ACEMS Clinical Operating Guidelines (2016)

Medical Directors Authorization
Clinical Operating Guidelines 2016
Anderson County Emergency Medical Services Guidelines (revision project completed February 2016) are hereby
adopted. They are to be initiated by EMS personnel within their scope of licensure whenever a patient presents with
injury or illness covered by the guidelines. Where indicated to contact Medical Control, the EMS Provider should
receive voice orders from Medical Control before proceeding. Other orders may be obtained from Medical Control
when the situation is not covered by the guidelines or as becomes necessary as deemed by the EMT or Paramedic
Effective Date of these SOPs: February 2016
____________________________________ _____________________________
Anderson County Medical Director Date
Anderson County Emergency Services -1- Clinical Operating Guidelines 2016

Section One
Professional Practice
Introduction (What is Professional Practice?)
EMS is a practice of medicine. A unique practice at that
Every EMS System is a complex marriage between sound science and the appropriate delivery of that science to a
patient in a compassionate, operationally sound way. The Professional Practice section of the Anderson County
Emergency Services Clinical Operating Guidelines defines those areas of the Practice that support the delivery of
sound science to the ill and injured patients we are summoned to care for. In essence, this is the art of delivering
medical care
The concepts and specific issues discussed in the Professional Practice section describe how we deliver clinical
medicine to our patients and the rules of membership in this System.
Logistics of Patient Care On-Scene (The who calls the shots Question)
Authority for Patient Care/On-Scene Healthcare Providers
Credentialed Providers within Anderson County Emergency Services System are responsible for providing patient
care in accordance with the established Clinical Operating Guidelines. Emphasis should always be placed on
providing appropriate, safe, patient-focused care. On occasion, there may be disagreement regarding how that
care should be provided. Similarly, there may be operational interventions that impact clinical care of patients.
While questions regarding care are a healthy part of any practice of medicine, delays or on-scene conflicts in
emergency care are not. In ANY disagreement regarding patient care or issues that impact patient care on a
scene, decisions must always focus on what is in the best interest of the patient and can be delivered safely by the
Providers on the scene.
In the event of conflicting approaches to providing patient care, extraction, or transport, it is the responsibility of the
on-scene Credentialed Providers to reach consensus as to the most appropriate care for the patient(s). In the
event of unresolved conflict, the Senior Credentialed Provider on-scene has final authority for decisions regarding
patient care. Seniority of Credentials (in ascending order) is:
First Responder
Emergency Medical Technician Basic
Emergency Medical Technician - Advance
Emergency Medical Technician Paramedic
Emergency Medical Technician Critical Care Paramedic
On-scene Physician
On-Line Medical Consultation Physician
EMS System Medical Director
All significant or unresolved conflicts regarding on-scene management of patients should be reported via the
appropriate chain of command and will be retrospectively reviewed by the Healthcare Quality Committee or their
designees.

