naloxone	Torsemide
Digoxin	Insulin-regular	Nifedipine	Vecuronium
Diltiazem	Ipatropium	Nitroglycerin spray	Verapamil

DEFINITIONS

The following is a definition of frequently used terms:

• EMT-B - Person currently registered as an EMT-Basic by the Department of Health.
• EMT-I - Person currently registered as an EMT-Intermediate by the Department of Health.
• EMT-P - Person currently registered as an EMT-Paramedic by the Department of Health.
• Critical Care Transport Technician or Advanced Paramedic - Person currently registered as an EMT-Paramedic by the Department of Health who has completed an approved Critical Care Transport course and who has been approved by the medical director to function at this advanced level of care.
• locally registered - EMT-I or EMT-P who is currently registered as an ALS provider in the local city and county Control System.
• standing orders - Advanced life support interventions which may be undertaken before contacting on line medical control.
• protocols - Guidelines for prehospital patient care. Only the portion of the guidelines which are designated "standing orders" may be undertaken before contacting on-line medical control.
• on-line medical control - Medical direction of prehospital ALS activities by direct radio or telephonic communications with an on-line medical control physician.

APPLICATION OF THESE PROTOCOLS

These "Critical Care Transport Standing Orders and Protocols" are only to be used by personnel assigned to units which have been designated as a "Critical Care Transport Unit" by the system medical director and management. Critical Care Transport Units may include both ground and aerial (rotary and fixed-wing) units. These protocols are NOT to be used for routine advanced life support care. Routine advanced life support care is directed by the "PARAMEDIC MEDICAL PROTOCOLS AND STANDING ORDERS."

Purpose

The primary purpose of these protocols is to serve as guidelines for out-of-hospital (prehospital and interhospital) care. Quality out-of-hospital care is the direct result of comprehensive education, accurate patient assessment, good judgement, and continuous quality improvement. All EMS personnel are expected to know the protocols and understand the reason for their use. EMS personnel should not perform any step or steps in a standing order or protocol if they have not been trained to perform the procedure or treatment in question.

Protocols and Standing Orders--Who May Use

These protocols may only be used by EMS personnel who are registered with the Trauma Team, Int'l. Control System and designated as a "Critical Care Transport Technician" or " Advanced Paramedic" by the system medical director. These protocols are ONLY for use by agencies who are contracted with the Trauma Team, Int'l. Medical Control System. EMS personnel who are authorized to operate under the Trauma Team, Int'l. Medical Control System may not utilize these standing orders outside of their work with the contracted agency or company unless such work is with another agency or company contracted with the system. All EMS personnel must adhere to the standards defined in these protocols, or face revocation of medical control if these standards are violated.

COMMUNICATION PROBLEMS

In the event an ambulance cannot contact medical control (i.e. mass casualty or radio/telephone problem), all protocols become standing orders. Likewise, in the event that a medical control physician cannot respond to the radio/telephone within two minutes of the call, all protocols are considered standing orders. An emergency department nurse at the medical control hospital may relay orders from the emergency physician in cases where it is impractical for he or she to come to the radio/telephone. It is not necessary to speak with a medical control physician concerning treatment modalities that are considered to be standing orders except if a question arises concerning the planned treatment.

In the event medical control cannot be contacted, and treatment protocols were carried out as standing orders, the record should be pulled for review by the medical director. Following review, the record will be signed by the medical record indicating retroactive approval.

GENERAL GUIDELINES FOR PROTOCOL USAGE

1. The patient history should not be obtained at the expense of the patient. Life-threatening problems detected during the primary assessment must be treated first.
2. Cardiac arrest due to trauma is not treated by medical cardiac arrest protocols. Trauma patients should be transported promptly with CPR, control of external hemorrhage, cervical spine immobilization, and other indicated procedures attempted en route.
3. In patients with non-life-threatening emergencies who require IVs, only two attempts at IV insertion should be attempted in the field. Further attempts must be approved by medical control.
4. Patient transport, or other needed treatments, must not be delayed for multiple attempts at endotracheal intubation.
5. Verbally repeat all orders received prior to their initiation.
6. Any patient with a cardiac history, irregular pulse, unstable blood pressure, dyspnea, or chest pain should be placed on a cardiac monitor.
7. If the patient's condition does not seem to fit a protocol or protocols, always contact medical control.

NEVER HESITATE TO CONTACT MEDCIAL CONTROL FOR ANY PROBLEM, QUESTION, OR FOR ADDITIONAL INFORMATION.

SPECIAL CONSIDERATIONS

IV Therapy

1. All trauma patients should receive at least one, and preferably two, IV's of lactated Ringer's via large bore (14 or 16 gauge) catheters. Trauma patients with a systolic blood pressure <90 mmHg should be receive wide open fluids until the systolic blood pressure is >90 mmHg. Trauma patients with a systolic blood pressure >90 mmHg should receive fluids at a "to keep open (TKO)" rate or as directed in the applicable protocol.
2. Intraosseous infusion may be performed on pediatric patients up to six years of age. This procedure should be limited to cardiac arrest and unresponsive patients after 2 unsuccessful peripheral IV attempts.
3. All pediatric peripheral IVs should be started with a minidrip administration set.
4. All IV attempts are to be peripheral. The external jugular vein is considered a peripheral vein. Placement of an intraosseous needle is permitted in children less than 6 years of age who have a life-threatening emergency where immediate fluid or medication administration is necessary. Only paramedics who have obtained the required education in intraosseous needle placement and who have been approved by the system medical director may place intraosseous needles. Persons who are designated "Critical Care Transport Technicians" may place intraosseous needles. This procedure should only be performed with permission of medical control (except in the case of pediatric cardiac arrest or pediatric multiple trauma.)
5. Access of indwelling central lines (i.e Hickman Catheters) is permitted only in patients where peripheral IV attempts have been unsuccessful and the needs of intended therapy outweigh the risks. Note, many of these catheters require special access needles. Do not attempt access if special needles are required unless the patient has access needles available.
6. Each IV bag should be labeled with the following data:
   • Time and date of IV start
   • IV cannula size
   • Initials of paramedic who started the IV.

Endotracheal Intubation

1. Proper endotracheal tube placement must be documented by at least three different methods. These include:
   • presence of bilateral breath sounds
   • absence of breath sounds over the epigastrium
   • presence of condensation on the inside of the endotracheal tube
   • end-tidal carbon dioxide monitoring
   • use of an endotracheal esophageal detector
   • visualizing the tube passing through the cords

   All three verification methods must be documented in the medical record!!

2. Following endotracheal intubation, tube placement should be re-verified every 5-10 minutes by noting bilateral breath sounds and continuing end-tidal carbon dioxide readings.

Endotracheal Drug Administration

1. Only the following four drugs can be administered via an endotracheal tube:

   L - Lidocaine
   E - Epinephrine
   A - Atropine Sulfate
   N - Naloxone
   Note: Diazepam (Valium) should NOT be administered via an endotracheal tube.

2. When administering drugs via the endotracheal tube, administer 2.0 - 2.5 times the IV dose. Also, dilute the drug in enough lactated Ringer's or normal saline to result in a total volume of at least 10 mL. This will facilitate endotracheal instillation and aid in increased drug delivery to the respiratory tissues.

RESUSCITATION CONSIDERATIONS

1. Do Not Resuscitate (DNR) orders should be honored when valid. If a patient's family presents you with a DNR order written by the patient's physician, the following procedures should be followed:
   • Contact medical control
   • Provide a brief synopsis of the situation. Be sure to include the diagnosis which resulted in the DNR order (i.e. cancer).
   • Provide a brief report the patient's current status (vital signs, ECG tracing)
   • Confirm receipt of written DNR. Be sure to note issuing physician's name.
   • The medical control physician will determine whether to accept or deny the DNR order.
   • If the patient is in cardiac arrest upon EMS arrival, initiate BLS while contacting medical control.
2. Resuscitation should not be attempted in the field in cases of:
   • Rigor mortis
   • Decapitation
   • Decomposition
   • Dependent lividity.
   • Obvious massive head or trunk trauma which is incompatible with life (provided the patient does not have vital signs.)
3. Consider the potential for organ donation. Patient's who have sustained mortal injuries may still warrant emergent care until a determination can be made whether the patient may be a potential organ or tissue donor.
4. When possible, place the quick look paddles or the ECG leads to confirm asystole or an agonal rhythm and attach a copy of the strip to the run report.

Orders From Transferring/Receiving Physicians

During interhospital transport, medical crews will be asked to continue treatment initiated at the transferring hospital. These orders may be written or verbal. Verbal orders must be written by the medical crew and attached to the record. Ideally, the transferring physician should sign these orders. If, at any time the Critical Care Transport Crew questions orders from a referring or receiving physician, on-line medical control MUST be contacted. Likewise, anytime a transferring or receiving physician asks the Critical Care Transport crew to carry out medical treatment for which they have not been trained, or which appears to be in conflict with established treatment protocols, on-line medical control MUST be contacted before initiating care.

SCENE RESPONSES / ON-SCENE PHYSICIANS

EMS personnel functioning under the Trauma Team, Int'l. Medical Control System may not accept orders from an on-scene physician. The exception is when a patient is being retrieved from the physician's office. Then, any care which differs significantly from protocol must be approved by the on-line medical control physician prior to initiation.

If a controversy arises with an on-scene physician, place the on-scene physician in contact with the on-line medical control physician via cellular telephone or radio.

PASG / MAST Trousers

PASG / MAST trousers are no longer required by the system medical director. However, individual departments can elect to carry and utilize the PASG / MAST as directed in the standing orders/protocols.

CRITICAL CARE TRANSPORT MEDICATION LIST

Generic Name	Trade Name	Concentration	Number
Activated Charcoal	Actidose	(50 g)	2
Adenosine	Adenocard	(6 mg vial)	4
Albuterol	Ventolin	(0.5 mL in premix)	3
Aminophylline	Somophylline	(250 mg vial)	2
Aspirin	Bufferin	(325 mg tabs)	1
Atropine Sulfate	-	(1.0 mg syringe)	6
Bretylium tosylate	Bretylol	(500 milligram vial)	2
Calcium Chloride	-	(1 g syringe)	2
Dexamethasone	Decadron	(4 mg vial)	2
Dextrose, 50%	-	(25 grams syringe)	4
Diazepam	Valium	(10 mg syringe)	2
Digoxin	Lanoxin	(0.5 mg ampule)	1
Diltiazem	Cardizem	(25 mg vial)	1
Dimenhydrinate	Dramamine	(50 mg vial)	2
Diphenhydramine	Benadryl	(50 mg vial)	2
Dobutamine	Dobutrex	(250 mg vial)	2
Dopamine	Intropin	(800 mg pre-mix)	2
Epinephrine 1:1,000	Adrenalin	(1.0 mg ampule)	4
Epinephrine 1:10,000	Adrenalin	(1.0 mg syringe)	8
Flumazenil	Romazicon	(0.5 mg vial)	2
Furosemide	Lasix	(40 mg vial)	4
Glucagon	-	(1 mg vial)	1
Haloperidol	Haldol	(5 mg vial)	2
Heparin	-	(5,000 IU)	2
Hydroxyzine	Vistaril	(50 mg vial)	2
Insulin-regular	Humulin R	(1 vial)	1
Ipatropium	Atrovent	(2.5 ml prefill)	4
Isoetharine	Bronkosol	(1% nebulizer solution)	4
Ketorolac	Toradol	(60 mg vial)	2
Labetalol	Normodyne	(200 mg vial)	2
Lidocaine	Xylocaine	(100 mg syringe)	4
Lidocaine	Xylocaine	(2 grams pre-mix)	2
Magnesium Sulfate	-	(1 gram vial)	2
Mannitol	Osmotrol	(25% solution vial)	2
Methylprednisolone	Solu-Medrol	(125 mg vial)	2
Methylprednisolone	Solu-Medrol	(1 gram vial)	2
Midazolam	Versed	(5 mg vial)	2
Morphine	-	(10 mg syringe)	4
Nalbuphine	Nubain	(10 mg vial)	2
Naloxone	Narcan	(2 mg vial)	2
Nifedipine	Procardia	(10 mg capsules)	4
Nitroglycerin drip	Tridil	(50 mg vial)	2
Nitroglycerin spray	Nitrolingual	(0.4 mg)	1
Nitroglycerin paste	Nitro-Dur	(1 tube)	1
Norepinephrine	Levophed	(4 mg vial)	2
Phenytoin	Dilantin	(1 gram vial)	1
Procainamide	Pronestyl	(1,000 mg)	1
Prochlorperazine	Compazine	(10 mg vial)	2
Promethazine	Phenergan	(25 mg vial)	2
Racemic Epinephrine	VapoNefrin	(2.25% solution)	2
Sodium Bicarbonate	-	(50 mEq)	2
Succinylcholine	Anectine	(200 mg)	2
Tetracaine	Tetracaine	(1 mL unit dose)	2
Thiamine	Vitamin B1	(100 mg)	1
Torsemide	Demadex	(20 mg)	2
Vecuronium	Norcuron	(10 mg)	3
Verapamil	Isoptin	(10 mg)	2

