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Advanced Life Support Treatment Protocol

St. Mary Medical Center EMS Program

_________________________________________________________ John P. Mulligan, M.D. EMS Medical Director _________________________________________________________ Robert Boby, R.N. EMS Coordinator

Revision #12 (02/21/13)

St. Mary Medical Center ALS Protocol Table of Contents

Medical Code Description 1 Routine Patient Care 2 Radio Report 3 Accelerated Transport 4 Refusal of Services 5 DNR Orders, Out of Hospital 6 Hazmat Response 7 Mass Casualty Response 8 Abdominal Emergencies 9 Pain Management 10 Suspected Cardiac Patient 11 Pulmonary Edema 12 Cardiogenic Shock 13 PVCs 14 Asystole 15 VF/Pulseless VT 16 Bradycardia 17 Tachycardia 18 PEA 19 Airway Obstruction 20 Asthma/COPD 21 Allergic Reaction/Anaphylaxis 22 Diabetic Emergencies 23 Drug Overdose 24 Coma 25 Seizures 26 Stroke Brain Attack 27 Near Drowning 28 Cold Emergencies 29 Heat Emergencies Code 30 31 32 33 39 Description Psychological Emergencies Implanted defibrillator Medication Assisted Intubation Hypertensive Crisis Poison/Toxin Emergencies Code 50 51 52 53 54 55 56 57 58 59 Description Emergency Childbirth Maternal Care Newborn Care Prolapsed Cord Breech Birth Pre-Eclampsia Third Trimester Bleeding

Trauma Code Description 40 Routine Trauma Care 41 Suspected SCI 42 Hemorrhagic Shock 43 Head Trauma 44 Amputated parts 45 Burns 46 Chest Trauma 47 Trauma in Pregnancy 48 Trauma Arrest 49 Ophthalmic Emergencies OB

Pediatric Code Description 60 Pediatric Bradycardia 61 Pediatric VF/Pulseless VT 62 Pediatric PEA 63 Pediatric Asystole 64 Pediatric Diabetic Emergencies 65 Pediatric Seizures 66 Pediatric Respiratory Distress 67 Pediatric Allergic Anaphylactic Reaction 68 Pediatric Narrow Tachycardia 69 Pediatric Wide Tachycardia 70 Pediatric Altered Level of Consciousness
71 Pediatric Airway Obstruction

St. Mary Medical Center ALS Protocol Revision Sheet

Revision Date Codes Amended System Approval Medical Director Approval Comments

Code 1
Routine Medical Care SAMPLE HISTORY S= Signs & Symptom A= Allergies M= Medications P = Past History L= Last Oral Intake E= Events Leading To Incident or Illness

1. 2. 3. 4. 5.

Perform Scene Survey and ensure the safety of all personnel. Reassure patient, provide comfort, and loosen tight clothing. Place patient in position of comfort. Assess and maintain ABCs. Supplemental oxygen at 2-6 L/min nasal cannula 10-15 L/min mask Perform EKG And perform 12-lead if indicated Obtain IV access if appropriate, Attempt x 2-3. See IV Access Appendix. Contact receiving hospital as soon as patients condition permits. Transmit assessment information. Contact supervising hospital as needed. Recheck vitals every 15 minutes for stable patients and every 5 minutes for unstable patients and record on the run form with proper times noted.

6. 7. 8. 9.

10. Transport to the closest most appropriate hospital. 11. If medical direction is ever needed you may speak to a St. Mary Medical Center ER Physician at (219) 947-6232. Note: In a combative or uncooperative patient, the requirement to initiate routine patient care, as written, may be altered or waived in favor of rapidly transporting the patient for definitive care. Document the patients actions or behaviors which interfered with the performance of any assessments and/or interventions.

Trauma Assessment D= Deformity C= Contusions A= Abrasions P= Puncture B= Burns T= Tenderness L= Lacerations S= Swelling

Medical Assessment

O= Onset P= Precipitating Q= Quality R= Radiating S= Severity T= Time


* Nausea/Vomiting If no contraindications are present, may administer a one time dose of zofran 4mg IV

Code 2

Radio Report

Outline for Radio Report (Transmitting as few words as possible)

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.

Name and unit number of provider. ALS or BLS designation Age, Sex, and approximate weight of patient. Chief complaint, to include symptoms and degree of distress. Level of consciousness, orientation. Vital signs (include pain scale) Clinical condition: Focused and detailed patient assessment findings (only pertinent +/- findings) History of present illness/injury. History: allergies, medications, past history, last oral intake, events surrounding incident. Treatment rendered and response. Destination and ETA Trauma Name and unit number of provider. Age, Sex, and mechanism of injury. Chief complaint, to include symptoms and degree of distress. Level of consciousness, orientation. Vital signs (include pain scale) Focused and detailed patient assessment findings (only pertinent +/- findings) Medical history: allergies, medications, past history, last oral intake, events surrounding incident. Treatment rendered and response. Destination and ETA. Mass Casualty Incident Name and unit number of provider. Approximate number of victims and approximate triage levels: green, yellow, red, black. Mechanism of injury. Report any scene hazards. Medical communication should utilize the IHERN radio frequency unless otherwise specified by local plans.

1. 2. 3. 4. 5. 6. 7. 8. 9.

1. 2. 3. 4. 5.

Code 3

Accelerated Transport
Certain situations require treatment within minutes. These situations occur when a problem is discovered in the primary survey that cannot be rapidly resolved by field intervention. Only airway and spinal immobilization should be managed prior to transport. Further efforts at stabilization should be performed en route and should not delay transport. If circumstances demand hospital care for patient stability, rapid transport is indicated. Each case will be unique and compelling reasons must be documented. Notify receiving hospital of the situation so that preparations can be made. Primary resuscitative measures must be initiated. Contact receiving hospital/medical control ASAP.

Examples include, but are not limited to: Inability to secure airway Severe head trauma Profound shock Respiratory failure Penetrating wounds to chest, neck, abdomen Trauma arrest Pediatric arrest

Trauma Transports
Consider transporting to the nearest appropriate Trauma Center (Within a 45 minute transport time) when your patient meets these criteria: They fall under Level I or II under the CDC 2011 Field Triage Guidelines. (See ALS Appendicies) A thorough assessment determines that your patient is stable enough to endure a 45 minute transport time. The EMS personnel can be reasonably certain that the transport time will take no longer than 45 minutes taking into account weather conditions, traffic problems, construction, etc. If any of the above conditions are not met, then transport to the closest appropriate Emergency Department. If any questions arise, contact Medical Control.

