for EMT-INTERMEDIATE SERVICES
in SOUTHWESTERN OHIO

Acknowledgments: 

Thanks to the members of the Southwestern Ohio PreHospital Care Operations protocol subcommittee for the hard work and dedication shown this project.

• Ray Mueller, RN, CEN, EMT-P Middletown Regional Hospital
• Debbie Boatright, RN, EMT-I Mercy Anderson Hospital
• Linda Lotz, EMT-I North College Hill Fire Department
• Gail Rose, EMT-P Sycamore Township Fire / Rescue
• Daniel Lankin, MD, FACEP Chairman

Table of Contents

ADMINISTRATIVE PROTOCOLS

INITIATING MEDICAL CONTROL CALL
COMMUNICATION VARIANCE FORM
CONTROL OF EMERGENCY MEDICAL SERVICES IN THE FIELD
PREHOSPITAL TRAUMA TRIAGE CONSIDERATIONS
DETERMINATION OF DEATH
DO NOT RESUSCITATE ORDERS IN THE FIELD

MEDICAL TREATMENT PROTOCOLS

CARDIAC ARRHYTHMIAS

VENTRICULAR FIBRILLATION
VENTRICULAR TACHYCARDIA WITH A PULSE (UNSTABLE)
ASYSTOLE (CARDIAC STAND STILL)
PULSELESS ELECTRICAL ACTIVITY -PEA (formally EMD)
BRADYCARDIA
PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA - (STABLE)
PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA - (UNSTABLE)

MEDICAL PROBLEMS

CHEST PAIN
HYPERTENSIVE EMERGENCY
CARDIOGENIC SHOCK
RESPIRATORY DISTRESS (Obstruction or stridor)
RESPIRATORY DISTRESS (Asthma/COPD/CHF)
ALTERED LEVEL OF CONSCIOUSNESS
ANAPHYLAXIS/ALLERGIC REACTIONS
SEIZURE
TOXICOLOGIC EMERGENCIES
HYPOTHERMIA

SURGICAL PROBLEMS

HEMORRHAGIC SHOCK
HIGH RISK POTENTIAL FOR SHOCK
HEAD OR SPINAL TRAUMA
BURNS (Thermal or Electrical)
IMMINENT DELIVERY

PEDIATRIC PROBLEMS

NEWBORN RESUSCITATION
PEDIATRIC ASYSTOLE
PEDIATRIC BRADYCARDIA
PEDIATRIC PULSELESS ELECTRICAL ACTIVITY - PEA
PEDIATRIC PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA

Appendix A: Medication List
Appendix B: Equipment List

ACADEMY OF MEDICINE OF CINCINNATI

ADMINISTRATIVE PROTOCOLS

1. Calls may only be initiated from an Academy of Medicine Intermediate department to an Academy of Medicine recognized medical command base station.

2. A call MUST be initiated:

a. about any patient who is unstable,
b. when required to do so in the applicable management protocol,
c. when there is doubt about diagnosis, treatment, or disposition of the patient,
d. for multiple casualty incidents (greater than 5 victims),
e. for radiation or other hazardous materials incidents are encountered.

3. A call MAY be initiated:

a. when notification will speed or improve patient care or,
b. whenever it is thought necessary by the intermediate

4. When a call is not possible, these protocols shall act as standing orders for procedures which may be performed by certified intermediates and intermediate trainees under the direct supervision of a certified paramedic who is in direct contact with the on-line medical control physician. Certain procedures and medications require physician consultation prior to performance of the procedure or administration of the medication. These procedures are noted in the individual protocols. Under the certain circumstances, an exception is permitted when communication problems are encountered. In these cases, a communication variance is to be completed.

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COMMUNICATION VARIANCE FORM

This form must be completed whenever a procedure which normally requires the approval of a medical control physician has been performed without such approval. Certain procedures and drugs may not be given without medical control approval under any circumstances.

Copy 1: EMS Service Copy 2: Hospital EMS Coordinator
Copy 3: Regional EMS Committee

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CONTROL OF EMERGENCY MEDICAL SERVICES
AT THE SCENE OF AN EMERGENCY.

One of the most difficult situations for the intermediate is that created by the arrival of a physician at the scene. A different set of responsibilities exists when that physician knows and has established a previous doctor-patient relationship with the patient as opposed to when no such relationship exists. Physicians who are part of the EMS system such as the service's medical advisor or on-line medical control physician are generally responsible for patient care.

Physician Without Previous Doctor-Patient Relationship

1. For a fully licensed physician who is not part of the EMS system to assume control at the scene of an emergency, all of the following must take place:

a. Proof of the physician's identity and current Ohio licensure must be provided to the senior EMT-I.

b. The physician must agree to accompany the patient to the hospital.

c. The on-line medical control physician must be notified and agree to relinquish control to the on-scene physician. This can usually best be accomplished by having the medical control physician speak directly with the physician at the scene.

d. The physician at the scene must agree to sign his or her orders.

2. If control of the emergency is given to the on-scene physician, then the physician can only issue orders within the scope of training and practice of the EMT-I.

3. Any orders or procedures outside of the EMT-I's scope of practice will have to be carried out personally by the on-scene physician.

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Physician with Previous Doctor-Patient Relationship

1. As a general rule, it is desirable that the EMT-I's called to the scene of an emergency, even within a physician's office, perform an assessment and manage the patient just as would be done in any other location.

2. If the physician wishes to take control of the patient's management, he or she may do so if:

a. communication is established between on-line medical control and the physician at the scene, and

b. the scene physician agrees to accompany the patient to the hospital.

3. If control of the emergency is assumed by the on-scene physician then:

a. The physician's Ohio license number will be recorded on the run report.

b. Orders within the scope of training and practice of the EMT-I will be carried out.

c. Orders or procedures outside the scope of training and practice of the EMT-I will be personally carried out by the on-scene physician.

d. The on-scene physician will sign his or her orders.

e. The on-scene physician must accompany the patient in the ambulance to the hospital unless released by the on-line medical control physician.

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Prehospital Trauma Triage Considerations

In cases of significant trauma, transport to a trauma center should be considered. Individual circumstances may demand flexibility and judgement on the part of the responsible paramedic or physician. These guidelines are not to be construed as mandatory or all inclusive.

Time, distance, and patient condition are extremely important variables to consider when triaging injured patients to hospitals. In the rural environment, an injured patient may be at substantial distance from a trauma center. Such patients may be treated initially at the nearest JCAHO approved (24 hour physician coverage) emergency facility.

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Determination of Death

Protocol

1. Resuscitative efforts must be started on all patients who are found apneic and pulseless,

UNLESS:

A. The emergency care providers are presented with a valid Do Not Resuscitate order as defined in the Do Not Resuscitate protocol, OR

B. There is an injury that is obviously incompatible with life. Examples are decapitation or burned beyond recognition, OR

C. The victim shows signs of rigor mortis (in a warm environment) or decomposition.

2. Once started, resuscitation efforts must continue until the resuscitation is terminated by a physician.

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Do Not Resuscitate Orders
in the Field

Protocol

1. All home care Do Not Resuscitate (DNR) orders must be dated and signed by the patient and at least two witnesses.

A. Home care DNR's shall not expire unless the document specifies a time for expiration. If the patient lacks capacity to make informed health care decisions on the date the DNR would expire, then the DNR shall continue in effect until the patient regains capacity to make informed health care decisions for themselves.