IV FLUIDS

Name	Volume	Number
lactated Ringer's	(1,000 mL)	8
0.9% sodium chloride	(1,000 mL)	4
dextrose, 5% in water	(500 mL)	2
dextrose, 5% in 0.25% NaCl	(500 mL)	2

ROUTINE CARE

The following assessment is to be performed and information is to be obtained on all patients:

1. Always assure scene safety for yourself, your fellow rescuers, and your patient.
2. Primary survey:
   A = Airway with cervical spine control
   B = Breathing
   C = Circulation with control of bleeding

   (these three are referred to as the "ABCs".)

   D = Disability Determination

   A = alert and conscious
   V = responsive to verbal stimuli
   P = responsive to painful stimuli
   U = unresponsive
   

   (these four are referred to by the acronym "AVPU".)

   E = Exposure

3. Secondary survey:
   
   A. Obtain vital signs and perform objective head-to-toe assessment
   B. Obtain history
   • Sex, age, and approximate weight
   • Chief complaint
   • Precipitating factors
   • Significant past medical history
   • Allergies
   • Current medications
4. Place monitoring equipment, if indicated.
   
   • ECG monitor
   • Pulse oximetry
   • Capnography (when indicated)
5. Apply appropriate protocol and standing order based on assessment.
6. Contact medical control as designated in protocol or for any problems or questions.
7. Position patient comfortably as indicated by condition or situation.
8. Reassure and calm patient. Loosen any restrictive clothing or remove as indicated.
9. Transport as soon as feasible.

ABDOMINAL TRAUMA

GUIDELINES FOR CARE

1. Assure ABCs.
2. Oxygen via non-rebreather mask. Consider intubation and hyperventilation with 100% oxygen for markedly decreased LOC, inability to maintain a patient airway, or for GCS * 8.
3. Attach cardiac monitor and pulse oximeter.
4. Establish two large bore IVs of lactated Ringer's to maintain systolic pressure > 90 mmHg.
5. Impaled objects should be stabilized in place.
6. Eviscerations should be covered with saline-soaked gauze. Do not attempt to push the organs back into the abdomen. Do not inflate the abdominal section of the PASG / MAST.
7. Rapid transport.
8. Contact medical control for any questions or problems.

ALCOHOL EMERGENCIES

GUIDELINES FOR CARE

1. Assure ABCs.
2. Oxygen via non-rebreather mask. Consider intubation and hyperventilation with 100% oxygen for markedly decreased LOC, inability to maintain a patient airway, or for GCS * 8.
3. Initiate IV of lactated Ringer's TKO.
4. Attach cardiac monitor and pulse oximeter.
5. Determine serum glucose level with Glucometer or DextroStix.
   • If glucose < 80 mg/dl, administer 25 gms 50% Dextrose IV.
   • If glucose > 80 mg/dl and < 250 mg/dl, go to step #6.
   • If glucose > 250 mg/dl, go to Hyperglycemia Protocol.
6. If history suspicious for alcoholism, administer 100 mg thiamine IV OR IM.
7. If history of drug abuse, and patient has constricted pupils or respiratory depression, administer Narcan 1.0-2.0 mg IV.
8. If history of possible Benzodiazepine usage, administer 0.3 mg of Flumazenil (Romazicon) IVP over 30 seconds. Repeat as needed to a maximum dose of 1.0 mg.
9. Provide supportive measures.
10. Transport to designated hospital.
11. Contact Medical Control for any questions or problems.

ALTERED MENTAL STATUS/COMA

GUIDELINES FOR CARE

1. Assure ABCs.
2. Oxygen via non-rebreather mask. Consider intubation and hyperventilation with 100% oxygen for markedly decreased LOC, inability to maintain a patient airway, or for GCS * 8.
3. Initiate IV lactated Ringer's TKO.
4. Attach cardiac monitor and pulse oximeter.
5. Determine serum glucose level with Glucometer or DextroStix.
   • If glucose < 80 mg/dl, administer 25 gms 50% Dextrose IV.
   • If glucose > 80 mg/dl and < 250 mg/dl, go to step #6.
   • If glucose > 250 mg/dl, go to Hyperglycemia Protocol.
6. If history suspicious for alcoholism, administer 100 mg thiamine IV OR IM.
7. If history of drug abuse, and patient has constricted pupils or respiratory depression, administer Narcan 1.0 - 2.0 mg IV.
8. If history of possible Benzodiazepine usage, administer 0.3 mg of Flumazenil (Romazicon) IVP over 30 seconds. Repeat as needed to a maximum dose of 1.0 mg.
9. Provide supportive measures.
10. Transport to designated hospital.
11. Contact Medical Control for any questions or problems.

AMPUTATIONS

GUIDELINES FOR CARE

1. Assure ABCs.
2. Control bleeding.
3. Oxygen via non-rebreather mask.
4. Large bore IV of lactated Ringer's solution at appropriate rate to maintain systolic > 90 mmHg.
5. Treat for shock, if indicated.
6. Rinse amputated part with normal saline to remove loose debris. DO NOT SCRUB.
7. Wrap amputated part in gauze moistened with saline.
8. Place wrapped part in plastic bag and seal. Label with NAME, DATE, and TIME.
9. Place sealed bag in container filled with water and several ice cubes.
10. Consider Morphine 2-5 mg IVP for pain control. May repeat in 5 minutes up to a maximum of 10 mg.
11. If partial amputation, place in anatomical position to facilitate the best vascular status and wrap in bulky dressings. If the vascalarity to the distal part is compromised, wrap the distil part and apply ice. (Consider placing the pulse oximeter probe on a finger or toe of the affected extremity to monitor the vascular status of the injured extremity.)
12. Transport to designated facility.
13. Contact medical control for any questions or problems.

ANAPHYLAXIS/ALLERGIC REACTIONS

GUIDELINES FOR CARE

1. Assure ABCs.
2. Oxygen via non-rebreather mask. Consider intubation and hyperventilation with 100% oxygen for markedly decreased LOC, inability to maintain a patient airway, or for GCS * 8.
3. Attach cardiac monitor and pulse oximeter.
4. IV of lactated Ringer's TKO.
5. If blood pressure normal:
   • Consider Benadryl 50 mg IM or slow IV push.
6. If hypotensive (systolic <90 mmHg) and patient has mild - moderate respiratory distress:
   • Open IV and infuse fluid bolus (500 ml for adults or 20 ml/kg for children.)
   • Apply uninflated PASG and elevate legs.
   • administer Epinephrine 1:1,000 subcutaneously. (Adult: 0.3 ml / Pedi: 0.01 ml/kg.)
   • Transport.
   • Contact medical control en route.
7. If refractory hypotension, or sever repspiratory distress:
   • Administer Epinephrine 1:1,000 subcutaneously (Adult: 0.3 ml / Pedi: 0.01 ml/kg.)
   • Transport.
   • Contact medical control en route.
   • Consider Epinephrine 1:10,000 3-5 ml intravenously.
   • Consider Dopamine drip starting at 2 µg/kg/minute and titrate to effect.
8. Contact medical control for any questions or problems

AORTIC ANEURYSM / DISSECTION

GUIDELINES FOR CARE

1. Assure ABCs.
2. Oxygen via non-rebreather mask. Consider intubation and hyperventilation with 100% oxygen for markedly decreased LOC, inability to maintain a patient airway, or for GCS * 8.
3. Attach cardiac monitor and pulse oximeter.
4. Establish two large bore IVs of lactated Ringer's to maintain systolic pressure > 90 mmHg.
5. If blood pressure normal:
   • Consider Morphine 2-5 mg IVP for pain relief.
6. If hypertensive, go to Hypertensive Crisis Protocol.
7. Consider application of the PASG and inflation to maintain systolic BP > 90 mmHg if unable to maintain BP with IV fluids. (Do not use the PASG in patients with known or suspected thoracic aneurysms).
8. Notify receiving facility of patient's condition to expedite admission to surgery for definitive care.
9. Contact medical control for any questions or problems.

ASTHMA

GUIDELINES FOR CARE

1. Assure ABCs.
2. Oxygen via non-rebreather mask if no history of COPD. If history of COPD, administer oxygen at 2-3 lpm via nasal cannula. Consider intubation and hyperventilation with 100% oxygen for markedly decreased LOC, inability to maintain a patient airway, or for GCS * 8.
3. Initiate IV lactated Ringer's TKO
4. Attach cardiac monitor and pulse oximeter.
5. If signs of severe hypoventilation:
   1. Assist ventilations with BVM with 100% oxygen.
   2. Consider endotracheal intubation.
   3. Contact medical control.
6. If history of asthma, and patient exhibiting wheezing, cough, tachypnea, or retractions:
   1. Obtain baseline peak expiratory flow rate (PEFR) while preparing nebulizer.
   2. Administer Albuterol breathing treatment (Adult 0.5 mL). (Albuterol can be readministered every 10 minutes. Discontinue therapy if patient develops marked tachycardia or chest pain.)
   3. Consider Epinephrine 1:1,000 0.3 mg subcutaneously. (pediatric dose = 0.01 mL/kg) if ordered by medical control.
   4. If patient has received an Albuterol treatment in the last two hours, consider using Isoetharine (Bronkosol) (Adult 0.5 mL) instead of Albuterol.
   5. Ipratropium (Atrovent) (Adult 500 µg) may be added to the initial nebulizer treatment with Albuterol or Isoetharine.
   6. Obtain post-treatment PEFR rate after each treatment.
   7. Consider Methylprednisolone 80-125 mg IVP
   8. Contact medical control for any questions or problems
   9. Transport.
7. Contact medical control for any questions or problems.