Code 4 Refusal of Services

Begin evaluation and care

The patient refuses care

Altered Mental Status (i.e., alcohol, drugs, head trauma, mental retardation, etc.)

If yes, Deny refusal and refer to appropriate SOP

If No, Age >18 years, (unless emancipated or parent or guardian present) Altered medical decision capacity?

1. 2. 3. 4. 5. 6.

Document situation in all cases of refusal and contact medical control as needed. List the presence or absence of factors that enable refusal. For refusals, initiate a refusal form. Obtain a full set of vital signs, if patient refuses, document the refusal. List the consequences of refusal and have each refusing patient or guardian sign. Each refusing patient should be evaluated and each should sign a refusal form. If a patient wishes to refuse, and yet will not sign the refusal form, document the situation on the EMS report form. All personnel who witness the event should sign the EMS report form. Patients signature should be witnessed by family, friends, police,(EMS personnel when no one else is available). For minors, attempt to contact parents or adult caregiver to inform them of situation. Obtain phone consent of refusal and document who you spoke with.

7. 8. 9.

Code 5 DNR, Out of Hospital

DNR Cause of action prescribed by a physician to withhold resuscitation measures on a victim of cardiac arrest.

Identify Patient

- Pre-hospital personnel must make a reasonable attempt to verify the identification of the patient named in a valid DNR Order. - Patient should be a resident of a long-term care facility; hospice patient; home care patient; or inter-hospital transfer.
Identify Valid DNR Orders

- Must contain the following information: 1) State form #49559 (Indiana State Form) 2) Patients name and signature (or legal representative) 3) Name and signature of attending physician 4) Effective Date 5) Signature of witnesses
Revocation of a Valid DNR Order

- The patient, physician who signed the DNR Order, or the consenting party to the DNR

Care Instructions

General Guidelines: -Provide comfort care and compassion for the patient. - Treat acute airway obstruction, even if intubation is required. - Treat problems not specifically listed (i.e., atropine for symptomatic Bradycardia with


Code 6

Hazardous Materials
Scene survey: Ensure scene safety Request additional resources

Isolate scene, Notify Medical Control and receiving hospital ASAP

Identify hazard (DOT Emergency Response Guide) Product Name, U.N. number, STML number, MSDS, Container Type

Maintain Airway, Administer 100% oxygen

IV Normal Saline TKO

Cardiac Monitoring

Treat per SOP: Shock, Arrhythmias, Pulmonary Edema, Seizures, Burns, Hypothermia Unconsciousness, Wheezing

If indicated, flush skin with copious amounts of water

Other Treatment: per Medical Control


Code 7

Mass Casualty Incident Response

Basic IMS Structure

Incident Command Safety Officer Medical Command






With this format, resources can be managed for any size incident, large or small. Medical communication should utilize the IHERN Radio frequency, unless otherwise specified by local plans.

The use of the S.T.A.R.T. triage system will help maintain the continuity of care and control of every victim, injured or uninjured. Every victim will be placed into one of the four Triage categories listed below with necessary information completed on the corresponding Triage tags.





Minor Injuries Uninjured

Burns Fractures Non-life Threats

Multi-System Trauma Head Injuries Chest Trauma Life-Threats

Dead Patients Non-salvageable Patients

Code 8

Abdominal Emergencies
Routine Patient Care Position Patient for Comfort Assess Pain Level

Administer 0.9% Normal Saline Bolus 250-500cc

* Analgesic Alternative
Patients with right flank pain and history of kidney stones with no contraindications may receive Toradol 30mg IV. If unsure, contact medical control I f nausea and vomiting occur and no contraindications are present, may administer 4mg Zofran IV

Monitor patient condition If continued pain and SBP greater than 100mmHg, may administer morphine 2-4 mg IV


Code 9

Pain Management
Routine Patient Care Position Patient for Comfort Assess Pain Level (0-10) Appropriate splinting, ice, positioning Indications Extremity injury (including hip and shoulder injury) Back or flank pain Burns Chest Pain Crush Injuries Minor Traumatic Injuries CONTACT MEDICAL CONTROL FOR OTHER INDICATIONS OR UNSURE OF DOSAGE Contraindications Contact Medical Control prior to administration of pain medication if any of the following are observed: 1. Altered level of consciousness, any etiology 2. Hypotension, auscultated BP less than 90 mmHG 3. Respiratory compromise, hypoxemia 4. Mechanism of injury meeting multi-system trauma criteria 5. Pregnancy 6. Known allergy or hypersensitivity to pain medication 7. Toradol may only be given to patients 15-70 years old, no renal/dialysis patients, no diabetics, no NSAID/ASA allergies. May administer: Toradol 30 mg IV Morphine Sulfate 2-4 mg slow IV / IO every five (5) minutes until pain resolved, or to a total of 10mg in adults. Burn patients up to a maximum of 20 mg. OR Fentanyl 25-50 mcg slow IV / IO with 1 repeat dosage May administer MORPHINE SULFATE 5 10 mg IM or FENTANYL 50100mcg IM if unable to establish IV. Weight based dosing of morphine is 0.1 mg/kg IV for patients <15 y.o.

1. 2. 3. 4. 5. 6.

1. 2.

3. 4.

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Code 10

Suspected Cardiac Patient

(Based on chest pain or equivalent)

Routine Medical Care

SBP < 90 mmHg

SBP > 90mm Hg

4 baby ASA (324MG) chew and swallow unless contraindicated

4 baby ASA (324MG) chew and swallow

Note: Contraindications to ASA would include ASA allergy, Asthma, active bleeding or inability to swallow.


Nitroglycerine 0.4mg SL or spray May repeat X2. (if no IV, consider hospital contact prior to administration).