Cancellation or Alteration of a Response
Resources will be initially dispatched to a 9-1-1 request for service based on the currently approved Medical Priority
Dispatch (MPD) standards. During the course of providing care in the System, any Credentialed Provider may
modify or cancel the response mode of any other System Provider. If cancelled, responders may, at their discretion
and with legitimate cause, reduce their response to non lights and sirens and continue to the scene in order to
provide other assistance deemed appropriate by their organization or department. This does not apply to
responses for responsibilities other than patient care (scene safety, fluids, etc).
Transfer of Care to a Provider of Lesser Credentialing
Occasionally, Providers are presented with multiple patients, limited resources, or patient conditions requiring early
rapid transport in order to maximize potential outcome (for example one critically injured patient and multiple non-
injured occupants in a motor-vehicle crash). The ultimate decision of whether or not to initiate transport of a
critically ill or injured patient while awaiting additional resources rests with the on-scene Provider with the most
advanced level of system Credentials as defined in Authority for Patient Care. When making these determinations,
the following applies:
Leaving patients on-scene should not be a routine procedure. It is to be considered only when a patient
requires immediate transport in order to maximize potential outcome.
The transport Provider may transfer patient care to a Provider of lesser Credentialing while awaiting
additional transport resources when transfer of established care is not beyond the scope and/or training of
the Provider(s) assuming care (i.e., an intubated patient may not be left with an EMT-B Credentialed
Provider).
All patients should be accounted for, triaged, and appropriate additional resources requested prior to
transport of the critically injured patient.
No patient requiring immediate advanced stabilization (i.e., pleural decompression, intubation, defibrillation
etc.) is to be left on-scene awaiting additional resources unless an appropriately Credentialed and
equipped Provider is present and able to perform such care.
Mass and Multi-casualty incident transport decisions will be made by the On-scene Command Structure.
First Responder Accompanying Ambulance Transport of Critically Injured/Ill Patients
When requested, First Responders will accompany transport Providers during transport of critically ill/injured
patients.
If First Responders are unavailable to accompany a patient in an ambulance in need of additional Providers, an
additional resource should be requested (First Responders from another organization, an EMS Commander, or
other available resources) to accompany the patient to the hospital. On occasion, a rendezvous with additional
resources may be preferable and should be considered.
On-Line Medical Consultation (OLMC)
On occasion, it will be necessary or desirable to contact a physician for assistance with patient care decisions or to
approve specific clinical care. This may include discussing care with the patients personal physician, or requesting
guidance from OLMC. If contact with OLMC is required, it should be requested from the facility that the patient is
being transported to (or is requesting in cases of conflict), or with the facility responsible for receiving specific
patient populations (for example trauma, critical pediatrics, sexual assault, etc). To ensure continuity of care,
once OLMC has been established, the Provider will follow the physicians medical orders, within the scope of the
Providers Credentials. Orders from OLMC or a patients personal physician should be conveyed via ACEMS
Communications and fully documented on the Patient Care Record. Unless an alternate facility is approved by
OLMC, the patient should be transported to the contacted facility.

Interacting with On-Scene Healthcare Professionals
It is our collective desire to work collaboratively with appropriately identified (meaning they must have
documentation readily available or be known by the Provider on-scene) healthcare professionals on the scene of a
medical emergency to enhance patient care. It is also our collective responsibility to assure that our patients only
receive care from appropriate, acceptable practitioners.
According to the Tennessee State Board of Medical Examiners (TSBME), the licensing body for physicians in
Tennessee, control at the scene of a medical emergency shall be the responsibility of the individual in attendance
who is most appropriately trained and knowledgeable in providing prehospital emergency stabilization and
transport. The TSBME has specific rules pertaining to the authority of a physician to order specific patient care
interventions on the scene of a medical call. There are two different types of situations regarding on-scene
physicians. One is when the patients own physician is on-scene (Patients Personal Physician). The other is
when a physician that does not have an established relationship with the patient is on-scene (Intervener
Physician).
Physician On-Scene/General Guidelines

The Credentialed Provider on-scene is responsible for management of the patient(s) and acts as the agent
of the Medical Director or OLMC.
In order to participate in care physicians must present a valid Tennessee Board of Medical Examiners
License (all physicians are issued a wallet card) or be recognized as a physician by the Provider or
competent patient.
Patients Personal Physician On-Scene

If the patient's personal physician is present and assumes care, the Credentialed Provider should defer to
the orders of the patients personal physician.
The patients personal physician must document his or her interventions and/or orders on the EMS Patient
Care Record.
OLMC should be notified of the participation of the patient's personal physician either from the scene or on
arrival at the emergency department.
If there is a disagreement between the patients personal physician and the System COGs, the physician
shall be placed in direct communication with OLMC. If the patients personal physician and the on-line
physician disagree on treatment, the patients personal physician must either continue to provide direct
patient care and accompany the patient to the hospital, or must defer all remaining care to the on-line
physician.
Intervener Physician On-Scene

If an intervener physician is present at the scene, has been satisfactorily identified as a licensed physician
(by showing a valid copy of his/her Tennessee Medical License), and expressed willingness to assume
responsibility for care of the patient, OLMC should be contacted. The on-line physician has the option to:
manage the case exclusively
work with the intervener physician
allow the intervener physician to assume complete responsibility for the patient
If there is a disagreement between the intervener physician and OLMC, the Provider will take direction from
the on-line physician and place the intervener physician in contact with the on-line physician.