BURNS

GUIDELINES FOR CARE

1. Assure ABCs.
2. Extinguish any flames on patient, remove smoldering clothing (leather), and any constricting jewelry.
3. Remove from harmful environment and limit injury:
   1. CHEMICAL:Flush with water or normal saline. Brush off dry chemicals.
   2. TAR: Cool with water or normal saline (do not attempt to remove tar.)
   3. ELECTRICAL: Remove from contact with current source if equipped to do so. (Note any secondary fractures and Exit wounds caused by current.)
4. If respiratory distress, or airway burns exist, prepare to intubate. Consider RSI early if respiratory burns are present.
5. If pulseless or apneic, go to Cardiac Arrest Protocol.
6. If additional injuries, go to Trauma Management Protocol.
7. If significant 2° or 3° burns (> 20% BSA):
   1. Oxygen via non-rebreather mask
   2. Establish two large bore IVs of lactated Ringer's.
      Administer 4 ml X patient's weight (kg) X % BSA burned
      Give 1/2 in the first 8 hours post-burn,
      Give 1/4 in the second 8 hours,
      Give 1/4 in the third 8 hours.
   3. Contact medical control
   4. Consider Morphine 2-5 mg IVP. May repeat in five minutes to a maximum of 15 mg.
8. If altered LOC and/or signs of head injury (consider carbon monoxide poisoning if closed space burn):
   1. Oxygen via non-rebreather mask.
   2. Immobilize cervical spine.
   3. IV lactated Ringer's TKO.
   4. Contact medical control.
9. Transport all significantly burned patients on sterile dry sheets.
10. Consider Foley catheter insertion.
11. Monitor urine output. If output drops to less than 30-60 ml/hour (adults) OR 1.0 ml/kg/hour (pediatric), increase the IV fluids to maintain urine output at these levels.
12. Consider escharotomy if circumferential burns of the neck, chest, or extremities are interfering with effective ventilations or circulation.
13. Contact medical control for any questions or problems.

CARDIOGENIC SHOCK

GUIDELINES FOR CARE

1. Assure ABCs.
2. Oxygen via non-rebreather mask if no history of COPD. If history of COPD, titrate oxygen delivery to maintain SPO2 > 90%. Consider intubation and hyperventilation with 100% oxygen for markedly decreased LOC, inability to maintain a patient airway, or for GCS * 8.
3. Initiate IV lactated Ringer's TKO. If hypotensive, consider 250 mL fluid bolus.
4. Attach cardiac monitor and pulse oximeter.
5. Treat dysrhythmias per the appropriate protocol.
6. If signs of severe hypoventilation occur:
   1. Assist ventilations with BVM with 100% oxygen.
   2. Consider endotracheal intubation.
   3. Contact medical control
   4. Intubated patients with severe pulmonary congestion may require PEEP to maintain oxygenation status.
7. Monitor I&O closely.
8. If systolic BP >100 mmHg, consider Dobutamine at 2-20 µg/kg/min to maintain systolic blood pressure > 100 mmHg.
9. If systolic BP <100 mmHg, consider Dopamine at 2-20 µg/kg/min to maintain systolic >100 mmHg.
10. Consider Norepinephrine 0.5 - 30.0 µg/min if systolic <70 mmHg as ordered by medical control.
11. Contact medical control if not responsive to therapy.
12. Transport.

CHEST PAIN

GUIDELINES FOR CARE

1. Assure ABCs.
2. Oxygen via non-rebreather mask.
3. Attach cardiac monitor and pulse oximeter.
4. Place in position of comfort.
5. Initiate an IV of lactated Ringer's or normal saline at a TKO rate.
6. Administer 1 Nitroglycerin tablet (1/150) sublingually if systolic blood pressure greater than 100 mmHg. May be repeated every 5 minutes until:
   1. 3 tablets have been administered,
   2. Pain is relieved, or,
   3. Systolic blood pressure falls below 100 mmHg.
7. administer 1 Aspirin tablet (325 mg) PO or chew if patient not allergic to Aspirin and does not have ulcer disease.
8. Treat dysrhythmias per protocols.
9. consider Morphine 2 mg IVP every 5 minutes to a maximum of 10 mg in 1 hour. Monitor respirations and blood pressure closely.
10. consider Phenergan 12.5 - 25.0 mg or Compazine 5 - 10 mg IVP for nausea and vomiting.
11. Consider nitroglycerin drip for persistent or severe chest pain.
12. Minimize venipunctures.
13. Transport.
14. Contact medical control for any questions or problems.

CHEST TRAUMA

GUIDELINES FOR CARE

1. Assure ABCs.
2. Oxygen via non-rebreather mask. consider intubation and hyperventilation with 100% oxygen for markedly decreased LOC, inability to maintain a patient airway, or for GCS * 8.
3. Attach cardiac monitor and pulse oximeter.
4. Establish two large bore IVs of lactated Ringer's to maintain systolic pressure > 90 mmhg.
5. If penetrating or sucking chest wound (look for bubbles, listen for air leaks):
   1. Place occlusive dressing during exhalation (tape on 3 sides).
   2. Once occluded, monitor for tension pneumothorax.
6. If flail chest (unstable segment that does not expand with the remainder of the chest on inspiration):
   1. If conscious, stabilize flail segment with gauze pad, IV bag, etc.
   2. If unconscious, immobilize neck and intubate. ventilate with 100% oxygen by BVM.
   3. Re-assess, if tension pneumothorax develops, see #7 below.
7. If tension pneumothorax (unilateral absent breath sounds with or without tracheal deviation or bilaterally absent breath sounds:
   • Perform needle decompression per protocol.
8. Continued inadequate ventilations and decreasing LOC:
   1. Rapid secondary survey for additional injuries.
   2. Immobilize neck.
   3. Control hemorrhage.
   4. Intubate with cervical stabilization.
   5. Ventilate with 100% oxygen via BVM.
   6. Establish second IV lactated Ringer's wide open en route if signs of shock.
   7. Cardiac compressions if pulseless.
9. Impaled objects should be stabilized in place.
10. Treat any dysrhythmias per protocols.
11. Transport.
12. Contact medical control for any questions or problems.

CHILDBIRTH

GUIDELINES FOR CARE

1. Assure ABCs.
2. Oxygen via non-rebreather mask.
3. Secondary survey.
4. Obtain pertinent history:
   1. Number of pregnancies/deliveries.
   2. History of problems with pregnancy (vaginal bleeding, prior cesarean sections, high blood pressure, premature labor, premature rupture of membranes.
   3. Last menstrual period and due date (if known).
   4. Current complaints (onset of labor, timing of contractions, rupture of membranes, or urge to push.)
   5. Past medical history (including medications.)
5. Perineal examination (do not perform internal vaginal examination)
   • Vaginal bleeding or leakage of fluid.
   • Presence of meconium.
   • Crowning during a contraction.
   • Presenting part (head, face, foot, arm, cord.)
6. If active labor, and no vaginal bleeding or crowning:
   1. Check for fetal heart tones.
   2. Transport.
7. If vaginal bleeding with no signs of shock (systolic >90 mmhg):
   1. Transport.
   2. IV lactated Ringer's at 125 ml/hour.
   3. Cardiac monitor.
8. If heavy vaginal bleeding with signs of shock (systolic <90 mmhg):
   1. Transport with patient in left lateral recumbent position.
   2. Cardiac monitor.
   3. IV lactated Ringer's wide open.
9. If imminent delivery:
   1. Place mother in lithotomy position.
   2. Drape mother.
   3. Prepare for neonatal resuscitation.
   4. Assist delivery.
   5. Suction mouth, then nose with bulb suction (if meconium stained fluid, suction baby's airway until clear before stimulating first breath.
   6. Warm, dry, and stimulate infant.
   7. Wrap infant in sterile drape or dry blanket.
   8. Infuse mother's IV of lactated Ringer's at 125 ml/hour.
   9. Transport.
   10. If prolapsed cord:
       1. Place mother on back with hips elevated or place her in knee/chest position.
       2. Place sterile gloved index and middle fingers into the vagina and push the infant up to relieve pressure on the cord.
       3. Check cord for pulse.
       4. Transport and notify receiving hospital of impending arrival.
   11. If abnormal fetal presentation or decreased fetal heart tones:
       1. Place patient in left lateral recumbent position.
       2. Transport and notify receiving hospital of impending arrival.
       3. Attempt IV lactated Ringer's en route and run at 125 ml/hour.
   12. If delivery completed before arrival, or in-field:
       1. Protect infant from fall and temperature loss.
       2. Check infant's vital signs (perform CPR or assist ventilations as necessary.)
       3. Clamp cord in two places, six inches from infant, and cut cord between clamps.
       4. Suction, warm, dry, and stimulate infant.
       5. Give infant to mother.
       6. Massage uterus gently.
       7. Do not pull on cord or attempt to deliver placenta.
       8. Start IV lactated Ringer's and run at 200 ml/hour.
       9. Transport.
       10. Watch for external bleeding. place fundal pressure if placenta delivers.
   13. Contact medical control for any questions or problems.
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   CONGESTIVE HEART FAILURE/PULMONARY EDEMA

   GUIDELINES FOR CARE

   1. Assure ABCs.
   2. Oxygen via non-rebreather mask if no history of COPD. If history of COPD, titrate oxygen delivery to maintain SPO2 > 90%. Consider intubation and hyperventilation with 100% oxygen for markedly decreased LOC, inability to maintain a patient airway, or for GCS * 8.
   3. Initiate IV lactated Ringer's TKO.
   4. Attach cardiac monitor and pulse oximeter.
   5. If signs of severe hypoventilation:
      1. Assist ventilations with BVM with 100% oxygen.
      2. Consider endotracheal intubation.
      3. Contact medical control.
   6. If history of CHF, and patient exhibiting tachypnea, orthopnea, JVD, edema, moist breath sounds (rales):
      1. Place in seated position (semi-fowler's.)
      2. Administer nitroglycerin 1/150 sublingually (if BP >120 systolic.)
      3. Administer Lasix 40-80 mg IV.
      4. Consider Morphine 2-5 mg every 5 minutes (do not exceed a total of 10 mg). Carefully monitor blood pressure and respirations.
      5. If systolic BP >100 mmhg, consider Dobutamine at 2-20 µg/kg/min to maintain systolic blood pressure >100 mmhg.
      6. If systolic BP <100 mmhg, consider Dopamine at 2-20 µg/kg/min to maintain systolic >100 mmhg.
      7. Consider Norepinephrine 0.5 - 30.0 µg/min if systolic <70 mmhg as ordered by medical control.
      8. Contact medical control if not responsive to therapy.
      9. Transport.
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   CVA / STROKE

   GUIDELINES FOR CARE

   1. Assure ABCs.
   2. Oxygen via non-rebreather mask. consider intubation and hyperventilation with 100% oxygen for markedly decreased LOC, inability to maintain a patient airway, or for GCS * 8.
   3. Initiate IV lactated Ringer's TKO.
   4. Attach cardiac monitor and pulse oximeter.
   5. Elevate head of bed if possible.
   6. Determine serum glucose level with Glucometer or DextroStix.
      1. If glucose < 80 mg/dl, administer 25 gms 50% dextrose IV.
      2. If glucose > 80 mg/dl and < 250 mg/dl, go to step #7.
      3. If glucose > 250 mg/dl, go to Hyperglycemia Protocol.
   7. Place in recovery position (unless spinal injury suspected).
   8. Prepare to suction and manage airway.
   9. Repeat vital signs frequently. if hypertensive, go to Hypertensive Crisis Protocol.
   10. Treat seizures with 5-10 mg Valium IVP. contact medical control if no response to Valium.
   11. Control agitation with Valium 2-5 mg IVP. may repeat every 10 minutes to a maximum of 10 mg.
   12. If the patient is able to swallow, administer 325 mg aspirin PO (chewed or swallowed).
   13. Transport to designated hospital.
   14. Consider Mannitol 0.5-1.0 gm/kg given IVP over 5-10 minutes for signs and symptoms of increased intracranial pressure.
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   DEHYDRATION

   GUIDELINES FOR CARE

   1. Assure ABCs.
   2. Oxygen via non-rebreather mask.
   3. Attach cardiac monitor and pulse oximeter.
   4. Establish two large bore IVs of lactated Ringer's. Infuse to maintain a systolic pressure > 90 mmhg (20 ml/kg boluses for children.)
   5. Be alert for dysrhythmias.
   6. transport.
   7. contact medical control for any questions or problems.
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   DIABETIC EMERGENCIES/HYPOGLYCEMIA