Consider medical control contact (for Nitro order and/or MS orders) Thrombolytic Checklist Clinical Presentation Y N Chest Pain Y N Unrelieved with Ntg x3 Y N Last > 30 Minutes Contraindications to Thrombolytics Y N History of CVA or TIA (6mo) Y N Active Internal Bleeding Y N Hx of Bleeding Disorders Y N Uncontrolled Hypertension Y N Intracranial or Intraspinal surgery past 2 months Y N Intracranial or Intraspinal neoplasm, AVM or aneurysm Y N Hx Trauma or Surgery Within 2 weeks Y N Pregnancy Y N Previous Thrombolytic Use Y N Recent (1 month) Head Trauma Y N Suspected aortic dissection Y N Suspected Pericarditis


Transport MS 2mg slow IV to a maximum of 10 mg for chest pain as needed. Use Narcan 2 mg IV to reverse effect if necessary. Repeat vitals after q 2 mg

Repeat Vital Signs

If 12 lead EKG is positive for STEMI, notify receiving hospital of a Cardiac Alert


Code 11 Pulmonary Edema

Routine Medical Care

SBP<100mm Hg

SBP >100mm Hg

Refer to Cardiogenic Shock Code 12 with limited fluid bolus of 200ml NS

Lasix 40mg IV push (may double home dose up to 80mg)


Nitroglycerine 1.2mg SL or spray. May repeat every 5 minutes X2. If no IV, consider hospital contact prior to administration

* Consider initiating the use of CPAP with patients in respiratory distress associated with pulmonary edema. If CPAP does not improve patient condition consider intubation as per protocol.

Administer Morphine 2-4mg increments to a maximum of 10 mg IV Push Contact Medical Control for additional medication


Code 12

Cardiogenic Shock

Routine Medical Care

SBP < 100mm Hg without Dysrhythmias

SBP > 100mm Hg with Dysrhythmias

Transport ASAP

Treat underlying dysrhythmia and transport ASAP

IV NS fluid challenge in 200ml increments up to 1000ml (if lungs are clear)

SBP > 100mm Hg



Continue Routine Medical Care and Rapid Transport

Dopamine drip at 5-20mcg/kg/min titrate to maintain SBP > 100mm Hg

Dopamine Drip Chart 400mg/250ml D5W Starting Drip Rate (5mcg/kg/min) Weight Lb Kg Hypotension 88 40 8gtts/min 99 45 8 gtts/min 110 50 9gtts/min 154 70 13gtts/min 176 80 15gtts/min 198 90 17gtts/min 209 95 18gtts/min 220 100 19gtts/min 253 115 22gtts/min

Continue Routine Medical Care and Rapid Transport

Code 13 Premature Ventricular Contractions Routine Medical Care

Do not treat PVCs unless directed by medical control.

See VT protocol if necessary

Code 14


Assess and Maintain CABs Begin CPR within 10 seconds of finding pulses absent EKG Monitor (Confirm asystole in 2 leads) Intubate & ventilate with 100% Oxygen Establish IV/IO access

Possible Causes & Management: Hypoxia: Confirm ET tube placement Pre-oxygenate with 100% Oxygen Hypovolemia: Administer IV/IO bolus 20ml/kg Tension Pneumothorax: Perform needle decompression Overdose: Administer Naloxone 2mg IV/IO push Consider D50 if hypoglycemic Electrolyte imbalance (Dialysis Patient): Consider CaCl 10ml IV/IO push Consider Sodium Bicarb 0.5-1.0mEq/kg IVP/IO Consider D50 if hypoglycemic Consider Magnesium Sulfate 12 gm IVP/IO Acidosis: Confirm adequate airway tube placement Pre-oxygenate with 100% Oxygen Consider Sodium Bicarb 0.5-1.0mEq/kg IVP/IO Hypothermia: Passive rewarming Active rewarming

*IO insertion may be considered if no other IV access is available

Consider possible causes and treatments:

*May give 1 dose of vasopressin 40 U IV/IO to replace first or second dose of epinephrine.

**Administer Epinephrine 1:10,000* 1mg IVP/IO May repeat every 3-5 minutes

ROSC? Induce Hypothermia (See Appendices)

Consider Sodium Bicarb Administration 0.5-1.0mEq/kg IVP/IO for extended down time


*may give double the dose via ETT

Code 15 Ventricular Fibrillation / Pulseless V-Tach

*IO insertion may be considered if no other IV access is available

Assess and maintain CABs Begin CPR within 10 seconds of finding pulses absent defibrillate at maximum joules (360j monophasic) or biphasic (200j) resume CPR immediately

Rhythm after first 5 cycles of CPR? Persistent VF/VT Asystole Refer to Code 14 PEA Refer to Code 18 Return of Spontaneous Circulation

CPR, Intubate, IV Magnesium Sulfate: dilute 1gm in 10ml NS. Give slow IVP/IO or dilute 1gm in 100ml NS and give rapid IV drip. Routine Medical Care

Epinephrine(1:10,000) 1mg IVP/IO or 2mg ETT *(see insert) Repeat every 3-5 minutes

Defibrillate at maximum joules

Lidocaine Drip: (premixed) (2 gm/500ml) 60 gtt tubing = Drops/min = 15 30 45 60 1 2 3 4 mg/min =

Lidocaine 1-1.5mg/kg IVP/IO Begin Lidocaine drip at 2mg/min

Consider an Anti-arrhythmic: Consider Amiodarone bolus: 300mg IV/IO Repeat Amiodarone @ 150mg IV/IO OR Lidocaine 1-1.5mg/kg IVP/IO Repeat Lidocaine @ .5 1.5mg/kg Continue drug-shock-drug-shock sequence

Titrate to effect

Induce Hypothermia (See Appendices)

Transport *May give 1 dose of vasopressin 40 U IV/IO to replace first or second dose of epinephrine.

Consider Calcium Chloride if dialysis patient.