The intervener physician must document his or her interventions and/or orders on the EMS Patient Care
Record.
The decision of the intervener physician to not accompany the patient to the hospital shall be made with the
approval of the on-line physician.
Medical orders are not accepted by any non-physician health care Providers unless specifically approved
by OLMC.

Applicability of Clinical Operating Guidelines (COGs)
When do the COGs apply? What is a patient? When can a patient consent or refuse? When should resuscitation
be implemented or stopped?
One of the toughest parts of any medical practice is determining when specific guidelines apply and in what
circumstances they apply. The following definitions apply to specific circumstances commonly encountered in our
System. As in all patient care guidelines, Provider judgment, experience and evaluation of the circumstances are
essential for us to make the most appropriate decisions as consistently as possible.
What is the Definition of a Patient?
With the advent of cell phones and the increased number of requests for emergency medical care by individuals
other than patients themselves (for example, a passer-by that calls 9-1-1 for a motor vehicle crash where there are
no injuries, complaints or indication of injury, and EMS is dispatched to the scene), it is necessary to define a
patient in our System. Why? Because anyone that fits the definition of a patient must be properly evaluated and/or
appropriate treatment options taken (including an informed refusal if the competent patient absolutely does not wish
medical care or transport despite our suggestions that they do). Similarly, anyone that does not fit the definition of
a patient as defined by our System does not require an evaluation or completion of a Patient Care Record. If there
is ever any doubt, an individual should be deemed a patient and appropriate evaluation should take place.
It is important to remember that the definition of a patient requires the input of both the individual and the Provider,
and an assessment of the circumstances that led to the 9-1-1 call. The definition of a patient is a separate question
from whether or not the patient gets evaluated or treated.
The definition of a patient is any human being that:

Has a complaint suggestive of potential illness or injury
Requests evaluation for potential illness or injury
Has obvious evidence of illness or injury
Has experienced an acute event that could reasonably lead to illness or injury
Is in a circumstance or situation that could reasonably lead to illness or injury
All individuals meeting any of the above criteria are considered patients in the Anderson County Emergency
Services System. These criteria are intended to be considered in the widest sense. If there are any questions
or doubts, the individual should be considered a patient.
To assist in further distinguishing our patients, the following should apply:
The definition of an adult is:

One who has reached the age of legal consent and refusal for medical treatment? In Tennessee, this is 18
years of age.
The definition of a minor is:

One who has not yet reached the age of consent and refusal for purposes of medical treatment. Generally,
minors can neither consent to, nor refuse, medical treatment. Some minors however, are considered to be
emancipated, which means either that a court of law somewhere has removed the minors disability to
make legally binding decisions or, that as a practical matter, they are living apart from their parents and
functioning on their own as adults.