   GUIDELINES FOR CARE

   1. Assure ABCs.
   2. Oxygen via non-rebreather mask.
   3. Initiate IV lactated Ringer's TKO and draw tube of blood.
   4. Attach cardiac monitor and pulse oximeter.
   5. Determine serum glucose level with Glucometer or DextroStix.
      1. If glucose < 80 mg/dl, administer 25 gms 50% dextrose IV.
      2. If glucose > 80 mg/dl and < 250 mg/dl, go to step #6.
      3. If glucose > 250 mg/dl, go to Hyperglycemia Protocol.
   6. If unable to establish IV, give Glucagon 1 mg IM.
   7. Transport.
   8. Repeat glucose determination in 5 minutes:
      • If glucose remains < 80 mg/dl, and no significant change in mental status, administer a second 25 gms 50% dextrose IV.
   9. Provide supportive measures.
   10. Contact medical control for any questions or problems.
   11. Label the pre-treatment blood vial and provide it to the receiving hospital with the patient.
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   DIABETIC EMERGENCIES/HYPERGLYCEMIA (KETOACIDOSIS)

   GUIDELINES FOR CARE

   1. Assure ABCs.
   2. Oxygen via non-rebreather mask. Consider intubation and hyperventilation with 100% oxygen for markedly decreased LOC, inability to maintain a patient airway, or for GCS * 8.
   3. Initiate IV lactated Ringer's TKO and draw tube of blood.
   4. Attach cardiac monitor and pulse oximeter.
   5. Determine serum glucose level with Glucometer or DextroStix.
      1. if glucose < 80 mg/dl, go to Hypoglycemia Protocol.
      2. if glucose > 80 mg/dl and < 250 mg/dl, go to step #6.
      3. if glucose > 250 mg/dl, go to #7.
   6. Transport.
   7. If glucose > 250 mg/dl, and patient exhibiting altered mental status, Kussmaul respirations, dry skin with poor turgor, and/or ketotic breath:
      1. Open lactated Ringer's wide open.
      2. Contact medical control for Insulin and bicarb orders.
      3. Transport.
   8. Contact medical control for any questions or problems.
   9. Consider NG tube placement.
   10. Consider thiamine 100 mg IVP.
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   DIVING EMERGENCIES (DECOMPRESSION SICKNESS)

   GUIDELINES FOR CARE

   1. Assure ABCs.
   2. Administer oxygen via non-rebreather mask.
   3. Place the patient in a supine head-down left lateral decubitus position.
   4. Attach monitor and pulse oximeter.
   5. Start an IV of lactated Ringer's TKO.
   6. Protect against hypothermia and hyperthermia.
   7. Monitor closely for complications (pneumothorax, shock, seizures) and treat per standing orders/protocols.
   8. Contact medical control if analgesics indicated.
   9. Assess vital signs, including temperature, every 10 minutes.
   10. Consider transport to a hyperbaric facility. provide hyperbaric personnel with a detailed history of the dive (depth and duration, timing and onset of symptoms, complications, and any treatment rendered).
   11. Transport at cabin altitude as low as possible or as directed by medical control or receiving physician.
   12. Contact medical control for any questions or problems.
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   DYSPNEA

   GUIDELINES FOR CARE

   1. Assure ABCs.
   2. Oxygen via non-rebreather mask if no history of COPD. If history of COPD, titrate oxygen delivery to maintain SPO2 > 90%. consider intubation and hyperventilation with 100% oxygen for markedly decreased LOC, inability to maintain a patient airway, or for GCS * 8.
   3. Initiate IV lactated Ringer's TKO.
   4. Attach cardiac monitor and pulse oximeter.
   5. If signs of severe hypoventilation:
      1. Assist ventilations with BVM with 100% oxygen.
      2. Consider endotracheal intubation
      3. Contact medical control
   6. If history of COPD (emphysema/chronic bronchitis):
      • Obtain baseline peak expiratory flow rate (PEFR) while preparing nebulizer.
      • Administer Albuterol breathing treatment (adult 0.5 ml). Albuterol can readministered every 10 minutes. discontinue therapy if patient develops marked tachycardia or chest pain.
      • If patient has received an Albuterol treatment in the last two hours, consider using Isoetharine (Bronkosol) (adult 0.5 ml) instead of Albuterol.
      • Ipratropium (Atrovent) (adult 500 µg) may added to the initial nebulizer treatment with Albuterol or Isoetharine.
      • Obtain post-treatment PEFR rate after each treatment.
      • Contact medical control for any questions or problems.
      • Transport.
   7. If history of fever and/or productive cough:
      • Place in position of comfort.
      • Transport.
   8. If allergen exposure, edema, rash, and wheezing:
      • Go to Anaphylaxis/Allergic Reaction Protocol
      • Contact medical control
      • Transport.
   9. If history of pulmonary embolism:
      • Place in position of comfort (preferably with extremities lower than level of heart)
      • Consider Morphine 2-5 mg IVP for pain. may repeat to a maximum of 10 mg.
      • Consider Valium 2-5 mg IVP for anxiety.
      • Transport.
   10. If history of CHF, and patient exhibiting tachypnea, orthopnea, JVD, edema, moist breath sounds (rales):
       • Place in seated position (semi-fowler's)
       • Administer Nitroglycerin 1/150 sublingually (if BP >120 mmhg systolic).
       • Administer Lasix 40-80 mg IV.
       • Consider Morphine 2-5 mg every 5 minutes (do not exceed a total of 10 mg.) carefully monitor blood pressure and respirations.
       • If systolic BP >100 mmhg, consider Dobutamine at 2-20 µg/kg/min to maintain systolic blood pressure > 100 mmhg.
       • If systolic BP <100 mmhg, consider Dopamine at 2-20 µg/kg/min to maintain systolic >100 mmhg.
       • Consider Norepinephrine 0.5 - 30.0 µg/min if systolic <70 mmhg as ordered by medical control.
       • Contact medical control if not responsive to therapy.
       • Transport.
   11. If history of asthma, and patient exhibiting wheezing, cough, tachypnea, or retractions:
       • Obtain baseline peak expiratory flow rate (PEFR) while preparing nebulizer.
       • Administer Albuterol breathing treatment (adult 0.5 ml). Albuterol can readministered every 10 minutes. discontinue therapy if patient develops marked tachycardia or chest pain.
       • Consider Epinephrine 1:1,000 0.3 mg subcutaneously. (pediatric dose = 0.01 ml/kg) if ordered by medical control.
       • If patient has received an Albuterol treatment in the last two hours, consider using Isoetharine (Bronkosol) (adult 0.5 ml) instead of Albuterol.
       • Ipratropium (Atrovent) (adult 500 µg) may added to the initial nebulizer treatment with Albuterol or Isoetharine.
       • Obtain post-treatment PEFR rate after each treatment.
       • Consider Methylprednisolone 80-125 mg IVP.
       • Contact medical control for any questions or problems.
       • Transport.
       12. contact medical control for any questions or problems.
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   DYSRHYTHMIAS

   GUIDELINES FOR CARE

   Care of cardiac dysrhythmias is based on standards established by the American Heart Association committee on emergency cardiac care. please look to the specific protocol which follows for:

   • Asystole
   • Bradycardia (symptomatic)
   • Narrow Complex Tachycardia (symptomatic)
   • Pulseless Electrical Activity (electromechanical dissociation)
   • Ventricular Fibrillation
   • Ventricular Tachycardia (with pulse)
   • Ventricular Tachycardia (without pulse)
   • Premature Ventricular Contractions

   Other points to remember include:

   1. Always treat the patient, not the monitor.
   2. Cardiac arrest due to trauma is not treated by medical protocols.
   3. Protocols for cardiac arrest situations presumes that the condition under discussion continually persists, that the patient remains in cardiac arrest, and that CPR is always performed.
   4. Adequate airway, ventilation, oxygenation, chest compressions, and defibrillation are more important than administration of medications and take precedence over initiating an intravenous line or injecting medications.
   5. Remember, Lidocaine, Epinephrine, Atropine, and Naloxone can be administered via the endotracheal tube.
   6. After each intravenous medication, give a 20- to 30-ml bolus of intravenous fluid and immediately elevate the extremity. this will enhance delivery of the drug to the central circulation.
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   DYSRHYTHMIAS (ASYSTOLE)

   GUIDELINES FOR CARE

   1. Assure ABCs.
   2. Initiate and continue CPR.
   3. Intubate at once.
   4. Initiate IV of lactated Ringer's TKO.
   5. Confirm asystole in more than one lead.
   6. Consider possible causes:
      • Hypoxia
      • Hyperkalemia (increased potassium)
      • Hypokalemia (decreased potassium)
      • Pre-existing Acidosis
      • Drug overdose
      • Hypothermia
   7. Consider immediate transcutaneous cardiac pacing, if available.
   8. Administer 1 milligram of Epinephrine 1:10,000 every 3-5 minutes IV. follow each intravenous drug bolus with 20 milliliters of IV fluid and elevate extremity. if unable to establish IV access, administer Epinephrine endotracheally.
   9. Administer Atropine 1 mg IV. may repeat every 3-5 minutes up to:
      • 2 mg for patients weighing less than 110 pounds (<50 kg)
      • 3 mg for patients weighing 110-165 pounds (50-75 kg)
      • 4 mg for patients weighing 165-220 pounds (75-100 kg)
   10. Contact medical control for further direction.
   11. Transport.
   12. Contact medical control for any questions or problems.
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   DYSRHYTHMIAS (BRADYCARDIA--SYMPTOMATIC)

   GUIDELINES FOR CARE

   1. Assure ABCs.
   2. Administer oxygen.
   3. Attach monitor.
   4. Start IV of lactated Ringer's TKO.
   5. Assess vital signs.
   6. If heart rate < 60 per minute and patient exhibits any of the following signs or symptoms:
      • Chest pain
      • Shortness of breath
      • Decreased level of consciousness
      • Low blood pressure
      • Shock
      • Pulmonary edema
      • Congestive heart failure
      • Acute MI

      administer 0.5 mg Atropine intravenously.

   7. Contact medical control.
   8. May repeat intravenous Atropine every 3-5 minutes up to:
      • 2 mg for patients weighing less than 110 pounds (<50 kg)
      • 3 mg for patients weighing 110-165 pounds (50-75 kg)
      • 4 mg for patients weighing 165-220 pounds (75-100 kg)
   9. Consider transcutaneous cardiac pacing.
   10. Transport.
   11. Contact medical control for any questions or problems.
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   DYSRHYTHMIAS (NARROW COMPLEX TACHYCARDIA--SYMPTOMATIC)

   GUIDELINES FOR CARE

   1. Assure ABCs.
   2. Administer oxygen.
   3. Attach monitor. verify narrow complex tachycardia. if wide-complex tachycardia, see Ventricular Tachycardia Protocol.
   4. Assess vital signs.
   5. Start IV of lactated Ringer's TKO.
   6. If patient exhibits any of the following signs or symptoms:
      • Chest pain
      • Shortness of breath
      • Decreased level of consciousness
      • Low blood pressure / shock
      • Pulmonary edema / congestive heart failure
      • Acute MI

      consider patient to be unstable.