Consider Magnesium Sulfate (see insert)

Consider Sodium Bicarb Administration 0.5-1.0mEq/kg IVP/IO

Code 16 Bradycardias
Routine Medical Care Protocol

*IO insertion may be considered if no other IV access is available

Hemodynamically Unstable Patient (Signs of hypoperfusion or altered mental status)

Hemodynamically Stable Patient

Continue monitoring Administer Atropine 0.5-1.0mgIV/IO* May repeat every 3-5 min (max dose 0.04mg/kg or 3.0 mg total) Transport

Consider External Pacing at rate of 70, increase mA until capture. May sedate if conscious, Administer Versed 2.5 5 mg IV or Diazepam 2-10mg slow IV (Contact medical control for additional sedation)

Consider Dopamine 5mcg/kg/min IV/IO Drip (See chart) to maintain SPB > 100mm Hg

Dopamine Drip Chart 400mg/250ml D5W Starting Drip Rate (5mcg/kg/min) Weight Lb Kg Hypotension 88 40 8gtts/min 99 45 8 gtts/min 110 50 9gtts/min 154 70 13gtts/min 176 80 15gtts/min 198 90 17gtts/min 209 95 18gtts/min 220 100 19gtts/min 253 115 22gtts/min

Transport *May double-dose via ETT

Note: 1. Signs of hypoperfusion include: severe chest pain, severe SOB, SBP < 100mm Hg, diaphoresis, altered mental status. 2. Do Not delay transcutaneous pacer while awaiting IV/IO access or for Atropine to take effect if patient is symptomatic. 3. Do not give Lidocaine to patients with AV blocks, idoventricular rhythm, or severe hypoperfusion.

Code 17 Tachycardias (with pulse) (of Cardiac Origin)

Routine Medical Care Protocol Consider non-cardiac causes and treatment Note: 1. Signs of hypoperfusion: severe chest pain, severe SOB, SBP<100mm Hg, diaphoresis, altered mental status. 2. Lidocaine should be administered slowly, over 2 minutes. 3. When an unstable patient is cardioverted to a stable rhythm from a wide complex tachycardia, administer lidocaine and recheck vital signs. 4. Adenosine (Adenocard) should always be administered Rapidly IVP and immediately followed with a 20ml NS bolus. (Antecubital vein is preferred site) 5. Always record rhythm strip and deliver to physician caring for patient. 6. Wide Complex=QRS>.12sec.

Stable Patient is alert, without any signs of hypoperfusion

Unstable (signs of hypoperfusion)

Narrow Complex* (QRS <0.12 sec)

Wide Complex* (QRS >0.12 sec)

Consider sedation with Versed 2.5 5 mg slow IV or Diazepam (Valium) 2-10 mg slow IV (if conscious)

Vagal Maneuvers x 2

Lidocaine 1.5mg/kg

Lidocaine 0.75mg/kg Supraventicular tachycardia Adenosine (Adenocard) 6mg Rapid IVP Followed by 12mg Rapid IVP May Repeat x1. If no result, consider cardizem.

Synchronized Cardioversion @ 100J (no response-200J) (no reponse-360J) (or biphasic equivalent)

Wide Complex

Narrow Complex

Lidocaine 1.5mg/kg Contact Medical Control Accelerated Transport

For uncontrolled SVT, atrial fibrillation or atrial flutter administer Cardizem (diltiazem) 0.25mg/kg initial and 0.35 mg/kg for the repeat, with a max dose of 20mg and 25mg respectively

SynchronizedCardioversion @ 360J Or biphasic equivalent

Continue Routine Medical Care and Transport *0.12 seconds = 3 small boxes

At Discretion of Physician or Radio Nurse: Adenosine (Adenocard) for children < 15 yrs. 0.05mg/kg may be increased to 0.1mg and 0.15mg/kg maximum 12mg/dose. Bolus 5-20ml saline. Cardioversion for children < 15 yrs., 0.5J/kg up to 1.0J/kg Fluid Bolus for Hypotension.

Code 18 Pulseless Electrical Activity (PEA)

Assess and maintain CABs Begin CPR within 10 seconds of finding pulses absent Intubate and Ventilate with 100% Oxygen Apply and interpret EKG Establish IV Access Apply Pulse Oximetry (if available)

Causes and Management: Hypoxia: Confirm ET tube placement Hyperventilate with 100% Oxygen Hypovolemia: Administer IV/IO Bolus 20ml/kg Repeat as needed Tension Pneumothorax: Perform Needle Decompression Overdose: Refer to Code 23 Electrolyte imbalance (Dialysis Patient): Consider Calcium Chloride 10ml IV/IO Push slowly Consider Sodium Bicarb 1-2mEq/kg IV/IO Consider D50 if hypoglycemic Consider Magnesium Sulfate 1 gm IVP/IO Acidosis: Hyperventilate with 100% oxygen Consider Sodium Bicarb 1-2mEq/kg IV/IO Hypothermia: Passively rewarm Actively rewarm

*IO insertion may be considered if no other IV access is available

Consider Causes and Treatment

***May give 1 dose of vasopressin 40 U IV/IO to replace first or second dose of epinephrine.

Administer ** Epinephrine 1:10,000 1mg IV/IO Push or 2 mgETT May repeat every 3-5 min

ROSC? Induce Hypothermia (See Appendices)

Monitor Patient Condition Initiate Transport Contact Medical Control

Code 19


Assess and Maintain ABCs Unconscious Patient Conscious Patient (Unable to Speak) Position Patient Supine Perform 5 Chest Thrusts Clear Airway &Ventilate Repeat if Necessary

Perform Heimlich Maneuver Provide support for patient



Remains Obstructed Attempt to visualize obstruction & remove with Magill forceps Ventilate with 100% Oxygen

Administer supplemental oxygen Re-assess Patient Condition

Repeat Heimlich or Abdominal Thrusts Clear Airway & Attempt Ventilation

If still unable to ventilate, intubate and pass tube pushing foreign body into right mainstem bronchus, then pull back tube and ventilate left lung

Initiate Transport Contact Medical Control Monitor Patient Condition

If still obstructed refer to unconscious patient

Remains Obstructed Consider appropriate Cricothyroidotomy procedure Assess & Maintain Airway

Transport STAT

Code 20 Asthma/COPD with Wheezing * Consider initiating the use of CPAP with conscious patients in respiratory distress. If CPAP does not improve patient condition consider intubation as per protocol.

Routine Medical Care * Prepare and initiate Transport Begin Albuterol (2.5mg) Nebulizer Treatment (May repeat times 3) For severe cases consider adding a one time dose of 0.5 mg Atrovent to the albuterol nebulizer treatment.

Patient Improving?



If patient < 50 years old and Pulse < 150 and no history of heart disease and patient not having chest pain Administer Epinephrine 1:1,000 0.1mg - 0.3mg SQ or IM

Consider administration of 125mg Solumedrol IV Push for continued dyspnea, if taking Prednisone p.o. or Cortisone Inhalers Monitor Patient Continue Transport

*Do not withhold oxygen to COPD patients in acute, severe distress. Be prepared to support patients respirations or intubate, if necessary.