The definition of a pediatric patient is:
Any patient younger than 16 years of age. Younger than 16 years of age applies specifically to Patient
Care Guidelines and the provision of treatment.
Patient Consent and Refusal
The United States Supreme Court has recognized that a person has a constitutionally protected liberty interest in
refusing unwanted medical treatment even if refusal could result in death. Although courts protect a patients
rights to refuse care, preservation of life, prevention of suicide, maintenance of the ethical integrity of the medical
profession, and protection of innocent third parties may also be considered when evaluating a patients wish to
refuse treatment. Each case must be examined individually.
In providing medical care, the universal goal is to act in the best interest of the patient. This goal is based on the
principle of autonomy, which allows patients to decide what is best for them. A patients best interest may be
served by providing leading-edge medical treatment, or it may be served simply by honoring a patients refusal of
care. Although complicated issues can arise when Providers and patients disagree, the best policy is to provide
adequate information to the patient, allow time for ample discussion, and document the medical record
meticulously.
With certain exceptions (see Implied Consent), all adult patients, and select minor patients, have a right to consent
to medical evaluation and/or treatment, or to refuse medical evaluation and/or treatment if they have the legal
competency and present mental capacity to do so. There are three specific forms of consent that apply to EMS:
Informed Consent, Implied Consent, and Substituted Consent.
Informed Consent
Informed consent is more than legality. It is a moral responsibility on the part of the Provider, based in the
recognition of individual autonomy, dignity, and the present mental capacity for self-determination. With
informed consent, the patient is aware of, and understands, the risk(s) of any care provided, procedures
performed, medications administered, and the consequences of refusing treatment and/or transport. They
should also be aware of the options available to them if they choose not to accept our evaluation and/or
treatment.
Implied Consent
In potentially life-threatening emergency situations, consent for treatment is not required. The law
presumes that if the individual with a real or potential life-threatening injury or illness were conscious and
able to communicate, he/she would consent to emergency treatment. In life-threatening emergency
situations, consent for emergency care is not required if the individual is:
Unable to communicate because of an injury, accident, illness, or unconsciousness and suffering from
what reasonably appears to be a life-threatening injury or illness
OR
Suffering from impaired present mental capacity
OR
A minor who is suffering from what appears to be a life-threatening injury or illness and whose parents,
managing or possessory conservator, or guardian is not present
Substituted Consent
This is the situation in which another person consents for the patient, as in minors, incapacitated patients,
incarcerated patients, and those determined by courts to be legally incompetent. The fundamental issue in
informed, substituted consent for minors is a question of how decisions should be made for those who are
not fully competent to decide for themselves. Parents or guardians are entitled to provide permission
because they have the legal responsibility, and in the absence of abuse or neglect, are assumed to act in
the best interests of the child. However, there is a moral and ethical need to respect the rights and
autonomy of every individual, regardless of age. Providers must walk a fine line between respect for
minors autonomy, respect for parental rights, and the law. Laws may be ethical or unethical; ethical
actions may be legal or illegal.
The whole issue of when a patient may or may not be considered legally competent and possessing the present
mental capacity to consent to, or refuse care, is complex and confusing in the emergency care environment. It is
our obligation to make sure we address each of the following principles:
When they can, patients must give us permission to evaluate and/or treat them for any presumed or real
medical condition.
We must evaluate and/or treat those patients who are unable to make a decision due to their illness, injury
or circumstances.
We must be able to determine whether a patient has the legal competency and present mental capacity to
refuse evaluation and/or treatment.
We must inform the patient of the risks and potential alternatives to refusing or accepting care and be
reasonably certain they understand.
We must honor a patients refusal of evaluation and/or treatment if they have the legal competency and
present mental capacity to refuse that evaluation and/or treatment.
Any person, eighteen (18) years of age or older, that is deemed to have the legal competency and present mental
capacity to consent, may consent to, or refuse evaluation, treatment, and/or transportation. That person may also
sign a legal document (Patient Refusal Form).
If the patient has the legal competency and present mental capacity to consent, and chooses to refuse further
evaluation and/or treatment, the Provider must, after assessing the patients ability to understand, provide the
patient with information regarding the risks of refusal, the alternative options available, and what to do if conditions
persist or worsen.
A Provider may be denied access to personal property (land and home) by the property owner or patient, if there is
no obvious immediate life threat to a patient.
Legal Competency and Present Mental Capacity to Consent or Refuse Evaluation or Treatment
It is our obligation to offer evaluation and/or treatment to anyone with evidence of illness or injury regardless of
whether they initially choose to refuse that evaluation and/or treatment. However, a patient must have the legal
competency and present mental capacity to consent before consent is deemed to be valid.
Mental competency: legal term, and there is a presumption of legal mental competency unless one has
been declared mentally incompetent by a court of law. Legally competent individuals have a right to refuse
medical treatment.
Present mental capacity: refers to ones present mental ability to understand and appreciate the nature
and consequences of his/her condition and to make rational treatment decisions.
While there are criteria for legal competency and present mental capacity as defined below, there is no way to
cover every potential circumstance with a written guideline. Thus, we should always determine a patient disposition
that is safe and appropriate given the circumstances
18 years of age or older
Alert, able to communicate, and demonstrates appropriate cognitive skills for the circumstances of the
situation
Showing no indication of impairment by alcohol or drug use
Showing no current evidence of suicidal ideations, suicide attempts or any indication that they may be a
danger to themselves or others. Law enforcement must be requested for this patient population.