   7. Attempt vagal maneuvers if not contraindicated.
   8. If vagal maneuvers unsuccessful, administer Adenosine 6 mg rapid IV push over 1-3 seconds in medication port nearest patient.
   9. If, after 1-2 minutes, no response noted, administer Adenosine 12 mg IV push over 1-3 seconds in medication port nearest patient.
   10. Consider synchronized cardioversion, especially if vital signs deteriorating. if time permits, premedicate with Valium 2-5 mg IVP, Versed 1-2 mg IVP, or Morphine 2-5 mg IVP.2
   11. If rhythm is atrial fibrillation or atrial flutter with rapid ventricular response, consider Diltiazem 20 mg slow IVP (over 2 minutes)
   12. Transport.
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   DYSRHYTHMIAS (PREMATURE VENTRICULAR CONTRACTIONS)

   GUIDELINES FOR CARE

   1. Assure ABCs.
   2. Administer oxygen.
   3. Start IV of lactated Ringer's TKO.
   4. Attach monitor. verify premature ventricular contractions.
   5. Assess vital signs.
   6. If patient is asymptomatic, transport with continued monitoring en route.
   7. If patient exhibits any of the following signs or symptoms:
      • Chest pain
      • Dizziness
      • Symptoms of acute MI

      and premature ventricular contractions are malignant:

      • > 6 per minute
      • Multi-focal
      • Occurring in couplets
      • Exhibiting "r on t phenomenon"
      • Exhibiting runs of ventricular tachycardia

      then, administer Lidocaine 1.0 - 1.5 mg/kg IV push (reduce dosage by 50% if patient >70 years of age or has known liver disease).

   8. If, after 5 minutes, PVCs persist, repeat Lidocaine at 1/2 the initial dose. if PVC's suppressed, begin Lidocaine drip at 2 mg/minute. contact medical control.
   9. Consider Procainamide at 30 mg/minute to a maximum of 17 mg/kg if PVCs persist.
   10. If patient at any time becomes pulseless, switch to Pulseless Ventricular Tachycardia Protocol (or other appropriate protocol).
   11. Transport.
   12. Contact medical control for any questions or problems.
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   DYSRHYTHMIAS (PULSELESS ELECTRICAL ACTIVITY) [PEA]

   GUIDELINES FOR CARE

   1. Assure ABCs.
   2. Initiate and continue CPR.
   3. Intubate at once.
   4. Initiate IV of lactated Ringer's wide open.
   5. Confirm asystole in more than one lead.
   6. Consider possible causes:
      • Hypovolemia
      • Hypoxia
      • Hyperkalemia (increased potassium)
      • Cardiac tamponade
      • Pre-existing acidosis
      • Drug overdose
      • Hypothermia
      • Tension pneumothorax
      • Massive pulmonary embolism
      • Massive acute myocardial infarction
   7. Administer 1 milligram of Epinephrine 1:10,000 every 3-5 minutes IV. follow each intravenous drug bolus with 20 milliliters of IV fluid and elevate extremity. if unable to establish IV access, administer Epinephrine endotracheally.
   8. If heart rate < 60 per minute, or relative bradycardia, administer Atropine 1 mg IV. may repeat intravenous Atropine every 3-5 minutes up to:
      • 2 mg for patients weighing less than 110 pounds (<50 kg)
      • 3 mg for patients weighing 110-165 pounds (50-75 kg)
      • 4 mg for patients weighing 165-220 pounds (75-100 kg)
   9. Contact medical control.
   10. Consider sodium bicarbonate.
   11. Consider transcutaneous cardiac pacing.
   12. Transport.
   13. Contact medical control for any questions or problems.
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   DYSRHYTHMIAS (VENTRICULAR FIBRILLATION)

   GUIDELINES FOR CARE

   1. Assure ABCs.
   2. Initiate and continue CPR until defibrillator attached.
   3. Confirm ventricular fibrillation (VF) or non-perfusing ventricular tachycardia (VT) on monitor.
   4. Defibrillate up to 3 times as needed for persistent VF or VT:
      • #1 at 200 joules
      • #2 at 300 joules
      • #3 at 360 joules
   5. If VF or VT persists, continue CPR. If patient develops PEA or asystole, go to appropriate protocol.
   6. Intubate.
   7. Start an IV of lactated Ringer's TKO.
   8. Administer 1 milligram of Epinephrine 1:10,000 every 3-5 minutes IV. follow each intravenous drug bolus with 20 milliliters of IV fluid and elevate extremity. If unable to establish IV access, administer A HREF="../glossary/drugs.htm#epinephrine">Epinephrine endotracheally.
   9. Defibrillate at 360 joules within 30-60 seconds following administration of each drug.
   10. Administer 1.5 mg/kg Lidocaine intravenously. repeat every 3-5 minutes until a total of 3 mg/kg has been administered. If unable to establish IV access, administer Lidocaine endotracheally.
   11. Consider Bretylium 5 mg/kg IV.
   12. Contact medical control.
   13. Consider Sodium Bicarbonate IV.
   14. Transport.
   15. Contact medical control for any questions or problems.
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   DYSRHYTHMIAS (VENTRICULAR TACHYCARDIA--WITH PULSE)

   GUIDELINES FOR CARE

   1. Assure ABCs.
   2. Administer oxygen.
   3. Start IV of lactated Ringer's TKO.
   4. Attach monitor. Verify ventricular tachycardia.
   5. Assess vital signs.
   6. If patient exhibits any of the following signs or symptoms:
      • Chest pain
      • Shortness of breath
      • Decreased level of consciousness
      • Low blood pressure
      • Shock
      • Pulmonary edema
      • Congestive heart failure
      • Acute MI

      consider patient to be unstable.

   7. Administer Lidocaine 1.0 - 1.5 mg/kg IV push.
   8. Administer Lidocaine 0.50 - 0.75 mg/kg IV push every 5-10 minutes until ventricular tachycardia abolished or 3.0 mg/kg of the drug has been administered.
   9. Consider Procainamide at 30 mg/minute to a maximum of 17 mg/kg.
   10. Consider Bretylium 5 - 10 mg/kg every 8-10 minutes to a maximum of 30 mg/kg.
   11. Consider synchronized cardioversion. If time permits, premedicate with Valium 2-5 mg IVP, Versed 1-2 mg IVP, or Morphine 2-5 mg IVP.
   12. If patient at any time becomes pulseless, switch to pulseless Ventricular Tachycardia Protocol (or other appropriate protocol).
   13. Transport.
   14. Contact medical control for any questions or problems.
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   DYSRHYTHMIAS (VENTRICULAR TACHYCARDIA--WITHOUT PULSE)

   GUIDELINES FOR CARE

   1. Assure ABCs.
   2. Initiate and continue CPR until defibrillator attached.
   3. Confirm ventricular fibrillation (VF) or non-perfusing ventricular tachycardia (VT) on monitor.
   4. Defibrillate up to 3 times as needed for persistent VF or VT:
      • #1 at 200 joules
      • #2 at 300 joules
      • #3 at 360 joules
   5. If VF or VT persists, continue CPR. if patient develops PEA or asystole, go to appropriate protocol.
   6. Intubate.
   7. Start an IV of lactated Ringer's TKO.
   8. Administer 1 milligram of Epinephrine 1:10,000 every 3-5 minutes IV. Follow each intravenous drug bolus with 20 milliliters of IV fluid and elevate extremity. If unable to establish IV access, administer Epinephrine endotracheally.
   9. Defibrillate at 360 joules within 30-60 seconds following administration of each drug.
   10. Administer 1.5 mg/kg Lidocaine intravenously. Repeat every 3-5 minutes until a total of 3 mg/kg has been administered. If unable to establish IV access, administer Lidocaine endotracheally.
   11. Contact medical control.
   12. Consider Bretylium 5 mg/kg IV.
   13. Consider Sodium Bicarbonate IV.
   14. Transport.
   15. Contact medical control for any questions or problems.
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   ECLAMPSIA

   GUIDELINES FOR CARE

   1. 1. Assure ABCs.
   2. Oxygen via non-rebreather mask. consider intubation and hyperventilation with 100% oxygen for markedly decreased LOC, inability to maintain a patient airway, or for GCS * 8.
   3. Secondary survey.
   4. Establish IV of lactated Ringer's at 125 ml/hr.
   5. Valium 5 - 10 mg IVP over 1 minute for seizures.
   6. Monitor EKG, vital signs, fetal heart tones, level of consciousness, patellar reflexes, respiratory rate, oxygenation status every 5 minutes. If patellar reflexes are absent, shut off the infusion and contact medical control immediately.
   7. Keep the patient in left lateral recumbent position.
   8. Contact medical control for other hypertensive agent orders.
   9. Monitor urinary output if possible
   10. Evaluate for pulmonary edema. if present, consider Morphine 2-5 mg IVP over 1-2 minutes and/or Furosemide 20-40 mg IVP over 2-3 minutes.
   11. consider magnesium sulfate if ordered by medical control. begin with a loading dose of 4 - 6 grams of magnesium sulfate (8 ml of 50% solution) in 100 ml of LR over 30 minutes. After loading dose, start magnesium sulfate infusion. Place 10 grams of magnesium sulfate (20 ml of 50% solution) in 250 ml of LR and infuse at 50 ml/hr (2 grams/hr). Remember, magnesium sulfate can cause respiratory depression with cardiovascular collapse. Antidote is calcium chloride IV over 5 minutes.
   12. Place NG tube if appropriate.
   13. Contact medical control for any questions or problems.
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   ENVIRONMENTAL EMERGENCIES (FROSTBITE)

   GUIDELINES FOR CARE

   1. Assure ABCs.
   2. Administer oxygen via non-rebreather mask.
   3. Cardiac monitor and pulse oximeter.
   4. Check core temperature. if core temperature < 35° c, go to Hypothermia Protocol.
   5. Attend to injured areas:
      • Protect injured areas from pressure, trauma, and friction.
        Do not rub or break blisters.
      • Do not allow limb to thaw if there is a chance it will re-freeze.
      • Do not allow patient to ambulate once the limb has started to thaw.
      • Maintain core temperature by keeping victim warm with blankets.
      • Warm fluids may be administered orally to conscious patients.
   6. Consider using the pulse oximeter probe to detect peripheral perfusion in affected tissues.
   7. Consider Morphine or Nalbuphine for pain control.
   8. Transport.
   9. Contact medical control for any questions or problems.
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   ENVIRONMENTAL EMERGENCIES (HYPERTHERMIA)

   GUIDELINES FOR CARE

   1. Assure ABCs.
   2. Administer oxygen via non-rebreather mask.
   3. Start two large bore IVs of lactated Ringer's at TKO. bolus as required to maintain systolic BP >90 mmhg.
   4. Attach monitor and pulse oximeter.
   5. Assess vital signs, including temperature, every 10 minutes.
   6. If history suggestive of heat exhaustion or heat stroke:
      • Remove to cooler environment
      • Cool with ice packs or moist sheets (must have good ambient air flow)
      • Stop cooling measures when core body temp is 39° c.
   7. If seizures are present, and suspected to be heat-related:
      • Protect airway with appropriate airway adjuncts.
      • Valium 2-5 mg IV.
   8. For hypotension refractory to cooling and fluid boluses, initiate Dopamine drip and titrate to maintain systolic BP > 90 mmhg.
   9. Consider NG tube to low suction.
   10. Consider Foley catheter to monitor urine output.
   11. Consider Mannitol 0.5 - 1.0 gm/kg for decreased urine output or altered mental status.
   12. Transport.
   13. Contact medical control for any questions or problems.
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   ENVIRONMENTAL EMERGENCIES (HYPOTHERMIA)