Code 21 Allergic Reaction/Anaphylactic Shock

ABCs Routine Medical Care Remove insult Cryotherapy to bite, sting

Mild Local reaction only Local redness, itching etc. Alert, oriented, normo-tensive

Moderate Generalized itching, hives etc. Mild respiratory signs/symptoms normotensive

Any respiratory distress, severe allergic symptoms, altered level of consciousness, hypotensive

Cool packs to site (if not contraindicated)

Epinephrine (1:1,000) 0.3-0.5 ml subQ or IM or Epi-pen

If IV present:

Epi (1:10,000): 0.5mg slow IVP. May repeat in 3-5 min.

If no IV present:

Epi pen or Epi 1:1000 subQ (0.5ml) or IM or Transport Benadryl 25-50 mg slow IVP IV wide open

Dopamine Drip Chart 400mg/250ml D5W Starting Drip Rate (5mcg/kg/min) Weight Lb 88 99 110 154 176 198 209 220 253 Kg 40 45 50 70 80 90 95 100 115 Hypotension 8gtts/min 8 gtts/min 9gtts/min 13gtts/min 15gtts/min 17gtts/min 18gtts/min 19gtts/min 22gtts/min

If wheezing or respiratory symptoms, Albuterol Nebulizer May add .5mg atrovent x1

If severely compromised, attempt intubation. If unsuccessful: appropriate cricothyroidotomy procedure

Benadryl 25-50 mg IVP (may give IM if no IV) Transport ASAP Albuterol/Atrovent Nebulizer (if able)

Dopamine drip

Transport STAT

Code 22

Diabetic Emergencies
Routine Medical Care

Obtain Random Blood Sugar*

Blood Sugar <60mg/dl

Blood Sugar >180mg/dl Signs & Symptoms of ketoacidosis

Administer 50% Dextrose 50ml IVP (slow) or Administer Glucagon 1mg IM (if unable to establish IV access)

Administer 250ml IV Bolus of NS If lungs remain clear, repeat 250ml bolus

If no response, may repeat 50% Dextrose 50ml IVP

Monitor Patient Condition Transport

Monitor Patient Condition Recheck blood sugar Transport

Note to Pre-hospital Personnel:

If after treatment, patient is awake, alert, and competent, and refuses transport, contact medical control for assistance

*If unable to obtain blood sugar in an unconscious, known diabetic, administer 50% dextrose IV or GlucagonIM.

Code 23

Drug Overdose
Routine Medical Care

Manage ABCs

Obtain Random Blood Sugar

Code 22 for diabetic emergencies

Treat per suspected overdose:

Narcotic: (Respiratory depression, pinpoint pupils)

Narcan (Naloxone): 2mg IVP to a maximum of 6mg Cyclic: (wide QRS, hypoperfusion) IV wide open Sodium Bicarbonate: 1mEq/kg IVP

Beta/Calcium Channel Blockers (Bradycardia, hypoperfusion): Glucagon 1mg slow IVP. May repeat X 1 For known meth-amphetamine type overdose, i.e. Bath Salts,: Consider ativan 1-2 mg IV/IM for extreme agitation. Call medical control for any additional orders.

Narcotic or Synthetic Narcotic:

Morphine, Demerol, Heroin, Methadone, Codeine, Fentanyl, Vicodin, Hydrocodone, Dilaudid, Darvon. Elavil, Amtiriptyline, Triavil, Norpramine, Tofranil, Pamelor, Sinequan, Ludiomil, Desyrel, Clomipramine (Anafranil), Endep, Doxepine (Sinequan), Imipramine, Trimipramine (Surmontil), Amoxapine (Ascendin), Despramine (Norpramin), Nortriptyline, Aventyl, Protriptyline (Vivactil). Halcion, Ativan, Centrax, Doral, Restoril, Versed, Valium, Xanax, Librium, Klonopin, Dalmane, Rophynol. Enderal, Corgard, Lopressor, Atenolol, Labetalol, Propanolol, Cardizem, Procardia, Calan/Verapamil/Isoptin/Adalat, Diltiazem

Tricyclic antidepressants include:


Beta-Blocker: Calcium Channel Blocker:

Code 24 Coma (No History of Trauma)

Routine Medical Care

Identify Possible Causes:

Assess Level of Consciousness Glasgow Coma Scale AVPU Scale A = Alcohol E = Endocrine I = Insulin O = Oxygen/Opiates U = Uremia, Renal T = Trauma I = Infection P = Psychiatric S = Space occupying lesions; stroke

Wave ONE broken Ammonia Capsule under patients nose Note Response

If Diabetic Emergency Obtain Random Blood Sugar Refer to Code 22

Consider Naloxone (Narcan) 2mg IVP Slowly

Monitor Patient Condition Secure Patient Using Spinal Precautions (if indicated) Protect airway.


Code 25 Seizures

Routine Medical Care

Protect patient from injury Protect Airway

Obtain Random Blood Sugar

Treat as per Code 22 if Hypoglycemic

If allergic to ativan may administer valium 2-10mg IV (titrate to end seizure activity)

If seizure activity last > 2-3 minutes Ativan 1-2mg IVP Slowly May give Ativan 2 mg IM if unable to obtain IV

Monitor respiratory status closely and be prepared to support patient

Observe patients sensorium during postictal period. Note any injuries incurred and/or incontinence


Code 26 Stroke/ Brain Attack

Routine Medical Care 100% Oxygen Limit scene time

Obtain stroke time of onset

Random blood glucose treat per protocol Pre-hospital Stroke Screen 1. Facial Droop (ask patient to show teeth or smile). Normal-(Both sides of face move equally well). Abnormal-(one side doesnt move as well as other). 2. Arm drift Normal-Both arms remain steady Abnormal-(one arm doesnt move at all or drifts down as compared to other arm). 3. Speech (Have the patient say, Its a sunny day at Superior). Normal-Clear speech Abnormal-(patient slurs words, says wrong words, unable to speak). 4. Glucose level 5. Symptom duration 6. Hx seizures? 7. Anticoagulant therapy? (Coumadin, Ticlid)

Monitor respiratory status closely and be prepared to support patient

Perform Pre-hospital Stroke Scale

Transport Family member with patient to hospital if possible

Notify Receiving Hospital of Stroke Alert if Prehospital stroke scale is positive

Code 27

Near Drowning
Initial Trauma Care (C-spine precautions as indicated)

100% Oxygen Establish and maintain airway Intubate if Necessary

Remove wet clothing Consider hypothermia

Awake, alert, or semiconscious with purposeful response to pain, normal respirations and pupil response

Comatose, unresponsive to verbal stimuli, abnormal response to pain, abnormal respirations or pupil response


Begin CPR if indicated

Hypothermic Normothermic See Cold Emergencies Code 28 Treat dysrhythmias per appropriate SOP Transport Transport

Code 28

Cold Emergencies
Move Patient to a warm environment as soon as possible


Systemic Hypothermia

Severe Hypothermia

Rapidly warm frozen area with tepid water (105F) Hands or hotpacks wrapped in towels may be used. DO NOT RUB. Do not thaw if there is a chance of refreezing.