2. DNR's set forth in long-term care facility medical records shall be signed by the attending physician and dated.

A. DNR's set forth in long-term care facility medical records shall not expire unless the document specifies a time for expiration. If the patient lacks capacity to make informed health care decisions on the date the DNR would expire, then the DNR shall continue in effect until the patient regains the capacity to make informed health care decisions for themselves.

3. In the event a DNR is presented to an EMT, communication with a base hospital physician, EMS medical advisor, family physician or physician on the scene shall be established.

A. A DNR may be honored in accordance with the provisions of this protocol where it is determined that the patient is no longer capable of making informed decisions.

B. A DNR may not be honored where the patient is pregnant, where withholding CPR would terminate the pregnancy, and where it is probable that the fetus will develop to the point of live birth if treatment is provided.

C. If the EMT believes a DNR is valid, there is no need to commence CPR while waiting for physician orders. If the EMT has any doubt, the EMT need not comply with the DNR (and may commence CPR) unless and until a physician has verbally authorized compliance. Such authorization shall be documented by the EMT's on the run report.

4. In the case of any doubt or reservation as to the validity or authority of any DNR, and

absent authorization by a base hospital physician, EMS medical advisor, family physician

or physician on the scene to withhold CPR, the EMT shall provide CPR to the patient and

shall document the reasons for not complying with the DNR.

5. In the event resuscitation is initiated on a patient and then a valid DNR is subsequently identified, resuscitation may be terminated in compliance with that DNR upon specific verbal authorization from a base hospital physician, EMS medical advisor, family physician, or physician on the scene. Documentation shall be made on the run sheet indicating the events that happened set forth in chronological order, including the authorization to stop CPR in the field. In the event a DNR is identified after a patient has been intubated, the tube shall not be removed in the prehospital setting. If the initial resuscitation has restored cardiac rhythm, the patient should be transported to the nearest appropriate medical facility with no further procedures or pharmacological measures undertaken, except by authorization from the base hospital physician, EMS medical advisor, family physician, or physician on the scene. Communication with a physician should be established.

6. A DNR signed by both parents of a minor child or by the spouse of a patient in a terminal condition who is no longer able to make informed decisions, and signed by two witnesses, may be honored.

7. A copy of the DNR shall be attached to the EMS run report and the medical record of the patient.

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MEDICAL TREATMENT PROTOCOLS

CARDIAC ARRHYTHMIAS

Ventricular Fibrillation (V-Fib) & Ventricular Tachycardia Without A Pulse

Historical Findings

1. Age > 14 years.
2. Patient is unconscious.

Physical Findings

1. Patient is unresponsive.
2. Patient is without a pulse.

EKG Findings

1. Ventricular Fibrillation or
2. Ventricular Tachycardia.

Protocol

1. If collapse is witnessed and monitored, administer a precordial thump.

2. Apply quick look paddles if not already monitored.

3. If rhythm is ventricular fibrillation or ventricular tachycardia, DEFIBRILLATE IMMEDIATELY AT 200 JOULES.

4. If no change, defibrillate at 300 Joules.

5. If no change, defibrillate at 360 Joules.

6. If no change, begin CPR, and do CPR for 1 full minute. CPR should not be interrupted for more than 30 seconds. Begin transport immediately and call for medic backup if available.

7. Aggressively assure good oxygenation of patient and secure airway, using bag-valve-mask and 100% O₂. Endotracheal intubate if authorized by Medical Director.

8. If no change in rhythm after 1 minute, then repeat defibrillation at 360 Joules three additional times.

9. Initiate IV with Normal Saline at keep open rate.

10. Contact medical control.

11. If VF or pulseless VT reoccur after transiently converting, defibrillate at whatever energy level has previously been successful for defibrillation.

Notes:

1. Defibrillation is the definitive way to treat VF and pulseless VT. It is the MOST important intervention in ACLS. The patient should be defibrillated as soon as possible. If other interventions can be accomplished simultaneously with defibrillation, they may be carried out. However, DO NOT DELAY DEFIBRILLATION. There should not be a pause for a pulse check between the first, second and third shocks in the initial sequence as long as the properly connected monitor continues to show persistent VF/VT. The use of adhesive pads may facilitate rapid shock delivery.

2. If VT or pulseless VT reoccur after transiently converting, defibrillate at whatever energy level has previously been successful for defibrillation.

3. Intubation is the preferable method of airway control. If it can be accomplished simultaneously with other techniques, then the earlier the better. In addition, intubation provides a route of administration of medication in the absence of an IV.

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Ventricular Tachycardia With A Pulse
(UNSTABLE)

Historical Findings

1. Age > 14 years.
2. Patient complains of chest pain, or shortness of breath.

Physical Findings

1. Palpable pulse with a rate > 150.
2. Systolic blood pressure less than 90 or
3. Signs of inadequate perfusion such as acute heart failure, delayed capillary refill, or altered mental status.

EKG Findings

1. Rate above 150.
2. Wide QRS (= 0.12 sec or 3 little blocks).
3. Absent P waves. NOTE: When doubt exists about whether the rhythm is ventricular tachycardia (VT) or supraventricular tachycardia, then treat for ventricular tachycardia.

Differential Diagnosis

1. Stable ventricular tachycardia.
2. Supraventricular tachycardia.

Protocol

1. Aggressively assure good oxygenation of patient and secure airway, administer 0₂ at high flow and high concentration, preferably by non-rebreather face mask at 10 L/min. Endotracheal intubate if authorized by Medical Director.

2. Determine the Level of Consciousness. Begin transport immediately and call for medic backup if available.

3. Maintain cardiac monitoring at all times.

4. Initiate large bore IV with Normal Saline to run at keep open rate.

5. Contact medical control.

6. If VT persists, medical control may order defibrillation at 100 joules.

7. If VT persists, repeat defibrillation at 200 joules.

8. If VT persists, repeat defibrillation at 300 joules.

9. If VT persists, repeat defibrillation at 360 joules.

Notes

1. If the patient is unconscious or severely obtunded, then proceed directly to contacting medical control for defibrillation before establishing an IV line.

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Asystole
(Cardiac Stand Still)

Historical Findings

1. Age > 14.
2. Patient is unconscious.

Physical Findings

1. Patient is unresponsive.
2. Patient is without a pulse.

EKG Findings

1. Rhythm is asystole (flat line)

Protocol

1. Apply quick look paddles if not already monitored.

2. Aggressively assure good oxygenation of patient and secure airway, initiate CPR using bag-valve-mask and 100% 0₂. Endotracheal intubate if authorized by Medical Director.

3. Attach monitor leads and confirm asystole in two leads.

4. If rhythm is unclear and there is a possibility that the rhythm is fine VF, then defibrillate as for ventricular fibrillation.

5. Monitor and begin transport immediately and call for medic backup if available.

6. Initiate IV of Normal Saline at keep open rate.

7. Contact medical control.

Notes

1. Intubation is the preferable method of airway control. If it can be accomplished simultaneously with other techniques, then the earlier the better.