   GUIDELINES FOR CARE

   1. Actions for all patients:
      • Remove wet garments
      • Protect against heat-loss and wind-chill
      • Maintain horizontal position
      • Avoid rough movement and excess activity
      • Monitor core temperature
      • Monitor cardiac rhythm
      • Treat major trauma as the first priority and hypothermia as the second.
   2. Assess responsiveness, breathing, and pulse:
      • If pulse/breathing absent, go to #3.
      • If pulse/breathing present, go to #5.
   3. If pulse/breathing absent:
      • Start CPR.
      • Defibrillate ventricular fibrillation/ventricular tachycardia up to a total of 3 shocks (200 j, 300 j, and 360 j)
      • Intubate.
      • Ventilate with warm, humid oxygen.
      • Establish IV of lactated Ringer's and infuse at 150 ml/hour.
   4. Determine core temperature:
      1. If core temperature <30°c, then
         1. Continue CPR.
         2. Withhold IV medications.
         3. Limit shocks to a maximum of 3.
         4. Transport to hospital.
      2. If core temperature >30°c, then
         1. Continue CPR.
         2. Give IV medications based on dysrhythmia (but at longer intervals.)
         3. Repeat defibrillation for ventricular fibrillation/ventricular tachycardia as core temperature rises.
         4. Transport to hospital.
   5. If pulse/breathing present, administer warm, humidified oxygen, and initiate IV of lactated Ringer's at 150 ml/hour.
   6. Determine serum glucose level with Glucometer or DextroStix. If glucose < 80 mg/dl, give 25 gms d50w IVP (0.5 gms/kg of d25w for children)
   7. Begin external re-warming.
   8. Insert Foley and NG tube for long transports.
   9. Contact medical control for additional orders and transport to hospital.
   10. Contact medical control for any questions or problems.
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   EYE INJURIES

   GUIDELINES FOR CARE

   1. Assure ABCs.
   2. Secondary survey
   3. If chemical injury or foreign body sensation, instill 2 drops Tetracaine ophthalmic drops (0.5% solution) in affected eye if patient not allergic to Tetracaine or the "caine" class of local anesthetics.
   4. If chemical injury, flush immediately with sterile normal saline. continue flushing en route.
   5. Contact medical control
   6. Transport.
   7. Bring chemical container or name of chemical with patient to the emergency department.
   8. Contact medical control for any questions or problems.
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   FRACTURES (GENERAL)

   GUIDELINES FOR CARE

   1. Assure ABCs.
   2. Secondary survey.
   3. Document LOC and orientation.
   4. Consider Nubain 5-10 mg IV or IM or Morphine 2-4 mg IV before moving patient if no evidence of head or abdomen injury.
   5. Immobilize fracture.
   6. Transport.
   7. Contact medical control for any questions or problems.
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   FRACTURES (FEMUR)

   GUIDELINES FOR CARE

   1. Assure ABCs.
   2. Administer oxygen via non-rebreather mask.
   3. Start IV of lactated Ringer's at 250 ml/hour.
   4. if evidence of shock (tachycardia, diaphoresis, hypotension, etc), start second IV of lactated Ringer's and infuse wide-open.
   5. Attach monitor.
   6. Assess vital signs.
   7. Consider Nubain 5-10 mg IV or IM or Morphine 2-4 mg IV before moving patient if no evidence of head or abdomen injury.
   8. Place traction device.
   9. Transport.
   10. Contact medical control for any questions or problems.
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   FRACTURES (PELVIS)

   GUIDELINES FOR CARE

   1. Assure ABCs.
   2. Administer oxygen via non-rebreather mask.
   3. Start IV of lactated Ringer's at 250 ml/hour.
   4. if evidence of shock (tachycardia, diaphoresis, hypotension, etc), start second IV of lactated Ringer's and infuse wide-open.
   5. Attach monitor.
   6. Assess vital signs.
   7. place PASG. Inflate if needed for immobilization or shock.
   8. Transport.
   9. Contact medical control for any questions or problems.
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   HEAD INJURY / SPINAL TRAUMA

   GUIDELINES FOR CARE

   1. Assure ABCs.
   2. Maintain cervical spine immobilization.
   3. Determine level of consciousness (AVPU).
   4. Complete motor examination (paralysis, weakness, posturing), if possible.
   5. Pupillary examination (size, equality).
   6. Complete sensory examination, if possible.
   7. Open wounds which expose the brain tissue should be covered with saline-soaked gauze.
   8. Oxygen via non-rebreather mask. consider intubation and hyperventilation with 100% oxygen for markedly decreased LOC, inability to maintain a patient airway, or for GCS * 8.
   9. if pulseless, apneic:
      Intubate with neck in neutral position (stabilized with traction by second EMT).
      1. Hyperventilate with 100% oxygen.
      2. CPR.
      3. Apply and inflate PASG.
      4. Transport.
      5. Attempt IV lactated Ringer's en route.
      6. Contact medical control en route.
   10. if patient unresponsive:
       1. Hyperventilate with 100% oxygen.
       2. Intubate with neck in neutral position (stabilized with traction by second EMT).
       3. Transport.
       4. Attempt IV lactated Ringer's en route.
   11. if BP <90 mmhg systolic, or signs of shock:
       1. Administer oxygen via a non-rebreather mask.
       2. Immobilize neck.
       3. Apply and inflate PASG.
       4. Transport.
       5. Attempt IV lactated Ringer's en route.
       6. Contact medical control en route.
       7. If combative, check airway, ensure oxygen delivery, and restrain as needed.
   12. Consider Mannitol 0.5 - 1.0 gm/kg IVP.
   13. Anticipate seizures and possible combativeness. Consider Valium 2 - 10 mg IVP for seizures and agitation. be prepared to maintain the airway and ventilate the patient as required.
   14. Consider rapid sequence induction (RSI) and intubation for combative patients. 0.08 - 0.10 mg Vecuronium (Norcuron) should be used for paralysis. May repeat Vecuronium 0.05 mg/kg for continued paralysis en route.
   15. Rapid transport.
   16. If spinal injury with neurological deficit present or suspected, contact medical control for possible initiation of high-dose corticosteroid therapy. Consider vasopressors for spinal shock if ordered by medical control.
   17. Contact medical control for any questions or problems.
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   HYPERTENSIVE CRISIS

   GUIDELINES FOR CARE

   1. Assure ABCs.
   2. Administer oxygen via non-rebreather mask.
   3. Cardiac monitor.
   4. IV lactated Ringer's TKO.
   5. If blood pressure greater than 200/130 mmhg and asymptomatic; or blood pressure greater than 180/110 mmhg and accompanied by tachycardia, headache, or confusion, administer 10 mg Procardia sublingually (puncture capsule with needle and place under patient's tongue or have patient chew the capsule). Do not administer Procardia if patient exhibiting symptoms of pulmonary edema.
   6. Monitor vital signs every 3-5 minutes.
   7. If little or no change in blood pressure following administration of Procardia, contact medical control for additional direction. consider Labetalol or similar agent.
   8. If response to Procardia is too great and hypotension ensues, elevate patient's feet and administer 250 ml fluid bolus of lactated Ringer's. Notify medical control.
   9. Transport.
   10. Contact medical control for any questions or problems.
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   INTRA-AORTIC BALLOON PUMP

   GUIDELINES FOR CARE

   1. Assure ABCs.
   2. Oxygen at 2-3 lpm via a nasal cannula. increase as needed to maintain oxygen saturation > 90%.
   3. Attach cardiac monitor and pulse oximeter.
   4. Establish two large bore IVs of lactated Ringer's at TKO (IV lines will typically be in place and initiated by transferring facility).
   5. Monitor vital signs, ECG, mental status, respiratory and oxygenation status every 10 minutes.
   6. treat dysrhythmias per the appropriate protocol.
   7. Keep the mean arterial pressure (map) between 60-80 mmhg.
   8. Do not elevate the head of the bed greater than 30 degrees. Aeromedical units should communicate with pilot regarding angle of attack during landing and take-off.
   9. Frequently reassess patient.
   10. Contact medical control for any problems.
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   MOTION SICKNESS

   GUIDELINES FOR CARE

   1. Assure ABCs.
   2. Oxygen via non-rebreather mask.
   3. Attach cardiac monitor and pulse oximeter.
   4. Initiate IV of lactated Ringer's at 125 ml/hr. Give 250 ml fluid bolus if systolic pressure < 90 mmhg (20 ml/kg for children).
   5. Be alert for dysrhythmias.
   6. Provide appropriate comfort measures (i.e cool cloth to forehead).
   7. If patient nauseated or has recently vomited, administer Phenergan 12.5 - 25.0 mg IVP or IM. Do not repeat more frequently than every 4 hours unless ordered by medical control.
   8. If patient complains of dizziness or motion sickness, consider administering 25 - 50 mg of Dimenhydrinate (Dramamine) IVP over 30 seconds.
   9. Monitor ECG, vital signs, pulse oximetry, and level of consciousness.
   10. contact medical control for any problems.
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   MULTIPLE TRAUMA

   SITUATIONAL GUIDELINES

   1. The first paramedic on the scene will become the scene director and others arriving later will follow his or her lead until a formal incident command system (ICS) is in place.
   2. Try to keep ambulance crews and equipment together to minimize confusion when several ambulances are present at the scene.
   3. Notify dispatch of the need for more help when the estimated number of injured can be determined.
   4. Note any hazards (chemical spills, downed power lines, etc.)
   5. Begin rendering emergency care with airway being the first priority, followed by oxygenation, and hemorrhage control.
   6. Begin transporting severely injured, but salvageable, patients first. Dead and hopelessly dying patients should not be transported until salvageable patients are removed.
   7. In airplane crashes, be sure to leave a marker noting the position of the patient before removing them from the scene.
   8. If more than 6 patients, use start triage system and declare a multiple casualty incident (see MCI Protocol.)
   9. The following are considered "load and go" situations:
      • Airway obstruction that cannot be relieved by mechanical methods
      • Conditions which result in inadequate respirations
      • Large open chest wounds (i.e. sucking chest wounds)
      • Large flail chest
      • Tension pneumothorax
      • Major blunt chest trauma
      • Traumatic cardiac arrest
      • Shock
      • head injury with unconsciousness, unequal pupils, or deteriorating neurological status.
      • Tender, distended abdomen
      • Bilateral femur fractures
      • Unstable pelvis
      • Development of respiratory difficulty

If patient has unstable vital signs:

1. If patient is severely injured, with systolic blood pressure <90 mmhg in adults, or children with capillary refill time >2 seconds:
   1. Airway with cervical spine control
   2. Breathing
   3. Circulation/perfusion with hemorrhage control
   4. Disability determination (AVPU, motor, posturing)
   5. Exposure
2. Perform a rapid, abbreviated full-body assessment in order to identify any major injuries.
3. If extrication required, perform quickly with spinal immobilization.
4. Place PASG and inflate if no contraindications.
5. Transport.
6. Start 2 IVs of lactated Ringer's en route and run wide open.
7. Contact medical control en route.

If the patient has stable vital signs

1. If the patient's systolic pressure is initially and continuously stable, without significant signs or symptoms of shock, more time may be taken for field assessment:
   1. Airway with cervical spine control.
   2. Breathing.
   3. Circulation/perfusion with hemorrhage control.
   4. Disability determination (AVPU, motor, posturing).
   5. Exposure.
2. Administer oxygen at 100% via non-rebreather mask.
3. Attach cardiac monitor and pulse oximeter.
4. Perform a rapid, full-body assessment in order to identify any major injuries.
5. If extrication required, perform with spinal immobilization.
6. Start an IV of lactated Ringer's en route at 150 ml/hour.
7. Complete splinting and packaging.
8. If head or spinal injury present, see Head Injury/Spinal Injury Protocol.
9. If pelvis or femur fractures present, see Fracture Protocols.
10. If chest trauma present, see Chest Trauma Protocol.
11. Transport.
12. Contact medical control for any questions or problems.

NAUSEA AND VOMITING

GUIDELINES FOR CARE

1. Assure ABCs.
2. Oxygen via a nasal cannula at 2 liters per minute unless higher concentrations warranted by patient condition.
3. Initiate IV of lactated Ringer's at 125 ml/hr.
4. Provide appropriate comfort measures (i.e cool cloth to forehead).
5. If patient nauseated or has recently vomited, administer Phenergan 12.5 - 25.0 mg IVP or IM. do not repeat more frequently than every 4 hours unless ordered by medical control.
6. If patient actively vomiting, administer 5 - 10 mg of Compazine IVP or IM (adult patients only)
7. Monitor ECG, vital signs, pulse oximetry, and level of consciousness.
8. Consider intubating patients with altered mental status who are vomiting.
9. Consider NG tube placement for patients with altered mental status and/or inability to maintain their airway.
10. Contact medical control for any problems.