Mild/Moderate 95-90F (35-32C):

90F or less (<32C)

Patient may appear uncoordinated with poor muscle control, or stiff simulating rigor mortis. There will be no shivering. Level of consciousness may be confused, lethargic, and/or withdrawn Coma

Conscious or altered sensorium with shivering

Oxygen 10-15L/mask

-Handle skin like a burn -Protect with light sterile dressings. -Do not let skin rub on skin (between fingers or toes.

Transport ASAP Re-warm patient Place patient in a warm environment. Remove wet clothing. Apply hot packs wrapped in towels to axilla, groin, neck, thorax. Wrap patient in blankets.

Cover with warm blankets and prevent re-exposure.

Oxygen 100% Do not hyperventilate

Transport Transport ASAP At discretion of a Physician or Nurse on Radio: Morphine Sulfate 2-10mg IVP

IV NS TKO (Attempt to warm IV bag and tubing with hot packs)

Note to prehospital providers: Assess pulse for 30 seconds before beginning CPR. Begin CPR only if rhythm is asystole or V-Fib. DO NOT GIVE ANY DRUGS. May attempt defibrillation X 3 at 360 Joules if V-Fib. Handle patient gently to avoid precipitating V-fib

Code 29 Heat Emergencies

Move patient to a cool environment

Initial Medical Care Heat Cramps or Tetany (IV may not be necessary) Allow for oral intake of water or electrolyte replacement fluids Heat Exhaustion or Syncope IV NS rapid rate Heat Stroke

Do not massage cramped muscles

100% 02 Manage Airway

Place patient in supine position with feet elevated Trendelenberg

Rapid cooling while preparing IV Transport IV NS boluses (200ml) up to 1000ml -orSBP>100 (check lungs after each bolus)

Remove as much clothing as possible to facilitate cooling


Seizure precautions (Code 25 if seizures)

Initiate rapid cooling:

Remove as much clothing as possible. Cool packs to lateral chest wall, groin, axilla, carotid arteries, temples, and behind knees and/or sponge with cool water or cover with wet sheet and fan body. Wet head if possible, avoid shivering.

Position with head elevated unless contraindicated


Code 30

Psychological Emergencies
I. Purpose/Definition Given the magnitude of the problems of abuse and violence in our society, early detection of domestic violence victims, appropriate legal and social service referrals and the delivery of timely medical care are essential. Domestic violence is a pattern of coercive behavior engaged in by someone who is or who was in an intimate relationship with the recipient. These behaviors may include: repeated battering, psychological abuse, sexual assault or social isolation such as restricted access to money, friends, transportation, healthcare or employment. Typically, the victims are female but it must be recognized that males can be victims of abuse as well. II. Domestic Violence Indicators

While sometimes the specific history of abuse is offered, many times the victim of abuse, (either out of fear or because of the coercive nature of the relationship or out of the desire to protect the abuser) will not volunteer a true history but instead ascribe injuries to another cause. Therefore, an appropriate review must be undertaken with respect to patients presenting with injuries: -That do not seem to correspond with the explanation offered. -That are of varying ages. -That have the contour of objects commonly used to inflict injury (i.e. hand, belt, rope, chain, teeth, cigarette) -During pregnancy Other factors include: -Partner accompanies patient and answers all questions directed to patient. -Patient reluctant to speak in front of partner. -Denial or minimalization of injury by partner or patient. -Intensive, irrational jealously or possessiveness expressed by partner. Physical injuries commonly associated with domestic violence: -Central injuries, specifically to the face, head, neck, chest, breasts, abdomen, or genital areas. -Contusions, lacerations, abrasions, stab wounds, burns human bites, fractures (particularly of nose and orbits), and spiral wrist fractures. -Complaints of acute or chronic pain without tissue injury -Signs of sexual assault -Injuries or vaginal bleeding during pregnancy, spontaneous or threatened miscarriage -Multiple injuries in different stages of healing Direct impact of domestic violence on pregnancy may include: -Abdominal trauma leading to abruption, pre-term labor, and delivery -Fetal fracture -Ruptured maternal liver, spleen, uterus -Antepartum hemorrhage -Exacerbation of chronic illness

Code 30 (Continued)
III. Approaches for Interviewing the patient

The goals of the physical examination are to identify injuries requiring further medical intervention and to make observations and collect evidence that may corroborate the patients report of abuse. A thorough physical examination is essential to uncover hidden injuries or compensated trauma. If the patient reports sexual assault, the sexual assault protocol should be followed: -Always interview the patient in a private place, away from anyone accompanying them to the ED. Questioning the patient in front of the batterer may place the patient and any children in danger. -You may be the first person or professional to acknowledge the abuse. It is important that you convey your concerns about what has happened to the patient to the Emergency Physician and Nurse. -When interviewing, do not ask patients if they were battered or abused (many battered persons do not consider themselves in this light). Instead, you can ask the patient: Have you had a fight with someone? Did anyone hurt you? Many times we have seen these types of injuries in patients who are hurt by someone else, did someone hurt you? I am concerned that someone may be hurting you or scaring you, can you tell me what has happened? -Most battered persons feel very shamed and humiliated about what has happened to them. It is important to acknowledge that you understand how difficult it is to talk about what happened. -Most battered persons will minimize the abuse or blame themselves for what happened. It is important that you repeatedly reinforce that no one deserves to be hurt no matter what they may or may not have done. -Questions/attitudes Not to ask/Express: -What keeps you with a person like that? -Do you get something out of violence? -What did you do at the moment that caused them to hit you?