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Pulseless Electrical Activity (PEA)

Historical Findings

1. Age > 14.
2. Patient is unconscious.

Physical Findings

1.     Patient is unresponsive.
2. Patient is without a pulse.

EKG Findings

1. There is some type of electrical activity other than ventricular fibrillation or ventricular tachycardia.

Protocol

1. Apply quick look paddles if not already monitored.

2. Aggressively assure good oxygenation of patient and secure airway, initiate CPR using bag-valve-mask and 100% 0₂. Endotracheal intubate if authorized by Medical Director.

3. Attach monitor leads.

4. Monitor and begin transport immediately and call for medic backup if available.

5. Initiate large bore IV of Normal Saline and begin to administer 1 liter wide open.

6. Search for possible causes of PEA.

7. Contact medical control.

Medical control may consider the following:

8. Additional fluid challenge.

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Symptomatic Bradycardia

Historical Findings

1. Age > 14 years.
2. Patient complains of chest pain, shortness of breath or inability to give history due to alteration in level of consciousness which are thought to be related to the slow heart rate.

Physical Findings

1. Pulse rate < 60.
2. Systolic blood pressure less than 90, cardiogenic shock, or pulmonary edema.

EKG Findings

1. Ventricular rate less than 60.

All of the above criteria should be present before proceeding with the protocol.

Protocol

1. Apply quick look paddles if not already monitored.

2. Rapidly assess airway adequacy and ventilation. Position and open the airway. Use airway adjuncts as necessary.

3. Administer high flow oxygen. Use 100% oxygen at high rate (e.g., non-rebreather mask at 10 L/min). Allow parent to assist in oxygen administration in young or anxious children. Where available, maintain oxygen saturation from pulse oximetry > 95%.

4. Check vital signs frequently. Monitor and begin transport immediately and call for medic backup if available.

5. Initiate IV of Normal Saline to run at keep open rate.

6. Contact medical control. Medical control may consider a fluid challenge.

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Paroxysmal Supraventricular Tachycardia (PSVT)
STABLE

Historical Findings

1. Age > 14.
2. Patient does not have chest pain or shortness of breath.

Physical Findings

1. Patient is alert.
2. Systolic blood pressure is above 90 mm Hg.

EKG Characteristics

1. Rapid (140-250), regular rate.
2. Normal QRS duration of less than 0.12 seconds (three little blocks).
3. P waves are usually absent.

Differential Diagnosis

1. Ventricular tachycardia.
2. Sinus tachycardia.
NOTE: Distinguishing PSVT from ventricular tachycardia is frequently difficult. If the duration of the QRS is 0.12 seconds or greater, assume the rhythm is ventricular tachycardia and treat accordingly. If there is any doubt about the origin of the rhythm, it is safer for the patient to assume the rhythm is ventricular tachycardia not PSVT.

Protocol

1. Rapidly assess airway adequacy and ventilation. Position and open the airway. Use airway adjuncts as necessary.

2. Administer high flow oxygen. Use 100% oxygen at high rate (e.g., non-rebreather mask at 10 L/min). Allow parent to assist in oxygen administration in young or anxious children. Where available, maintain oxygen saturation from pulse oximetry > 95%.

3. Place patient on cardiac monitor.

4. Initiate IV with Normal Saline to run at keep open rate.

5. Begin transport immediately and call for medic backup if available.

6. Contact medical control.

7. Have patient perform Valsalva.

8. Monitor patient frequently. If patient deteriorates, move to unstable arm of the PSVT protocol.

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Paroxysmal Supraventricular Tachycardia (PSVT)
UNSTABLE

Historical Findings

1. Age > 14.

Physical Findings

The presence of any of the following criteria means this rhythm is unstable:

1. Chest pain, or
2. Systolic blood pressure below 90 mm Hg, or
3. Signs of acute heart failure or pulmonary edema, or
4. Altered level of consciousness.

EKG Characteristics

1.     Rapid (140-250), regular rate.

2. Normal QRS duration of less than 0.12 seconds (three little blocks).

3. P waves are usually absent.

Differential Diagnosis

1. Ventricular tachycardia.

2. Sinus tachycardia. NOTE: Distinguishing PSVT from ventricular tachycardia is frequently difficult. If the duration of the QRS is 0.12 seconds or greater, assume the rhythm is ventricular tachycardia and treat accordingly. If there is any doubt about the origin of the rhythm, it is safer for the patient to assume the rhythm is ventricular tachycardia not PSVT.

Protocol

1. Rapidly assess airway adequacy and ventilation. Position and open the airway. Use airway adjuncts as necessary.

2. Administer high flow oxygen. Use 100% oxygen at high rate (e.g., non-rebreather mask at 10 L/min). Allow parent to assist in oxygen administration in young or anxious children. Where available, maintain oxygen saturation from pulse oximetry > 95%.

3. Place patient on monitor. Begin transport immediately and call for medic backup if available.

4. Establish IV with Normal Saline to run at keep open.

5. Contact medical control.

6. Have patient perform Valsalva.

7. Monitor closely, if patient continues to deteriorate, or becomes unresponsive medical control may elect to order defibrillation of the patient.

Notes

1 . Supraventricular tachycardia requires emergency treatment when it:

a. Causes or exacerbates cardiovascular dysfunction (e.g., induces or exacerbates chest pain, dyspnea, other signs of ischemia, hypotension, or congestive heart failure) or

b. Occurs in a setting where deleterious effects due to the tachycardia are likely (e.g., patients with acute ischemic heart disease such as acute myocardial infarction). In such cases synchronized cardioversion is the treatment of choice, hence the need for ALS back-up. (AHA, ACLS Manual, 1992)

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MEDICAL PROBLEMS

Chest Pain

Historical Findings

1. Age over 25 years.

2. Chest pain description suggests cardiac origin (heaviness, pressure, tightness, dull) and may be accompanied by shortness of breath, diaphoresis, nausea, vomiting or weakness.

3. Pain is not clearly pleuritic or musculoskeletal. If any doubt exists, treat as cardiac.

Physical Findings

1. Pulse between 60 and 140 beats per minute.
2. Systolic blood pressure greater than 100.

Differential Diagnosis

1. Non-cardiac chest pain.
2. COPD
3. Cardiogenic shock.
4. Arrhythmia.

Protocol

1. Initial patient contact - reassure, explain procedures.

2. Administer high flow oxygen. Use 100% oxygen at high rate (e.g., non-rebreather mask at 10 L/min). Allow parent to assist in oxygen administration in young or anxious children. Where available, maintain oxygen saturation from pulse oximetry > 95%.

3. Place patient on cardiac monitor and obtain rhythm strip. If not sinus rhythm between 60-140, go to arrhythmia protocols.

4. Begin transport immediately and call for medic backup if available. Monitor vital signs frequently.

5. Establish IV access with Saline Lock or Normal Saline at keep open rate.

6. Contact medical control.

7. Determine whether the patient has taken Sildenafil (Viagra) in the previous 24 hours.

8. If the patient has not taken Sildenafil in the previous 24 hours and the patient has Nitroglycerin, assist patient with dose of 0.4 mg Sublingual if BP = 100 systolic.

9. If no relief of chest pain after 5 minutes and systolic BP = 100, may assist patient administer a second Nitroglycerin. If no relief after another 5 minutes and systolic BP = 100, may assist patient administer a third Nitroglycerin.