A law enforcement officer may arrest a patient who threatens or attempts suicide. The statute also
covers other mentally ill patients and a similar statute allows an arrest for chemical dependency.
Remember though, only a law enforcement officer can make these arrests.
Showing no current evidence of bizarre/psychotic thoughts and/or behavior, or displaying behavior that is
inconsistent with the circumstances of the situation
No physical finding or evidence of illness or injury that may impair their ability to understand and evaluate
their current situation (for example, a patient with a head injury and an abnormal GCS, a patient with
significant hypoxia or hypotension, etc)
A patient that has NOT been declared legally incompetent by a court of law.
If a patient has been declared legally incompetent, his/her court appointed guardian has the right to
consent to, or refuse, evaluation, treatment, and/or transportation for the patient.
When evaluating a patient for the ability to consent to or refuse treatment, the Provider must determine whether or
not the patient possesses the present mental capacity to understand and appreciate the nature and
consequences of his/her condition and to make rational treatment decisions. Such an evaluation must take into
consideration not only the patients orientation to person, place, time, and event, but also their memory function,
their ability to engage in associative and abstract thinking about their condition, their ability to respond rationally to
questions, and their ability to apply information given to them by the Providers.
A thorough test of the patients mental status is one that assesses orientation, registration (memory), attention,
calculation, recall and language. This can be accomplished fairly rapidly. For example
Level of Consciousness - The use of appropriate noxious stimuli is an acceptable practice in our system
to assist in determining a patients level of consciousness. This may be in the form of ammonia inhalants
or painful stimuli through the application of pressure to the fingernail bed. Use of a sternal rub is NOT
appropriate.
Awake, alert, and oriented- elicit specific/detailed responses when questioning your patient to determine
A and A and O status
Registration- give your patient the name of 3 unrelated items (dog, pencil, ball) and ask them to repeat
them and remember them because you will ask again later
Attention and calculation- ask the patient to spell a five-letter word backwards (pound, earth, space,
ready, daily, etc.), or count backward from 100 subtracting 7s.
Recall- ask the patient to recall the 3 items identified in registration.
Language- state a simple phrase (no if, ands, or buts) and ask the patient to repeat. Also test the
patients ability to respond to verbal commands by asking the patient to do something with an object (hold
this piece of paper, fold this paper in half) or identify two objects held up such as a watch or pencil.
Patients with impaired present mental capacity may be treated under implied consent.
If the patient does not have the legal competency and present mental capacity to consent and the principles of
implied consent do not apply, OLMC must be contacted for specific orders and the patient should be transported to
a medical facility for further evaluation.
Online Medical Consultation must be contacted prior to any patient being transported against their will. An EMS
Commander must be dispatched to the scene and participate in the evaluation and decision process. Obviously, if
in the opinion of the ALS Credentialed Provider in charge, there is an immediate risk to life or significant morbidity,
patient safety and care are the priority (implied consent would apply here).
Finally, the Providers findings must be documented with facts, not conclusions, and such documentation must be
sufficient to demonstrate the patients mental status and understanding of his/her condition and the consequences
of refusing treatment.