-What could you have done to avoid or defuse the situation?

IV. Practice

-Treat obvious injuries: transport -Report your suspicion and supporting findings to the Emergency Department Physician and on the prehospital report form. -If the patient refuses transport, make appropriate referral and documentation on run sheet. -Document your findings on the prehospital report form: -Presenting condition. -Any suspicious indicators. -Physical exam including any evidence of abuse. -Treatment rendered.

Code 31

Implanted Cardiac Defibrillation (ICD, PCD, AICD) 1. Treat Dysrhythmias per appropriate SOP. 2. If external defibrillation is required: Avoid placement of pads or paddles over the ICD unit or path of wires (if possible) Defibrillate at 360 joules or biphasic equivalent; repeat as indicated

3. If ICD is repeatedly firing and patient is stable, may administer sedation order (Versed in 2mg increments)

Code 32 Medication Assisted Intubation Indications:

1. 2. 3. 4. Patients with actual or potential airway compromise due to altered mental status, GCS less than 8. Patients whose combativeness and agitation threatens the airway or spinal cord stability. Patients who demonstrate a high probability of airway compromise for any reason prior to, or during transport. Patients requiring ventilator assistance or airway protection.

Etomidate dosing chart

0.3 mg/kg IV Weight Lb Kg 88 40 99 110 154 176 198 209 220 253 45 50 70 80 90 95 100 115


Dose 12 mg IVP 13.5 mg IVP 15 mg IVP 21 mg IVP 24 mg IVP 27 mg IVP 28.5 mg IVP 30 mg IVP 34.5 mg IVP

1. 2. Lidocaine: 1.5 mg/kg IV, IO (utilize for patients with a head injury) Atropine : 0.5 mg/IV,IO for adult patients with bradycardia

1. Versed 2.5 5 mg IV, IO OR AFTER CONSULTATION WITH MEDICAL CONTROL: 2. Etomidate 0.3mg/kg IV, IO, may repeat one time

Post Intubation Sedation:

1. 2. 3. 4. Versed 2mg IV, IO increments unless patient is hemodynamically unstable. Ativan 1-2 mg IV, IO may also be used for post intubation sedation unless patient is hemodynamically unstable. Etomidate 0.3mg/kg IV, IO may be utilized one time for post intubation sedation. Consider pain management with patients with high probability of pain and normal sedation is not working adequately. Follow pain management protocol where indicated.

Code Code 3333

Hypertensive Crisis

Aggressive prehospital treatment of the

A hypertensive emergency exists when the systolic blood pressure is > 200mmHg or diastolic BP is > 100mmHg and the patient is symptomatic. Symptomatic examples include but are not limited to headache, diaphoresis, chest pain. Contact medical control prior to any medication administration if patient has signs and symptoms of CVA. Pregnant patients with hypertension follow protocol 55.

Establish Code 1

Nitroglycerin 0.4mg SL. May repeat every five minutes up to three doses, if no relief and systolic blood pressure >100 mmHg

If no improvement, administer Lopressor (metoprolol) 5mg IV over 1-2 minutes. Repeat 5mg IV every 5 minutes up to three doses.

Code 39 Poisoning Toxic Ingestion or Exposure

Routine Medical Care Maintain ABCs

1. Exposure protection as indicated 2. Contact Poison Control 1-800-222-1222 3. Be prepared for seizures 4. Be prepared for vomiting Bring all medication, poison bottles to the hospital (unless HAZMAT)

Conscious Patient

Unconscious Patient

Monitor closely Do not induce vomiting Contact medical control for permission to Administer activated Charcoal* Adult dose: 50gm Pediatric dose: 1 gm/kg

Support ABC's Recovery position Be Prepared to Suction Monitor closely Treat per appropriate protocol

Transport STAT

Transport STAT

Code 40 Routine Trauma Care

Assess Scene Safety (Consider Crime Scene)

1) Airway:
secure with c-spine precautions remove foreign bodies provide 100% oxygen Breathing: assess rate: depth; and adequacy note & manage JVD & tracheal deviation inspect, palpate, auscultate, and percuss the chest Circulation: stop life threatening hemorrhage assess peripheral pulses check capillary refill Disability: AVPU Score motor & sensory exam pupillary size and reactivity Expose: fully expose patient log roll to evaluate back for injuries

Analgesia Alternative May give 30mg Toradol IVP Or 60 mg Toradol IM Be aware of contraindications

Body Substance Isolation


Primary Patient Assessment


*IO insertion may be considered if unable to obtain IV access

Resuscitation: Secure & maintain airway Perform spinal immobilization


Analgesia Order

5) Transport as soon as possible performing treatment enroute Establish TWO (2) large-bore IVs enroute (if able) Evaluate ECG See analgesia insert

May give Morphine Sulfate 2-4mg slow IV repeating in 2mg increments (max 10mg) or Fentanyl 25-50 mcg slow IVfor:
severe burns isolated fx isolated crush amputations

Note to Pre-hospital Personnel:

- In a combative or uncooperative patient, the requirement to initiate initial trauma care, as written, may be altered or waived in favor of rapidly transporting the patient for definitive care. Document the patients actions and behaviors which interfered with the performance of any assessment and/or interventions. Initiate Trauma Alert for the following mechanisms of injury: ejection from motor vehicle death in same passenger compartment falls greater than 20 feet pediatric falls of greater than 3 times the height of the patient pregnant patient of greater than 24 weeks gestation

Secondary Patient Assessment:

Vital Signs Systematic head-to-toe exam Obtain SAMPLE History Contact hospital as soon as patients condition permits, transmit assessment information and await orders. Refer to appropriate protocol if unable to contact medical control Re-assess patient

Call medical control for dditi l d f

Code 41

Suspected Spinal Cord

Routine Trauma Care

Secure Airway with C-spine precautions (in-line intubation, digital etc.)