Notes

1. Since time is important in order to facilitate possible thrombolytic therapy, transport should not be delayed for medical control or additional Nitroglycerin. However, patient handling is extremely important with chest pain patients. Handle gently. The ambulance ride should be relaxed, with no lights/siren if practical. If lights/siren must be used, explain carefully to the patient.

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Hypertensive Emergency

Historical Findings

1. Age > 14.
2. Patient is NOT a victim of trauma or pregnant.
3. Patient has headache, confusion, vomiting, blurred vision, chest pain, or shortness of breath.

Physical Findings

1. Diastolic blood pressure of 130 or above, AND
2. Systolic blood pressure of 180 or above.

Notes

1. Hypertension associated with severe head trauma may be protective and field treatment should be aimed at the head injury not BP control.

2. Completely asymptomatic patients do not require treatment of their hypertension. Remember to treat the patient, not the number.

Protocol

1. Administer high flow oxygen. Use 100% oxygen at high rate (e.g., non-rebreather mask at 10 L/min). Allow parent to assist in oxygen administration in young or anxious children. Where available, maintain oxygen saturation from pulse oximetry > 95%.

2. Place patient at rest and reassure.

3. Repeat blood pressure in both arms. Monitor and begin transport immediately and call for medic backup if available.

4. Establish IV with Normal Saline at keep open rate.

5. Treat arrhythmias per protocol.

6. Treat chest pain, respiratory distress, seizures, or coma per protocol.

7. Contact medical control.

8. Determine whether the patient has taken Sildenafil (Viagra) in the previous 24 hours.

9. If the patient has not taken Sildenafil in the previous 24 hours, the patient has Nitroglycerin and blood pressure remains elevated on the order of the medical control physician, may assist patient with dose of Nitroglycerin, 0.4 mg.

10. If after 10 minutes there is not an adequate response to the first Nitroglycerin, medical control may order a second dose.

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Cardiogenic Shock

Historical Findings

1. Age > 14.
2. History of chest pain suggestive of cardiac origin and/or dyspnea.
3. No evidence or history of trauma or bleeding.

Physical Findings

1. Systolic blood pressure = 80 mm Hg supine, OR
2. Systolic blood pressure 80-100 mm Hg and one of the following:

A. Pulse greater than 120,
B. Skin changes suggestive of shock, OR
C. Altered level of consciousness, agitation, or restlessness.

Protocol

1. Administer high flow oxygen. Use 100% oxygen at high rate (e.g., non-rebreather mask at 10 L/min). Allow parent to assist in oxygen administration in young or anxious children. Where available, maintain oxygen saturation from pulse oximetry > 95%.

2. Place patient on cardiac monitor and obtain rhythm strip. If dysrhythmia is present, proceed to appropriate protocol.

3. Monitor vital signs frequently.

4. Begin transport immediately and call for medic backup if available.

5. Contact medical control.

6. Establish large bore IV with Normal Saline and infuse 500 ml fluid challenge if lungs are clear. If lungs are not clear, run IV at keep open rate or at rate specified by medical control.

7. Update medical control of patient's condition.

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Respiratory Distress
(Obstruction or Stridor)

Historical Findings

1. Patient complains of shortness of breath or cannot speak because of airway obstruction.

2. MAY have history suggestive of foreign body aspiration such as sudden onset of shortness of breath while eating.

Physical Findings

1. Airway exam has little or no air movement, stridor, or decreased breath sounds.

2. MAY have use of accessory muscles of respiration.

3. MAY have fever or drooling.

4. MAY have retractions or rapid respiratory rate.

EKG Findings

1. Normal sinus rhythm, sinus tachycardia, or atrial fibrillation with controlled ventricular response. If other rhythm is present, then proceed to appropriate arrhythmia protocol.

Differential Diagnosis

1. Congestive heart failure.
2. Foreign body aspiration.
3. Epiglottis.
4. Croup (in a child).
5. Asthma.

Protocol

1. Rapidly assess airway adequacy and ventilation. Position and open the airway. Use airway adjuncts as necessary.

2. Administer high flow oxygen. Use 100% oxygen at high rate (e.g., non-rebreather mask at 10 L/min). Allow parent to assist in oxygen administration in young or anxious children. Where available, maintain oxygen saturation from pulse oximetry > 95%.

3. If complete airway obstruction by foreign body is suspected and the patient is over 1 year of age:

A. If the patient is conscious:

I. have the patient cough forcefully if possible.

II. perform the Heimlich maneuver until successful or the victim becomes unconscious.

III. perform foreign body check (do not perform blind finger sweeps in children).

IV. open airway and perform rescue breathing.

V. if airway remains obstructed, give 5 abdominal thrusts,

1. go back to III. and repeat until personnel with intubation equipment are available or maneuvers are successful.

B. If the patient is unconscious when found:

I. open airway and perform rescue breathing.

II. perform 5 abdominal thrusts.

III. perform foreign body check (do not perform blind finger sweeps in children).

IV. open airway and perform rescue breathing.

V. go back to II. and repeat until personnel with intubation equipment are available or maneuvers are successful.

4. If complete airway obstruction by foreign body is suspected and the patient is less than 1 year old:

A. If infant is conscious:

I. deliver 5 back blows.

II. deliver 5 chest thrusts.

III. repeat steps I. and II. until either foreign body is expelled or the infant becomes unconscious.

IV. perform tongue-jaw lift. Remove foreign body only if you see it.

V. open airway and perform rescue breathing.

VI. deliver 5 back blows.

VII. deliver 5 chest thrusts.

VIII. go back to IV. and repeat until personnel with intubation equipment are available or maneuvers are successful.

B. If the infant is unconscious when found:

I. open airway and perform rescue breathing.

II. deliver 5 back blows.

III. deliver 5 chest thrusts.

IV. perform tongue-jaw lift. Remove foreign body only if you see it.

V. go back to I. and repeat until personnel with intubation equipment are available or maneuvers are successful.

5. Allow patient to sit up in position of comfort. If the patient is a young child, keep the patient with the parent and avoid unduly upsetting the child. Unless foreign body aspiration is suspected, do not perform a throat exam.

6. Obtain vital signs and apply cardiac monitor.

7. Perform patient assessment.

8. Begin transport immediately and call for medic backup if available.

9. Contact medical control, medical control will advise if IV is needed.

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Respiratory Distress
(Airway Obstruction, Asthma, Pneumonia, Pneumothorax, COPD, CHF)

Historical Findings

1. Patient or family reports difficulty breathing or shortness of breath,

2. Patient may have a history of asthma, previous pneumonia or respiratory problems, cystic fibrosis, emphysema, or COPD.

Physical Findings

1. Color may be pale or cyanotic.

2. Patient may have noisy breathing, wheezing or abnormal or decreased breath sounds or poor air exchange.

3. Patient may have rapid respiration, chest wall retractions, grunting or head bobbing in young children or pursed lip breathing or apnea.

EKG Findings

1. Normal sinus rhythm, sinus tachycardia, or atrial fibrillation with controlled ventricular response. If other rhythm is present, then proceed to appropriate arrhythmia protocol.