Consent to Evaluation/Treatment for a Minor and Refusal of Evaluation/Treatment for a Minor
The following person(s) may consent to, or refuse, the evaluation, treatment, and/or transportation of a minor:
Parent
Grandparent
Adult (> 18) brother or sister
Adult (> 18) aunt or uncle
Educational institution in which the child is enrolled that has received written authorization to
consent/refuse from a person having the right to consent/refuse.
Adult who has actual care, control, and possession of the child and/or has written authorization to
consent/refuse from a person having the right to consent/refuse (i.e., daycare camps, soccer moms,
carpools, etc.)
Adult who has actual care, control, and possession of a child under the jurisdiction of a juvenile court
A court having jurisdiction over a suit affecting the parent-child relationship of which the child is the subject
A peace officer who has lawfully taken custody of minor, if the peace officer has reasonable grounds to
believe the minor is in need of immediate medical treatment.
A managing or possessory conservator or guardian.
A Provider may be denied access to minor children by a parent or guardian if there is no obvious immediate life
threat to the patient. However, in general, parents or guardians cannot refuse life-saving therapy for a child based
on religious or other grounds.
In certain circumstances, a patient under 18 years of age (who has the legal competency and present mental
capacity to consent or refuse evaluation/treatment) may do so. In such cases, the law states that a person under
18 years of age may consent to evaluation and/or treatment if the person:
Is on active duty with the Armed Services of the United States of America OR
Is 16 years of age or older and resides separate and apart from his/her parents, managing conservator (an
individual appointed by the court, usually during divorce proceedings, to have custody of a minor, to make
decisions for the minor and to make a home for the minor), or guardian, with or without the consent of the
parents, managing conservator, or guardian regardless of the duration of the residence; and managing
their own financial affairs, regardless of the source of the income OR
Is consenting to the diagnosis and treatment of an infectious, contagious, or communicable disease that is
required by law or rule to be reported by the licensed physician or dentist to a local health officer or the
Tennessee Department of State Health Services OR
Is consenting to examination and treatment for drug or chemical addiction, drug or chemical dependency,
or any other condition directly related to drug or chemical use OR
Is unmarried and pregnant and consenting to evaluation and/or treatment related to the pregnancy OR
Is unmarried, is the parent of a child, and has actual custody of the child, consenting to evaluation and/or
treatment of the child.
A pregnant minor must have adult consent unless she fits within one of the previously mentioned exceptions.
When treating minors, it is important that there be an interactive process between them and the Provider. The
interaction should involve developmentally appropriate disclosure about the illness/injury, the solicitation of the
minors willingness and preferences regarding treatment, and decision options. Although the intent of this
interaction is to involve the child in decisions, the way in which the participation is framed is important. As with any
patient, minors should be treated with respect.
Restraint/Transport Against Patient Will
An EMS System has an obligation to treat and transport certain patients who may be suffering from an illness or
injury that impairs their ability to make an informed decision. These patients will often refuse treatment or transport
to a medical facility. In circumstances where an acute illness or injury impairs a patients ability to make an
Anderson County Emergency Services - 10 - Clinical Operating Guidelines 2016
informed decision AND the patient is in need of medical treatment or evaluation to prevent further significant illness
or injury, the patient shall be transported to an ED for further evaluation. There are certain circumstances where a
patients condition or behavior poses an immediate threat to the health and safety of themselves or others around
them. In these circumstances, the patient should be SAFELY and HUMANELY restrained and continuously
monitored during restraint. Patient should never be restrained in a prone position. Patient restraint and
transport against their will should never be taken lightly. Every individual has a legal and moral right to refuse
medical treatment, even if that refusal results in potential harm. It is our responsibility to make sure the patient is
making an informed decision and that the patient causes no harm to themselves or others as a result of their
behavior.
Determine scene safety. Attempts to physically restrain a patient should be made (when possible) with law
enforcement assistance.
Determine that a potentially harmful condition exists (if the condition is immediately life-threatening, the
patient should be treated and transported as soon as safely possible).
Determine patients competency to make an informed decision using the following:
Is the patient alert? Oriented times three (person, place, time)?
Does the patient understand his / her illness or injury and the potential for adverse outcome?
Can the patient describe his / her condition to you?
Does patient understand consequences (including death) of not treating his/her illness or injury?
Does the patient understand the alternatives to immediate care by EMS?
Does the patient have any physical findings suggestive of impaired physiology that could effect
decision making? hypotension, hypothermia, hypoxia, head injury, alcohol / drug intoxication,
evidence of CVA, symptoms of psychiatric decompensation
If, based on Provider assessment, the patient is not capable of making an informed decision (because of
abnormalities defined above) AND the patient has a potentially harmful illness or injury, the patient should
be extensively counseled regarding the need for medical care. If the patient STILL refuses further
care/evaluation, or is a harm to (him/her) self or others, the patient should be physically restrained by EMS
personnel (with law enforcement assistance, if available).
PHYSICAL RESTRAINTS should be safe & humane. At NO TIME should a patient be struck or managed in
such a way as to impose pain. Restrain in a position of comfort and safety.
Thoroughly document (on the PCR) the reason for restraint, the mental status exam, options attempted,
and method of restraint (no exceptions).
If CHEMICAL RESTRAINT is deemed necessary; refer to the Violent Patient Chemical Sedation Patient
Care Guideline. Patients should be continuously monitored during restraint period and findings
documented on PCR. Never leave a patient alone after any form of restraint.