NEAR-DROWNING

GUIDELINES FOR CARE

1. Assure ABCs.
2. Immobilize cervical spine.
3. Oxygen via non-rebreather mask.
4. Attach cardiac monitor and pulse oximeter.
5. IV of lactated Ringer's TKO.
6. If apneic:
   1. Initiate and maintain mechanical ventilation with 100% oxygen.
   2. Endotracheal intubation (with in-line cervical immobilization.)
   3. Treat any dysrhythmias per appropriate protocol.
   4. Transport and contact medical control en route.
7. Tf apneic and pulseless:
   1. Initiate and maintain mechanical ventilation with 100% oxygen.
   2. CPR.
   3. Endotracheal intubation (with in-line cervical immobilization.)
   4. Treat any dysrhythmias per appropriate protocol.
   5. Transport and contact medical control en route.
8. If hypotensive:
   1. Elevate legs.
   2. Administer 250 ml fluid bolus (20 ml/kg for children). Repeat to maintain systolic BP >90 mmhg. Consider starting a second IV of lactated Ringer's if multiple boluses required.
   3. Transport and contact medical control en route.
   4. Initiate Dopamine drip if patient unresponsive to fluid challenge. begin infusion at 2.0 µg/kg/min and titrate to maintain systolic BP >90 mmhg.
9. Treat dysrhythmias per the appropriate protocol.
10. Consider NG tube at low suction.
11. Start passive re-warming if patient hypothermic.
12. Consider Mannitol 0.5 - 1.0 gram/kg for deteriorating neurological status.
13. Obtain glucometer and administer 25 grams d50w if glucometer <80 mg/dl.
14. Contact medical control for any questions or problems.

PEDIATRIC EMERGENCIES

GUIDELINES FOR CARE

1. Remember that children are not small adults. Treatments vary as do drug dosages and fluid administration rates.
2. Cardiac arrest in children is not a sudden event. it is almost always due to a respiratory problem which leads to hypoxia, bradycardia, and eventually asystole. ventricular fibrillation is a rare event in children. initial treatment should be directed at establishment of an airway, administration of supplemental oxygen, and mechanical ventilation.
3. EOAs, EGTAs, PTL airways, and esophageal combitubes should not be used in children. the preferred method of airway management is endotracheal intubation. demand valves should not be used in children because of the tendency to cause barotrauma.
4. The intraosseous route of fluid and medication administration is available in children less than 6 years of age.
5. Blood pressure is a late sign of shock in children. Instead, you should evaluate end-organ perfusion.

Anticipating Cardiopulmonary Arrest

All sick children should undergo a rapid cardiopulmonary assessment. The goal is to answer the question, "Does this child have pulmonary or circulatory failure that may lead to cardiopulmonary arrest?" Recognition of the physiologically unstable infant is made by physical examination alone. Children who should receive the rapid cardiopulmonary assessment include those with the following conditions.

• respiratory rate greater than 60
• heart rate greater than 180 or less than 80 (under 5 years)
• heart rate greater than 180 or less than 60 (over 5 years)
• respiratory distress
• trauma
• burns
• cyanosis
• altered level of consciousness
• seizures
• fever with petechiae (small skin hemorrhages)

Rapid Cardiopulmonary Assessment

the rapid cardiopulmonary assessment is designed to assist you in recognizing respiratory failure and shock, thus anticipating cardiopulmonary arrest. the rapid cardiopulmonary assessment follows the basic ABCs of CPR.

Airway Patency

inspect the airway and ask yourself the following questions.

• is the airway patent?
• is it maintainable with head positioning, suctioning, or airway adjuncts?
• is the airway unmaintainable. if so, what action is required?

(endotracheal intubation, removal of a foreign body, and so on)

Breathing

evaluation of breathing includes assessment of the following conditions.

• Respiratory rate. Tachypnea is often the first manifestation of respiratory distress in infants. An infant breathing at a rapid rate will eventually tire. Thus, a decreasing respiratory rate is not necessarily a sign of improvement. A slow respiratory rate in an acutely ill infant or child is an ominous sign.
• Air entry. The quality of air entry can be assessed by observing for chest rise, breath sounds, stridor, or wheezing.
• Respiratory mechanics. Increased work of breathing in the infant and child is evidenced by nasal flaring and use of the accessory respiratory muscles.
• color. Cyanosis is a fairly late sign of respiratory failure and is most frequently seen in the mucous membranes of the mouth and the nail beds. Cyanosis of the extremities alone is more likely due to circulatory failure (shock) than respiratory failure.

Circulation

The cardiovascular assessment consists of the following procedures.

• heart rate. Infants develop sinus tachycardia in response to stress. Thus, any tachycardia in an infant or child requires further evaluation to determine the cause. Bradycardia in a distressed infant or child may indicate hypoxia and is an ominous sign of impending cardiac arrest.
• Blood pressure. Hypotension is a late and often sudden sign of cardiovascular decompensation. even mild hypotension should be taken seriously and treated quickly and vigorously, since cardiopulmonary arrest is imminent.
• Peripheral circulation. The presence of pulses is a good indicator of the adequacy of end-organ perfusion. The pulse pressure (the difference between the systolic and diastolic blood pressure) narrows as shock develops. Loss of central pulses is an ominous sign.
• End-organ perfusion. The end-organ perfusion is most evident in the skin, kidneys, and brain. Decreased perfusion of the skin is an early sign of shock. A capillary refill time of greater than 2 seconds is indicative of low cardiac output. Impairment of brain perfusion is usually evidenced by a change in mental status. The child may become confused or lethargic. seizures may occur. Failure of the child to recognize the parents' faces is often an ominous sign. Urine output is directly related to kidney perfusion. Normal urine output is 1-2 ml/kg/hr. urine flow of less than 1 ml/kg/hr is an indicator of poor renal perfusion.

The rapid cardiopulmonary assessment should be repeated throughout initial assessment and patient transport. This will help you determine whether the patient's condition is deteriorating or improving. any decompensation or change in the patient's status should be immediately treated.

PEDIATRIC EMERGENCIES:
CARDIAC ARREST (medical)

GUIDELINES FOR CARE

1. Determine pulselessness and begin CPR.
2. Confirm cardiac rhythm in more than 1 lead.
3. If asystole:
   1. Continue CPR
   2. Secure airway
   3. Hyperventilate with 100% oxygen
   4. Obtain IV or IO access.
   5. Epinephrine (first dose)
      • IV or IO: 0.01 mg/kg of 1:10,000 solution.
      • ET: 0.1 mg/kg of 1:1,000 solution.
   6. Epinephrine (second and subsequent doses)
      • IV, IO, or ET: 0.1 mg/kg of 1:1,000 solution: repeat every 3-5 minutes.
   7. Transport as soon as possible continuing resuscitation en route.
4. If pulseless electrical activity:
   1. Identify and treat causes including hypoxemia, acidosis, hypovolemia, tension pneumothorax, cardiac tamponade, or profound hypothermia.
   2. Continue CPR.
   3. Secure airway.
   4. Hyperventilate with 100% oxygen.
   5. obtain IV or IO access.
   6. Epinephrine (first dose)
      • IV or IO: 0.01 mg/kg of 1:10,000 solution.
      • ET: 0.1 mg/kg of 1:1,000 solution.
   7. Epinephrine (second and subsequent doses)
      • IV, IO, or ET: 0.1 mg/kg of 1:1,000 solution; repeat every 3-5 minutes.
   8. transport as soon as possible continuing resuscitation en route.
5. if ventricular fibrillation/pulseless ventricular tachycardia:
   1. Continue CPR.
   2. Secure airway.
   3. Hyperventilate with 100% oxygen.
   4. Obtain IV or IO access.
   5. Defibrillate up to 3 times (2 j/kg, 4 j/kg, and 4 j/kg).
   6. Epinephrine (first dose)
      • IV or IO: 0.01 mg/kg of 1:10,000 solution.
      • ET: 0.1 mg/kg of 1:1,000 solution
   7. Lidocaine 1 mg/kg IV, IO, or ET.
   8. Defibrillate at 4 j/kg 30-60 seconds after medication.
   9. Epinephrine (second and subsequent doses)
      • IV, IO, or ET: 0.1 mg/kg of 1:1,000 solution; repeat every 3-5 minutes.
   10. Defibrillate at 4 j/kg 30-60 seconds after medication.
   11. Lidocaine 1 mg/kg up to total dose of 3 mg/kg.
   12. Transport as soon as possible continuing resuscitation en route.
6. Contact medical control for any questions or problems.

PEDIATRIC EMERGENCIES
CARDIAC ARREST (trauma)

GUIDELINES FOR CARE

1. If patient is severely injured, and in cardiac arrest:
   • Airway with cervical spine control.
   • Breathing.
   • Circulation/perfusion with hemorrhage control.
   • Disability determination (AVPU, motor, posturing).
   • Exposure
2. If extrication required, perform quickly with spinal immobilization.
3. Perform endotracheal intubation with in-line stabilization of cervical spine.
4. Transport immediately and attempt IV or IO en route. give 20 ml/kg fluid boluses of lactated Ringer's.
5. Contact medical control en route
6. Consider correctable causes:
   • Severe hypoxemia
   • Cardiac tamponade
   • Tension pneumothorax
   • Severe acidosis
7. contact medical control for any questions or problems.

PEDIATRIC EMERGENCIES:
CROUP (LARYNGOTRACHEOBRONCHITIS)

GUIDELINES FOR CARE

1. Assure ABCs.
2. Administer humidified oxygen via non-rebreather mask.
3. Have equipment ready for endotracheal intubation.
4. Place in position of comfort.
5. Pulse oximetry and cardiac monitor.
6. Defer starting an IV if possible.
7. Contact medical control.
8. Consider Ventolin nebulizer or racemic Epinephrine treatment as ordered by medical control.
9. Transport. If child to be transported without intubation, have BVM and airway equipment at the head of the bed. endotracheal intubation equipment should be open and prepared for immediate use if required.
10. Contact medical control for any questions or problems
11. Severe respiratory distress despite the above measures requires intubation. Consider intubating with a tube one full size smaller than would normally be used. use an uncuffed tube.
12. Consider inserting an NG tube for gastric decompression if intubated.
13. If necessary, restrain the child to protect the ET tube. Agitation may be treated with Valium 0.1 - 0.3 mg/kg IV (with a maximum dose of 5.0 mg)

Do not examine pharynx as this may cause laryngospasm in cases of epiglottitis.

PEDIATRIC EMERGENCIES:
EPIGLOTTITIS

GUIDELINES FOR CARE

If necessary, restrain the child to protect the ET tube. agitation may be treated with Valium 0.1 - 0.3 mg/kg IV (with a maximum dose of 5.0 mg)

Do not examine pharynx as this may cause laryngospasm in cases of epiglottitis.

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PEDIATRIC EMERGENCIES:
SUDDEN INFANT DEATH SYNDROME (SIDS)

GUIDELINES FOR CARE

1. Start CPR unless obvious rigor mortis, severe lividity, or early tissue breakdown.
2. Note the condition of the child and the surroundings in which the child was found.
3. Obtain a brief medical history from the parents or guardians.
4. Use extreme tact and professionalism.
5. Transport.
6. See Pediatric Cardiac Arrest (medical) Protocol.
7. Contact medical control en route.
8. contact medical control for any questions or problems.