Differential Diagnosis

1. Upper airway obstruction.

2. Asthma, bronchitis, pneumonia, COPD.

3. Mechanical problems, trauma, pneumothorax.

4. Non-respiratory illness, CHF, congenital heart disease, other organ system failure, sepsis.

Protocol

1. Rapidly assess airway adequacy and ventilation. Position and open the airway. Use airway adjuncts as necessary.

2. Administer high flow oxygen. Use 100% oxygen at high rate (e.g., non-rebreather mask at 10 L/min). Allow parent to assist in oxygen administration in young or anxious children. Where available, maintain oxygen saturation from pulse oximetry > 95%.

3. Reassess for response and consider endotracheal intubation if impending respiratory failure if authorized by Medical Director. Call for ALS back-up.

4. AVOID DIRECT AIRWAY MANIPULATION IF PATIENT IS HIGH RISK OF UPPER AIRWAY OBSTRUCTION, EXCEPT WHEN IN EXTREMIS. (See Airway Obstruction)

5. Place or allow the patient to be in the most comfortable position to reduce breathing difficulty.

6. Place patient on cardiac monitor. Obtain rhythm strip. If dysphythmia is present, proceed to appropriate protocol.

7. Monitor vital signs frequently and contact medical control.

8. The medical control physician, may order Epinephrine 1: 1,000 solution subcutaneously (0.3ml adult; 0.01ml/kg in children) for suspected asthma. Not to be used if >40 years of age or history of coronary artery disease.

9. Begin transport quickly to appropriate medical facility. Do not delay transport to establish an IV line, unless transport time is long and only on the order of the medical control physician.

Notes

1. Patients with noisy inspiratory breathing (stridor), fever, drooling, decreased breath sounds and retractions are at high risk of upper airway obstructions such as epiglottis, tracheitis, etc. When not in extremis or responsive to routine airway assistance or supplemental oxygen, BEWARE OF ATTEMPTS TO MANAGE THE AIRWAY AGGRESSIVELY, as efforts may worsen the distress. This is particularly risky in patients with possible epiglottis (e.g., fever, stridor, drooling with respiratory distress without hoarseness). Treat such patients with calming reassurance and rapid transport maintaining oxygenation with supplemental oxygen unless this appears to worsen the patient. See Airway Obstruction for other specifics.

2. In differentiating CHF from COPD in adults, review the medication history to assist in determining which treatment protocol to use. The physical exam may be similar in both.

3. All patients with evidence of an oxygen requirement with respiratory distress should receive oxygen regardless of a history of COPD. The risk of supplemental oxygen in COPD patients is overemphasized in causing elevation of the C0₂.

4. Transport to the hospital should be as rapid as possible and with minimal prehospital delay.

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Altered Mental Status

Historical Findings

1. Patient has decreased level of consciousness without suspected trauma.

Physical Findings

1. Patient has a decreased level of consciousness.
2. Systolic blood pressure = 90 mm Hg or child with normal perfusion.

EKG Findings

1. Heart rate > 60.
2. NOT ventricular tachycardia.
3. NOT supraventricular tachycardia.

Differential Diagnosis

Protocol

1. Rapidly assess airway adequacy and ventilation. Position and open the airway. Use airway adjuncts as necessary.

2. Administer high flow oxygen. Use 100% oxygen at high rate (e.g., non-rebreather mask at 10 L/min). Allow parent to assist in oxygen administration in young or anxious children. Where available, maintain oxygen saturation from pulse oximetry > 95%.

3. Monitor cardiac rhythm and vital signs frequently. Begin transport immediately and call for medic backup if available.

4. Initiate IV with Normal Saline at keep open rate. If the patient is hypotensive, begin to administer I L (child 20 ml/kg) IV wide open.

5. Contact medical control.

6. If hypotension still persists, MEDICAL CONTROL MAY ORDER additional fluid challenge. Monitor lung sounds closely.

Notes

1. Although alcohol is a common cause of altered level of consciousness, it is rarely the cause of complete unresponsiveness. Do not let the patient's alcohol intoxication cloud your judgement. It is safer to assume that the intoxicated patient has a serious medical problem and treat accordingly than it is to conclude that the patient is "just drunk".

2. If there is strong suspicion of drug overdose, the patient will need administration of Narcan as soon as possible. Rapid transport is recommended.

3. If the patient has inadequate spontaneous ventilation, then control the airway with bag- valve-mask ventilation.

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Anaphylaxis / Allergic Reaction

Historical Findings

1. Exposure to allergen (insect sting, medications, foods, or chemicals).

2. Patient complains of itching, shortness of breath, tightness in chest or throat, weakness, or nausea.

Physical Findings (One or more)

1. Flushing, hives, or swelling.

2. Wheezing or stridor.

3. Anxiety or restlessness.

4. Pulse > 100 (adult).

5. Blood pressure < 90 in an adult, < 75 in a child < 5 years old, or < 85 in a child age 5-10 years old.

Protocol

1. Rapidly assess airway adequacy and ventilation. Position and open the airway. Use airway adjuncts as necessary.

2. Administer high flow oxygen. Use 100% oxygen at high rate (e.g., non-rebreather mask at 10 L/min). Allow parent to assist in oxygen administration in young or anxious children. Where available, maintain oxygen saturation from pulse oximetry > 95%.

3. Monitor cardiac rhythm and vital signs frequently. Begin transport immediately and call for medic backup if available.

4. Administer Epinephrine 0.3 ml (child 0.01 ml/kg) 1:1000 solution subcutaneously only if age = 40 and either hypotension or severe respiratory distress is present, and begin transport. May assist patient with self administration of epinephrine via Epi PenŽ or equivalent device.

5. Initiate IV with Normal Saline at keep open rate. If the patient is hypotensive, begin to administer I L (child 20 ml/kg) IV wide open.

6. Contact medical control.

7. If, after 5 minutes, hypotension persists despite fluid challenge and epinephrine administration, MEDICAL CONTROL MAY ORDER repeat epinephrine administration.

8. If hypotension still persists, MEDICAL CONTROL MAY ORDER additional fluid challenge. Monitor lung sounds closely.

9. Remove allergen (stinger from skin, etc).

Notes

1. Anaphylaxis in infants is rare.

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Seizure

Historical Findings

1. Patient suspected to have had grand mal seizure based upon description of eyewitnesses, incontinence of urine or stool, or history of previous seizures.

Physical Findings

1. MAY have current seizure activity.
2. Altered level of consciousness.

Protocol

1. Rapidly assess airway adequacy and ventilation. Position and open the airway. Use airway adjuncts as necessary.

2. Administer high flow oxygen. Use 100% oxygen at high rate (e.g., non-rebreather mask at 10 L/min). Allow parent to assist in oxygen administration in young or anxious children. Where available, maintain oxygen saturation from pulse oximetry > 95%.

3. Immobilize C-spine if evidence for significant trauma is present, otherwise position the patient in the lateral recumbent position.

4. Suction as needed. Begin transport immediately and call for medic backup if available.

5. Obtain vital signs and place on cardiac monitor.

6. Establish IV with Normal Saline at keep open rate and obtain red top tube.

7. Contact medical control.

Notes

1. Trauma to the tongue is unlikely to cause serious problems, but trauma to teeth may. Attempts to force an airway into the patient's mouth can completely obstruct the airway. Use of a nasopharyngeal airway may be helpful.