Initiation and Termination of Cardiopulmonary Resuscitation (CPR)
Initiation of Cardiopulmonary Resuscitation (CPR)
Initiation of Cardiopulmonary Resuscitation (CPR) by any credentialed Provider is not indicated for pulseless,
apneic patients in the presence of:
Obvious appearance of death
Decomposition
Rigor mortis
Obvious mortal wounds (massive burn injuries, severe traumatic injuries with obvious signs of organ
destruction such as brain, thoracic contents, etc.)
Severe extremity damage, including amputation, should not be considered an obvious mortal wound
without coexistent injury/illness
Patient submersion of greater than 20 minutes from arrival of the first Public Safety entity until the patient is
in a position for resuscitative efforts to be initiated
Operationally, on-scene rescuers should consider conversion from rescue to recovery at 20 minutes.
Exceptions to this guideline include any potential for a viable patient such as a diver with an air source
or a patient trapped with a potential air source. Final decision for transition from rescue to recovery
mode rests with on-scene command.
Out of Hospital Do Not Resuscitate (DNR) Directive
Valid Out-Of-Hospital Do Not Resuscitate Written Order or Device from any (US) State
A valid licensed physician on scene or by telephone orders no resuscitation efforts
A Provider credentialed at the EMT-IV level should elect not to begin resuscitative efforts for the pulseless, apneic
patient exhibiting obvious dependent lividity.
In addition to the previously stated criteria, unless patient arrests during transport, ALS credentialed Providers
should not initiate Cardiopulmonary Resuscitation (CPR) for pulseless, apneic patients in the presence of:
Blunt Traumatic Cardiopulmonary Arrest with clearly associated mechanism to the head and/or torso in
conjunction with the lack of spontaneous respirations following BLS airway maneuver
Penetrating Traumatic Cardiopulmonary Arrest with clearly associated mechanism to the head and/or torso
region:
When arrival at the hospital would exceed 20 minutes from arrival of first Credentialed Provider
OR
Lack of spontaneous respirations following BLS airway maneuver
AND
No evidence of organized electrical activity (rate >40) on ECG (if a monitor is not available, initiate CPR
until a monitor is available)
AND
No evidence of signs of life, specifically pupillary reflexes or spontaneous movement
Termination of Resuscitation Efforts Without Online Medical Control
Any System Credentialed Provider, in the following circumstances, may discontinue resuscitation efforts without
OLMC:
Resuscitation efforts were inappropriately initiated when criteria to not resuscitate were present