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POISONING / OVERDOSE

GUIDELINES FOR CARE

1. Assure ABCs.
2. Oxygen via non-rebreather mask.
3. Obtain history:
   • Type and amount of poison.
   • How poisoned (ingested, inhaled, injected, surface contamination.)
   • Time poisoned.
   • Has patient vomited? if so, when?
   • History of drug or EtOH usage.
   • Pre-existing medical problems.
4. Initiate IV lactated Ringer's TKO.
5. Attach cardiac monitor and pulse oximeter.
6. determine serum glucose level with Glucometer or DextroStix.
   • If glucose < 80 mg/dl, administer 25 gms 50% dextrose IV.
   • If glucose > 80 mg/dl and < 250 mg/dl, go to step #7.
7. If inadequate air exchange:
   • Initiate and maintain mechanical ventilation with 100% oxygen.
   • Treat any dysrhythmias per appropriate protocol.
   • Transport and contact medical control en route.
8. If apneic:
   • Initiate and maintain mechanical ventilation with 100% oxygen.
   • Endotracheal intubation.
   • Treat any dysrhythmias per appropriate protocol.
   • Transport and contact medical control en route.
9. If apneic and pulseless:
   • Initiate and maintain mechanical ventilation with 100% oxygen.
   • CPR.
   • Endotracheal intubation (with in-line cervical immobilization.)
   • Treat any dysrhythmias per appropriate protocol.
   • Transport and contact medical control en route.
10. If seizing:
    • Go to Seizure Protocol.
11. If inhaled poison:
    • Assure personal safety.
    • Remove patient to fresh air.
    • Administer 100% oxygen via non-rebreather mask.
12. If skin or eye contamination:
    • Assure personal safety.
    • Remove contaminated clothes.
    • Irrigate with water or normal saline.
13. If blood pressure <90 mmhg, and/or if respirations <10 per minute, and/or possible narcotic overdose:
    • Administer 100% oxygen via non-rebreather mask.
    • Assist ventilations as needed
    • Administer 1-2 mg Narcan IV push. may give IM or endotracheally if unable to start IV.
    • Transport and contact medical control en route
14. If antidepressant OD (tricyclics):
    • Contact medical control.
    • Transport.
    • Consider Sodium Bicarbonate.
15. if Benzodiazepine OD:
    • Administer Flumazenil 0.3 mg IV over 30 seconds. may repeat up to a total dose of 1.0 mg as needed.
    • Transport.
16. Transport.
17. Contact medical control for any questions or problems.
18. EMS units with cellular telephones may contact poison control directly for any questions.
19. Consider administration of activated charcoal.
20. Do not induce emesis in any patient without express orders from medical control.

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PREECLAMPSIA - PREGNANCY INDUCED HYPERTENSION

GUIDELINES FOR CARE

1. Assure ABCs.
2. Oxygen via non-rebreather mask.
3. Secondary survey.
4. Establish IV of lactated Ringer's at 125 ml/hr.
5. monitor ECG, vital signs, fetal heart tones, level of consciousness, patellar reflexes, respiratory rate, oxygenation status every 5 minutes. If patellar reflexes are absent, shut off the infusion and contact medical control immediately.
6. Keep the patient in left lateral recumbent position.
7. Contact medical control for antihypertensive agent orders.
8. Monitor urinary output if possible
9. Evaluate for pulmonary edema. If present, consider Morphine 2-5 mg IVP over 1-2 minutes and/or Furosemide 20-40 mg IVP over 2-3 minutes.
10. Consider magnesium sulfate if ordered by medical control. Begin with a loading dose of 4 - 6 grams of magnesium sulfate (8 ml of 50% solution) in 100 ml of LR over 30 minutes. After loading dose, start magnesium sulfate infusion. Place 10 grams of magnesium sulfate (20 ml of 50% solution) in 250 ml of LR and infuse at 50 ml/hr (2 grams/hr). Remember, magnesium sulfate can cause respiratory depression with cardiovascular collapse. antidote is calcium chloride IV over 5 minutes.
11. Place NG tube if appropriate.
12. Contact medical control for any questions or problems.

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PRE-TERM LABOR

GUIDELINES FOR CARE

1. Assure ABCs.
2. Oxygen via non-rebreather mask.
3. Secondary survey.
4. Establish IV of lactated Ringer's at 125 ml/hr.
5. Consider fluid bolus as initial tocolytic therapy.
6. Position the patient in the left lateral recumbent position.
7. Record frequency, character and duration of contractions, fetal heart tones, blood pressure, and pulse every 15 minutes.
8. Administer tocolytics as ordered.
9. Transport.

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PSYCHIATRIC EMERGENCIES

GUIDELINES FOR CARE

1. Assure personal safety. Call police.
2. Approach patient only when safe to do so.
3. Talk in an even, reassuring tone.
4. Restrain if suicidal or homicidal or if patient has a life-threatening emergency (with police assistance only.)
5. Perform primary assessment
6. Perform secondary assessment:
   • Look for medical or traumatic causes for the patient's behavior.
   • Note behavior.
   • Note mental status.
   • Obtain drug/alcohol/medical history/psychiatric history.
7. Administer oxygen at 6-10 lpm (if COPD, give 2 lpm via nasal cannula.
8. IV lactated Ringer's TKO.
9. Determine serum glucose level with Glucometer or DextroStix.
   • if glucose < 80 mg/dl, administer 25 gms 50% dextrose IV.
   • if glucose > 80 mg/dl and < 250 mg/dl, go to step #10.
10. If history of alcoholism, or alcoholism suspected:
    • administer Thiamine 100 mg IV or IM.
11. Transport (if restrained, have police accompany patient.)
12. Consider Haldol 2-5 mg IM for sedation.
13. Contact medical control for any problems or questions.

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PULMONARY EMBOLISM

GUIDELINES FOR CARE

1. Assure ABCs.
2. Oxygen via non-rebreather mask if no history of COPD. if history of COPD, titrate oxygen delivery to maintain SPO2 > 90%. consider intubation and hyperventilation with 100% oxygen for markedly decreased LOC, inability to maintain a patient airway, or for GCS * 8.
3. Initiate IV lactated Ringer's TKO.
4. Attach cardiac monitor and pulse oximeter.
5. If signs of severe hypoventilation:
   • Assist ventilations with BVM with 100% oxygen.
   • Consider endotracheal intubation
   • Contact medical control
6. If history suspicious for pulmonary embolism:
   • Place in position of comfort (preferably with extremities lower than level of heart)
   • Consider Morphine 2-5 mg IVP for pain. may repeat to a maximum of 10 mg.
   • Consider Valium 2-5 mg IVP for anxiety
   • Transport.
7. Contact medical control for any questions or problems.

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SEIZURES

GUIDELINES FOR CARE

1. Assure ABCs.
2. Oxygen via non-rebreather mask.
3. Initiate IV lactated Ringer's TKO.
4. If actively seizing, go to #7 below:
5. If not actively seizing:
   1. Open airway and suction PRN.
   2. Proceed with secondary survey.
   3. Obtain history.
   4. Apply cardiac monitor and pulse oximeter.
6. Determine serum glucose level with Glucometer or DextroStix.
   • If glucose < 80 mg/dl, administer 25 gms 50% Dextrose IV.
7. If actively seizing:
   1. Protect patient from injury.
   2. Do not attempt to insert tongue blade or oral airway.
   3. Suction prn.
   4. Nasopharyngeal airway may be useful.
8. if seizures prolonged (>5 minutes):
   1. Draw blood tube, if possible.
   2. Administer Valium 2-5 mg IV (adults.)
   3. Determine serum glucose level. if glucose < 80 mg/dl, administer 25 gms 50% dextrose IV.
   4. Transport and contact medical control en route.
9. If recent seizure, and patient is post-ictal:
   1. Place in recovery position.
   2. Suction prn.
   3. Transport.
10. If patient is a child, and actively seizing:
    1. Protect patient from injury.
    2. Contact medical control.
    3. Consider Valium as ordered by medical control.
    4. Transport.
11. Contact medical control for any questions or problems.

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SEXUAL ASSAULT

GUIDELINES FOR CARE

1. Assure ABCs.
2. Reassure patient and provide emotional support.
3. Perform secondary survey.
4. Treat all injuries appropriately, preferably with a relative present.
5. Protect the scene and preserve evidence. Do not allow the patient to bathe, change clothes, go to the bathroom, or douche.
6. Notify police if not already informed.
7. Transport to hospital which is equipped to perform sexual assault examinations.
8. Contact medical control for any questions or problems.

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SNAKEBITE

GUIDELINES FOR CARE

1. Kill the snake, if practical, and bring the dead snake to the emergency department (or identify). Do not mutilate the snake's head.
2. Assure ABCs.
3. Administer oxygen via non-rebreather mask.
4. If bite on extremity, immobilize affected extremity in dependent position. Patient should remain still. Place 1" wide venous constricting band proximal to bite. Check for arterial pulses before and after application. if no pulse, loosen band until pulse returns.
5. Remove watches, rings, and jewelry from affected extremity.
6. If signs of toxicity (local edema and hypotension):
   • increase oxygen delivery to 100% via non-rebreather mask
   • start IV lactated Ringer's at 150 ml/hour (wide open if signs of shock)
7. Contact medical control.
8. Reassure and transport.
9. Contact medical control for any questions or problems.

General Information:
Pit Vipers: rattlesnake, water moccasin, and copperhead typically cause puncture wounds. There may be ecchymosis at site, localized pain, swelling, weakness, tachycardia, nausea, shortness of breath, dim vision, vomiting, or shock.
Coral Snakes: Usually chewed wound. There may be slight burning pain, mild swelling, blurred vision, drooping eyelids, slurred speech, drowsiness, salivation and sweating, nausea and vomiting, shock, respiratory difficulty, paralysis, convulsions, and coma.

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SYNCOPE

GUIDELINES FOR CARE

1. Assure ABCs.
2. Oxygen via non-rebreather mask.
3. Initiate IV of lactated Ringer's.
4. Cardiac monitor. If dysrhythmia, go to appropriate protocol.
5. Obtain vital signs. if BP <90 mmhg systolic:
   1. Elevate legs.
   2. Recheck blood pressure.
   3. If still hypotensive, give 250 ml fluid bolus (20 ml/kg for children)
6. Pulse oximetry.
7. Obtain pertinent history:
   • Time of syncopal episode and length of unconsciousness.
   • Patient's position at time of syncope.
   • Symptoms preceding event (dizziness, nausea, chest pain, headache, seizures, etc.)
   • Medications / EtOH / drug usage.
   • Relevant past medical history.
8. Determine serum glucose level with Glucometer or DextroStix.
   • If glucose < 80 mg/dl, administer 25 gms 50% dextrose IV>
   • If glucose > 80 mg/dl and < 250 mg/dl, go to step #9.
9. Place in recovery position.
10. Prepare to suction and manage airway.
11. Repeat vital signs frequently. watch for hypertension.
12. Transport to designated hospital.
13. Contact medical control for any questions or problems.

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WEAK AND DIZZY

GUIDELINES FOR CARE

1. Assure ABCs.
2. Oxygen via non-rebreather mask.
3. Attach cardiac monitor and pulse oximeter.
4. Initiate IV of lactated Ringer's at 125 ml/hr. Give 250 ml fluid bolus if systolic pressure < 90 mmhg (20 ml/kg for children).
5. Be alert for dysrhythmias.
6. Provide appropriate comfort measures (i.e cool cloth to forehead).
7. If patient nauseated or has recently vomited, administer Phenergan 12.5 - 25.0 mg IVP or IM. Do not repeat more frequently than every 4 hours unless ordered by medical control.
8. If patient complains of dizziness or motion sickness, consider administering 25 - 50 mg of Dimenhydrinate (Dramamine) IVP over 30 seconds.
9. Monitor ECG, vital signs, pulse oximetry, and level of consciousness.
10. Contact medical control for any problems.

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Copyright © 1997