2. New seizures in patients over the age of 50 are often caused by cardiac arrhythmias.

3. Most patients with seizures need only oxygen and attention to airway management and will not need treatment with Diazepam.

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Toxicologic Emergencies

Historical Findings

1. History of actual or possible poisoning either through ingestion, inhalation, or skin exposure.

Physical Findings

1. Patient does NOT have an altered level of consciousness. If there is alteration in level of consciousness, see the Altered Level of Consciousness protocol.

2. Systolic blood pressure = 90 mm Hg in an ADULT

3. Child age < 5: systolic BP > 75 mm Hg or child age 5-10: systolic BP > 85 mm Hg.

Protocol

1. Evaluate scene for provider safety.

2. Administer high flow oxygen. Use 100% oxygen at high rate (e.g., non-rebreather mask at 10 L/min). Allow parent to assist in oxygen administration in young or anxious children. Where available, maintain oxygen saturation from pulse oximetry > 95%.

3. Monitor vital signs frequently, evaluate breath sounds and level of consciousness.

4. If toxin remains on patient, wash / brush off as appropriate. If in doubt contact medical control for clarification.

5. If there is eye exposure, flush the eyes with normal saline.

6. If patient has ingested medication or other substance, obtain container(s), if available and bring them with the patient.

7. Begin transport immediately and call for medic backup if available.

8. Contact medical control. Direct contact from the intermediate unit to the poison control center is discouraged. If necessary, medical control will contact the poison control center.

9. The medical control physician will order IV fluid or other medications as indicated by the toxic exposure.

10. Reassess vital signs, perfusion status and level of consciousness frequently. If there is any change in these findings, notify medical control.

Notes

1. Because of the wide variety of possible adverse effects of assorted toxins, it is not practical to detail the management of various toxic exposures. Consultation with medical control can enhance the prehospital care of patients with potentially dangerous exposures and is encouraged.

2. Since some toxic exposures have a high risk for causing rapid deterioration in the patient's mental status, ipecac should not be administered by the paramedic unless specifically ordered by medical control.

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Hypothermia

Historical Findings

1. High risk groups: elderly, infants, outdoor workers, alcoholics.
2. Predisposing factors:

A. Increased loss of body heat due to:

I. Prolonged exposure to cold

1. Inadequate clothing
2. Intoxication
3. Illness or injury

B. Decreased heat production due to:

I. Malnutrition
II.      Endocrine disorders

C. Impaired thermoregulation due to:

I. Hypoglycemia
II. Drugs (alcohol, barbiturates, phenothiazines)
III. Sepsis
IV. Central nervous system disorders.

3. Hypothermia can occur under relatively mild weather conditions.

Physical Findings

1. Variable presentation with range of presenting symptoms from mild nonspecific complaints to unresponsiveness.

2. Mild symptoms include decreases in coordination, reflexes, and alertness.

3. If unresponsive, may appear pulseless, with pupils fixed and dilated.

4. Pulse rate may be severely bradycardia. A radial pulse may be very difficult to palpate. The pulse rate should be obtained with palpation of a central pulse (carotid or femoral) for at least one minute.

5. Extremities may be stiff resembling rigor mortis, or may be cyanotic or edematous.

EKG Findings

1. Bradycardia.

Differential Diagnosis

1. Cardiac arrest.
2. Coma.
3. Severe shock.
4. Narcotic abuse.

PROTOCOL - GENERAL PROCEDURE

1. Gentle handling of the patient is important to avoid inducing ventricular fibrillation.

2. Begin transport immediately and call for medic backup if available.

3. Do NOT massage extremities (causes increased cutaneous vasodilation and decreases shivering).

4. Do NOT use hot packs (can cause serious burns, as well as possibly increased mortality).

IF PULSE & BREATHING ARE ABSENT:

5. Begin CPR. Begin transport immediately and call for medic backup if available.

6. Apply cardiac monitor. If the rhythm is ventricular fibrillation or ventricular tachycardia, then defibrillate up to a total of three shocks, starting at 200 joules (2 joules/kg for child), then 300 joules, and then 360 joules.

7. Rapidly assess airway adequacy and ventilation. Position and open the airway. Use airway adjuncts as necessary.

8. Administer high flow oxygen. Use 100% oxygen at high rate (e.g., non-rebreather mask at 10 L/min). Allow parent to assist in oxygen administration in young or anxious children. Where available, maintain oxygen saturation from pulse oximetry > 95%.

9. Contact medical control.

IF PATIENT HAS SPONTANEOUS RESPIRATIONS:

5. Monitor cardiac rhythm.

6. Rapidly assess airway adequacy and ventilation. Position and open the airway. Use airway adjuncts as necessary.

7. Administer high flow oxygen. Use 100% oxygen at high rate (e.g., non-rebreather mask at 10 L/min). Allow parent to assist in oxygen administration in young or anxious children. Where available, maintain oxygen saturation from pulse oximetry > 95%.

8. Establish large bore IV with Normal Saline and begin to administer 1 liter (child 20 ml/kg) fluid bolus.

9. Gentle evacuation is needed. Remove wet clothing, insulate with dry, warm blankets and immobilize to avoid exertion by the patient.

10. Notify the receiving hospital so that preparations can be made to warm the patient.

Notes

1. Some special equipment may be needed to warm IV fluids and oxygen. However given the short transport times present in most situations, warm blankets are probably the most practical equipment.

2. If the patient fails to respond to initial defibrillation attempts or initial drug therapy, subsequent defibrillation or additional boluses of medication should be avoided until core temperature rises above 30°C (86°F).

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SURGICAL PROBLEMS

Hemorrhagic Shock

Historical Findings

1. History of or suspected hemorrhage.

Physical Findings (One or more)

1. Active severe bleeding with signs of shock OR

2. Signs of poor tissue perfusion such as altered level of consciousness, cool clammy skin, delayed capillary refill, weak or absent radial pulse OR

3. Systolic blood pressure < 90 mm. Hg in an adult OR

4. Child age < 5 with systolic BP < 75 mm Hg or child age 5 -10 with systolic BP < 85 mm Hg.

Protocol

1. Rapidly assess airway adequacy and ventilation. Position and open the airway. Use airway adjuncts as necessary.

2. Administer high flow oxygen. Use 100% oxygen at high rate (e.g., non-rebreather mask at 10 L/min). Allow parent to assist in oxygen administration in young or anxious children. Where available, maintain oxygen saturation from pulse oximetry > 95%.

3. Identify and treat life-threatening breathing problems such as open chest wounds. Monitor and begin transport immediately and call for medic backup if available.

4. If patient is a victim of blunt trauma (e.g. MVA, fall) or penetrating injury to the head or neck, immobilize patient with rigid cervical collar, long back board and immobilize head such that the patient's head is secured to back board.

5. Control external bleeding.

6. Obtain vital signs, evaluate breath sounds and level of consciousness.

7. Without stopping transport, initiate 1-2 large bore IV's with Normal Saline. Administer 500-1000 ml wide open to the adult. In the child, 20 ml/kg is appropriate volume to infuse wide open.