Immobilize patient using backboard, c-collar, blanket rolls or other device, and secure patient to backboard

Guidelines for Field Clearance of Cervical Spine No reported or suspected loss of consciousness No complaints of head, neck, back pain Must be alert and oriented x 3 No neuro deficits i.e. numbness, tingling, confusion Must weigh more than 100 pounds Must be less than 70 years of age and greater than 18 years of age Must not have any history of osteoporosis or other skeletal conditions No alcohol ingestion No midline cervical tenderness No significant mechanism of injury or obvious distracting injury (high-speed collision, open penetrating wounds, dislocations, electrocution, high-impact blunt trauma to the head) * Please Note: These are guidelines, if there is any question regarding the potential for a cervical spine injury, the patient should be boarded and collared.

Monitor for spinal shock (low BP, normal HR or relative bradycardia)

Note to Prehospital Providers:

1. Suspect spinal injuries in all patients with: A. Any head or facial trauma (ie. injuries above the clavicle). B. Decreased or altered level of consciousness. C. Suspected deceleration injuries. D. Complaints of neck or back pain. E. Physical findings suggesting neck or back injury.

If no motor or sensory deficit, record as such and transport

Vomiting precautionshave suction ready, be prepared to log roll patient if needed


Code 42 Hemorrhagic Shock

Routine Trauma Care ABCs

Control significant external hemorrhage

If Patient in Cardiac Arrest:

Treat per appropriate Treatment Protocol Initiate TWO (2) large-bore IVs enroute (Wide Open Rate)

Monitor Patient Condition Transport

*IO insertion may be considered if unable to obtain IV access

Code 43

Head Trauma/Unconscious Patient

Routine Trauma Care

C-Spine Precautions


Alert ?



Record GCS Record pupil size

*IO insertion may be considered if unable to obtain IV access

100% oxygen random blood glucose

- Sedation orders Follow medication assisted intubation protocol if needed. - ET intubation with in-line manual stabilization

Accelerated Transport

Code 44

Amputated and Avulsed Parts

Initial Trauma Care DO NOT use a tourniquet unless all else fails and the patient is hemorrhaging: -Note time of placement -Apply as close to injury as possible -DO NOT release once applied

Control bleeding with direct pressure and elevation (tourniquet as last resort)

-Wrap part in moist sterile gauze, sheet or towel.

-Place part in waterproof bag or container and seal. -DO NOT immerse part in any solutions. -Place this container in a second one filled with ice, cold water or cold pack.

Transport part with patient to hospital


Code 45 Burns Routine Trauma Care Accelerated transport if airway involvement Consider Burn Center




Burn wound care*

Brush off excess chemical

Do not enter area until scene is safe. Assess for entrance and exit wounds

Consider analgesic

Flush with copious amount of water/saline unless contraindicated.

Maintain body temperature Protect unaffected eye IV Parkland formula* Burn wound care* Transport STAT Attempt to ID chemical Burn wound care* Treat dysrhythmias Immobilize as needed

Transport STAT

Cover with dry, sterile dressings/sheets Transport STAT

Code 45 (continued) Burns Wound Care 1. Assessment ABCs rapid transport if airway involvement Neurovascular status Depth of burn (partial vs full thickness) Percentage of burn (Rule of 9 vs Palm Rule) Visual acuity if indicated 2. Interventions Stop the burning process - Cool with tepid saline/water until skin temperature is normal - Remove jewelry and clothing (do not pull away clothing that is stuck to burn) - Do not use ice or ice water Wound care - Wear gloves/mask if 2nd degree or 3rd degree burns - Do not break blister or use dressings that will stick to burn - Do not apply ointments or creams - Cover cooled skin with appropriate dressing If 1st degree burn < 10% BSA, dress with sterile dry dressing If 2nd or 3rd degree burn or > 10% BSA, dress with sterile dry sheets/dressings Analgesia - Morphine sulfate in 2 mg increments up to 10 mg IVP - Call Medical Control for pediatric dosing and/or for greater than 10mg in adult Maintain body temperature - Cover patient with dry sheets/blankets over sheets - Prevent hypothermia at all costs

Code 45 (continued) Burns Wound Care Fluid replacement

Parkland Formula = 4 ml/kg/BSA burned to be given in the first 8 hours to be given in the next 8 hours to be given in the next 8 hours

3. SOP for other problems

Code 46

Chest Trauma
Routine Trauma Care

Chest Assessment

Pericardial Tamponade

Massive Hemothorax

Tension Pneumothorax

Sucking Chest Wound

Hemorrhagic Shock Hemorrhagic Shock Refer to Code 42 Needle Decompression Refer to Code 42

Stabilize with Partial Occlusive Dressing*

Monitor Condition Monitor Condition Transport STAT Transport STAT

Re-assess Patient

Re-assess Patient

Monitor Condition Transport STAT

Monitor Condition Transport STAT

*If patient deteriorates, temporarily remove dressing for air to escape.

Code 47

Trauma in Pregnancy
Routine Trauma Care

IV NS wide open if hypotensive

Check EXTERNALLY for uterine contractions Document Findings

Check EXTERNALLY for vaginal bleeding Document Findings

Elevate the right side of the backboard 20-30 in order to minimize uterine compression of the inferior vena cava while maintaining spinal immobilization. (transport on left side)

If CPR indicated, manually displace the uterus to the left.

Monitor Patient Condition Transport

Code 48

Trauma Arrest

Initial Trauma Care

Rapid extrication Spinal immobilization

Bilateral pleural decompression CPR

Refer to appropriate code*

Accelerated transport
* Give EPI via ETT if no IV Do not delay transport to in initiate IV May attempt IVx2 enroute IO insertion may be considered

Code 49

Ophthalmic Emergencies
Initial care: Assess pain scale Quickly obtain gross visual acuity Elevate head (if not contraindicated) Vomiting precautions Remove contact lenses

Chemical Splash

Corneal Abrasions

Penetrating injury/ruptured globe

Immediate irrigation with copious amounts of NS (at least 1000 per eye)

Immediately irrigate eyes if no chance of penetrating injury

Do not remove impaled object Do not irrigate eye Do not instill any drips Do not apply any pressure

Contact Medical Control for Tetracaine 0.5% 1-2 gtt order Contact Medical Control for Tetracaine 0.5% 1-2 gtt order Transport STAT Transport STAT

Cover eye with cup or metal protective shield. Patch unaffected eye also.

Transport STAT

1. 2. 3.

Gross Visual Acuity Test Determine if patient wears glasses/contacts Determine distance they can see Determine vision by holding up fingers at 1, 2, and 3 foot distance.