8. Reassess vital signs, perfusion status, and lung sounds at least every 5 minutes. Watch for signs of fluid overload.

9. Contact medical control with abbreviated report while en route.

10. MEDICAL CONTROL WILL INSTRUCT on additional fluid administration.

11. Continue secondary assessment as time permits and notify medical control of significant changes in patient status.

Notes

1. The key to good prehospital care of the hemorrhagic shock patient is rapid transport to definitive care. Except when the patient is entrapped, scene time should not ordinarily exceed 15 minutes.

2. A reasonable performance goal for an EMS system is that 90% of patients who have traumatic shock and are not entrapped should be delivered to a definitive trauma care facility within 30 minutes from the time of injury.

3. Patients with penetrating chest trauma and abnormal vital signs are especially in need of immediate transport to definitive care.

4. Application and inflation of the MAST at the scene has been shown to add about 4 minutes to scene time without improving outcome. MAST use is contraindicated in penetrating chest trauma.

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<High Risk Potential For Trauma/p>

This protocol is for use in those patients with the potential to deteriorate rapidly due to a significant mechanism of trauma or underlying medical condition.

Historical Findings

1. History of

1. Penetrating wound,
2. Pedestrian struck by vehicle,
3. Fall greater than 10 feet,
4. MVA with significant damage to vehicle,
5. MVA with rollover, patient entrapment or ejection,
6. Evidence of significant blunt force to the patient (e.g. "starred windshield", deformity to dashboard or steering wheel),
7. Motorcycle accident,
8. Gastrointestinal bleeding,
9. Severe abdominal pain,
10. Significant dehydration, OR
11. Other medical or traumatic condition which, in the paramedic's judgement, has a high risk for deterioration in the patient's condition.

Physical Findings

1 . No signs of shock. If shock is present, refer to Hemorrhagic Shock protocol.

Protocol

1. Rapidly assess airway adequacy and ventilation. Position and open the airway maintaining C-spine immobilization as needed. Use airway adjuncts as necessary.

2. Administer high flow oxygen. Use 100% oxygen at high rate (e.g., non-rebreather mask at 10 L/min). Allow parent to assist in oxygen administration in young or anxious children. Where available, maintain oxygen saturation from pulse oximetry > 95%.

3. Control any severe external bleeding.

4. Monitor and begin transport immediately and call for medic backup if available.

5. Contact medical control.

6. Obtain vital signs frequently and place on cardiac monitor.

7. If time permits, establish 1-2 large bore IV of Normal Saline at TKO rate (child 20ml/kg), unless otherwise ordered by medical control.

8. Medical control may order fluid bolus, different IV rate, or medications as needed. If patient develops shock, proceed to Shock protocol.

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Head Or Spinal Trauma

Historical Findings

1. History of loss of consciousness following head injury, OR
2. History of motor vehicle accident, diving accident, fall, or other trauma.

Physical Findings

1 . Head contusions, abrasions, or lacerations, OR
2. Fluid or blood from the nose, ears, or mouth, OR
3. Altered level of consciousness.
4. May have loss of sensation or movement.
5. May have pain in back or neck.
6. No signs of shock. if shock is present, refer to Hemorrhagic Shock protocol.

Protocol

1. Rapidly assess airway adequacy and ventilation. Position and open the airway maintaining C-spine immobilization as needed. Use airway adjuncts as necessary.

2. Administer high flow oxygen. Use 100% oxygen at high rate (e.g., non-rebreather mask at 10 L/min). Allow parent to assist in oxygen administration in young or anxious children. Where available, maintain oxygen saturation from pulse oximetry > 95%.

3. Obtain Glasgow Coma Scale.

4. If altered mental status, aggressively assure good oxygenation of patient and secure airway, endotracheal intubate if authorized by Medical Director. If head injury, then hyperventilate at 20 breaths/min (for a child hyperventilate at 30 breaths/min.)

5. Immobilize patient's C-spine with rigid cervical collar, long back board, and immobilize the head such that the patient's head is secured to the backboard.

6. Begin transport immediately and call for medic backup if available.

7. Obtain vital signs and monitor cardiac rhythm.

8. Establish large bore IV with Normal Saline at keep open rate.

9. Contact medical control.

10. Repeat vital signs at least every five minutes in transport.

Notes

1. Shock is not usually due to head injuries. If patient is in shock, consider another cause for the hypotension.

2. Remember that restlessness can be due to hypoxia and shock not just head injury.

3. In any multiple trauma patient, spine trauma should be assumed until proven otherwise in a hospital emergency department.

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Major Burns
(Thermal or Electrical)

Historical Findings

1. Patient complains of shortness of breath, cough or hoarseness.
2. Any patient with electrical injury.

Physical Findings

1. Second degree burns greater than 20% of body surface area, OR
2. Third degree burns greater than 15% of body surface area, OR
3. Singed nasal or facial hair, soot or erythema of mouth, or respiratory distress.

Protocol

1. Evaluate scene for safety.

2. Remove patient from source of burn including clothing.

3. Rapidly assess airway adequacy and ventilation. Position and open the airway. Use airway adjuncts as necessary.

4. Administer high flow oxygen. Use 100% oxygen at high rate (e.g., non-rebreather mask at 10 L/min). Allow parent to assist in oxygen administration in young or anxious children. Where available, maintain oxygen saturation from pulse oximetry > 95%.

5. Obtain vital signs and monitor cardiac rhythm.

6. Establish IV with Normal Saline at keep open rate.

7. Remove all prostheses, rings, and constricting bands from all extremities.

8. Cover burns with clean, dry sheet. May apply Burn Gel type product if desired and available.

9. Begin transport immediately and call for medic backup if available. Transport to an appropriate facility capable of treating major burns.

10. Contact medical control.

Notes

1. Consider carbon monoxide poisoning if the patient has headache, dizziness, nausea, vomiting, altered level of consciousness, syncope, or chest pain or was trapped in a closed space.

2. Remember that burn victims have suffered other trauma. These patients should be managed as multiple trauma patients.

3. Important historical information includes any inhalation problem or closed space exposure, duration of exposure and time elapsed since burn, chemical exposure and significant past medical problems.

4. Remember to keep the burned patient warm. It is important to avoid hypothermia since the skin injury disables much of the body's heat conservation methods. Only burns of less than 10% of body surface should be treated with local cooling such as wet dressings.

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Imminent Delivery

Historical Findings

1. Pregnant woman who is in active labor as defined by regular, frequent uterine contractions and who feels the urge to push.

Physical Findings

1. Crowning of fetal part at vaginal opening with imminent delivery.

Differential Diagnosis

1. Delivery not imminent.

Protocol

1. Administer high flow oxygen. Use 100% oxygen at high rate (e.g., non-rebreather mask at 10 L/min). Allow parent to assist in oxygen administration in young or anxious children. Where available, maintain oxygen saturation from pulse oximetry > 95%.

2. Obtain vital signs and begin transport to hospital if not already en route. Position mother on left side unless delivery is imminent.

3. If time permits, establish large bore IV with Normal Saline at keep open rate.

4. Assist with normal delivery.

5. If baby is delivered in malpresentation (e.g. foot or arm), elevate hips of mother and transport immediately. Call for medic backup if available and time permits.

6. If cord is prolapsed:

A. Relieve pressure on the cord with hand in vagina to maintain head of baby off cord.

B. Elevate hips of mother

C. Keep cord moist.

D. Transport.

7. If cord is wrapped about neck:

A. Attempt manual removal.

B. If unsuccessful, then clamp cord in two different locations and cut cord between the clamps, prior to completing delivery.

8. After the infant's head is delivered, suction the mouth, oropharynx, then nose.

9. After complete delivery, provide routine newborn care with special attention to maintenance of infant's body temperature (warmth), cover head. Place infant on Oxygen and suction if needed. Refer to Newborn Resuscitation protocol if needed.

10. Apply local pressure to any visible bleeding sites.

11. Contact medical control.

12. Resume transport to appropriate hospital of patient's choice or to a hospital with labor and delivery service.

13. If a complication such as massive bleeding or neonatal distress occurs, proceed to nearest appropriate hospital, request medic back-up if available.

14. Assist with delivery of placenta (DO NOT tug on cord) and begin gentle fundal massage.

Notes

1. Only deliver the placenta when it has detached. Do not pull on the umbilical cord to force out the placenta as this can lead to retained placenta or uterine eversion.

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PEDIATRIC PROBLEMS

Newborn Resuscitation

Historical Findings

1. Newborn infant.

Physical Findings

1. Central cyanosis, poor or no respiratory effort, or limp muscle tone.

Protocol

1. Ensure adequate airway. Suction mouth, oropharynx, then nose.

2. Dry infant to provide stimulation and prevent chilling. Keep the infant warm, especially the head. Monitor and begin transport immediately and call for medic backup if available.

3. Check heart rate. If less than 100, ventilate with 100% oxygen at a rate of 40 to 60 per minute. If heart rate is less than 60 beats/min, begin CPR.

4. Check color. If there is central cyanosis, provide 100% oxygen and assist ventilations if needed.

5. Assess response to oxygen and ventilation. If heart rate remains less than 100 after 15 to 30 seconds of assisted ventilation, reassess airway, begin chest compressions and contact medical control.

6. Contact medical control.

7. Provide medical control with patient update.

Notes

1. Newborn infants lose heat rapidly and need to be kept warm to decrease oxygen demands and prevent metabolic acidosis.

2. When dealing with such a short trachea, remember that slippage of even a centimeter in endotracheal tube position can result in inadvertent extubation.

3. If there is thick meconium present in the amniotic fluid at the time of delivery, the infant should be intubated and any meconium present in the airway should be suctioned prior to stimulation.

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Pediatric Asystole

Historical Findings

1. Unconscious patient.
2. Age = 14.

Physical Findings

1. Patient is not breathing.
2. Patient has no pulse.

Protocol

1. Ensure airway and begin ventilation with bag-valve-mask with 100% oxygen.

2. Begin CPR and aggressively manage airway. Endotracheal intubate if authorized by Medical Director.

3. Monitor and begin transport immediately and call for medic backup if available.

4. Attempt IV with Normal Saline at keep open rate.

5. Reassess airway and breathing.

6. Contact medical control.

Notes

1. The most common cause of pediatric cardiac arrest is hypoxia with ischemic insult. Therefore airway and breathing are especially important.

2. Epinephrine given through the ET tube should be diluted with 1 to 2 ml of saline prior to administration.

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Pediatric Bradycardia

The patient must be symptomatic before proceeding with this protocol.

Historical Findings

1. Age = 14.

Physical Findings

1. Patient may have altered level of consciousness, OR

2. Patient has weak peripheral pulses, OR

3. Patient has other signs of uncompensated shock such as poor perfusion or delayed capillary refill.

EKG Findings

1. Rhythm is sinus bradycardia for child's age.

Protocol

1. Ensure airway apply 100% oxygen, assist ventilations as needed, and recheck pulse.

2. Monitor and begin transport immediately and call for medic backup if available.

3. If heart rate is less than 60 in an infant and/or a child, perform chest compressions at a rate of at least 100.

4. Reassess airway and breathing.

5. Contact medical control.

6. Attempt IV of Normal Saline at keep open rate once en route to the hospital.

7. If hypotensive, administer Normal Saline 20 ml/kg IV push.

Notes

1. Most common cause of bradycardia in the child is hypoxia. Therefore attention to airway is the most important intervention.

2. It is important to treat the patient and not the number. Remember that athletes may have heart rates of 40-60.

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Pediatric Pulseless Electrical Activity (PEA)

Historical Findings

1. Age = 14.
2. Patient is unconscious.

Physical Findings

1. Patient has no pulse or blood pressure.

EKG Findings

1. There is an organized cardiac rhythm with QRS complexes.

Protocol

1. Ensure airway and begin ventilation with bag-valve-mask at 100% oxygen.

2. Begin CPR and aggressively manage the airway, endotracheal intubate if authorized by Medical Director.

3. Monitor and begin transport immediately and call for medic backup if available.

4. Attempt IV with Normal Saline, administer 20 ml/kg IV. Attempt only once while en route to the hospital.

5. Consider the causes of PEA and reassess airway and breathing.

6. Contact medical control.

Notes

1 A main cause of EMD is hypoxia, and the effectiveness of ventilation should be evaluated constantly.

2. The causes of EMD include hypovolemia, cardiac tamponade, tension pneumothorax, hypoxemia, acidosis, and pulmonary embolism.

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Pediatric Supraventricular Tachycardia (PSVT)

Historical Findings

1. Age = 14.
2. Older child may complain of chest pain or rapid heart rate.

Physical Findings

1. Heart rate in infants under age 2 is > 220. Heart rate in children age 2-14 is 150-250.

2. The unstable patient has poor skin perfusion, hypotension or altered level of consciousness.

EKG Findings

1. QRS duration = 0.12 sec (3 little boxes).
2. P waves may or may not be seen.

Protocol

1. Ensure airway and apply 100% oxygen.

2. Monitor and begin transport immediately and call for medic backup if available.

3. Contact medical control.

4. Reassess airway, breathing and circulation, consider CPR.

5. Attempt preferably in an antecubital vein IV access with normal saline at keep open rate. Do not delay transport to start an IV.

Notes

1. Children without underlying heart disease or myocardial dysfunction will tolerate the rhythm for up to 24 hours without compromise.

2. WARNING: Vagal maneuvers (e.g. ice bag) in young infants may cause asystole.

Appendix A: Medication List

Activated charcoal (50 gm)
Epinephrine 1:1,000
Ipecac (30 ml)
Normal Saline (0.9%)
Oral Glucose
Oxygen
Sterile Saline Irrigation

Appendix B: Equipment List

Airway Equipment:

Bag-Valve-Mask
Endotracheal Tubes
Nasal Airways
Oral Airways Suction

Blood Draw Sets
Cardiac Monitor Defibrillator
Cellular BLS/Telemetry
Communication equipment
Glucose Monitoring System
IV Equipment
Angiocaths - 14, 16, 18, 20 gauge
Gloves Goggles
Macrodrip tubing Minidrip tubing
Sharps container 25 / 27 gauge needles with TB/insulin syringe
Laryngoscope handle
Various blades 2.0, 3.0, 4.0 Miller & MacIntosh
Optional Equipment
Endotracheal Tubes EOA PTL
Pulse Oximeter Rapid Glucose Monitor
Standard EMT-B Equipment