A valid advanced directive was discovered after resuscitative efforts have been initiated
When a First responder, EMT-B, EMT-A, or EMT-P Credentialed Provider makes the decision to not initiate
resuscitative efforts, or to terminate efforts without involvement of OLMC, the provider(s) making that decision
should contact ACEMS Communications, cancel other first responder units, and reduce the transport unit to
Priority 3.
In addition to the previously stated criteria, an ALS Credentialed Provider, in the following circumstances, may
discontinue resuscitation efforts without OLMC:
In penetrating traumatic arrest, an ECG monitor becomes available after initial responders initiated
resuscitation and monitor demonstrates patient has electrical heart rate less than 40
Ongoing resuscitation attempts by a Credentialed Provider of 20 minutes or more without Return of
Spontaneous Circulation (ROSC) and no shocks indicated by AED/monitor (if available).
If at anytime during resuscitation attempts, ROSC is achieved, the 20 minute timeline should be
restarted.
When an ALS Credentialed Provider makes the decision to not initiate resuscitative efforts, or to terminate efforts
without involvement of OLMC, the following procedures should be followed by the Provider(s) making that decision:
Contact ACEMS Communications, by radio or telephone and request a time of death (This must be on a
recorded line.)
Cancel additional responding units
Document per System and agency protocols
Termination of Resuscitation Efforts Utilizing OLMC
There are instances when an ALS Credentialed Provider must contact OLMC when considering discontinuation of
resuscitation efforts. These include but are not limited to the following circumstances:
Hypothermia
Persistent ventricular fibrillation/ventricular tachycardia
Persistent PEA with an electrical heart rate greater than 40
For the intubated patient, ETCO2 >10 mmHg
When OLMC is involved in the decision to terminate resuscitative efforts, the following procedures should be
implemented:
Resuscitative efforts must be continued while requesting a pronouncement.
Document per System and agency protocols
Out of Hospital Advanced Directives Pertaining to Resuscitation
Patients have a legal right to consent to, or refuse, recommended medical procedures, including resuscitative
efforts. These patients require thoughtful consideration at critical times. The decision to honor, or not to honor, an
Out of Hospital Do Not Resuscitate (OOH DNR) must be made quickly and accurately. Remember, it is our
obligation to carry out the patients appropriately designated medical choices, even when they cant direct us in
cases of cardiopulmonary arrest.
An OOH DNR order should NOT be honored and resuscitative efforts should be initiated in the following
circumstances:
The patient or person who executed the order destroys the form and/or removes the identification device
OR
The patient or person who executed the order directs someone in their presence to destroy the form and/or
removes the identification device
OR
The patient or person who executed the order tells the EMS Providers or attending physician that it is
his/her intent to revoke the order
OR
The attending Physician or physicians designee, if present at the time of revocation, has recorded in the
patients medical record the time, date, and place of the revocation and enters VOID on each page of the
DNR order
OR
The patient is known to be pregnant.
In the event that there is a question as whether to honor or not honor an OOH DNR or Advanced Directive, contact
OLMC as needed.
Important Points to Remember
It is appropriate to transport patients who have arrested to the hospital for pronouncement if, in the
assessment of the transport Providers, circumstances mandate such an action (for example, death in a
public place).
Always rule out a non-traumatic etiology for what may be perceived as a traumatic arrest (for example,
primary Ventricular Fibrillation resulting in a minor car crash).
Anytime a DNR is not honored, the reason must be documented in the Patient Care Record (PCR).
An Advanced Directive does not imply that a patient refuses palliative and/or supportive care. Care
intended for the comfort of the patient should not be withheld based on a Medical Power of Attorney
(MPoA).
When an EMS Provider honors an appropriately executed DNR order, the law provides protection against
any charges of aiding in suicide.
When in doubt, always initiate resuscitative efforts. Later termination can be implemented if
appropriate.

Crime Scene Preservation Principles/Access to Patients in a Potential Crime Scene
(The specific details pertaining to how EMS interfaces with Law Enforcement requirements in
potential crime scenes)
Emergency personnel often respond to incidents where a crime may have been committed. It is every
Providers responsibility to maintain a heightened awareness of the possibility of weapons, and to preserve
evidence at potential crime scenes to the extent possible without compromising patient care. Any scene
involving a patient that is pulseless and apneic is to be considered a crime scene and treated accordingly.
General principles of crime scene management:

The first arriving Credentialed Provider on-scene must make patient access to determine whether
resuscitative efforts are indicated or not. If law enforcement prevents entry, notification should be made
to all responding units immediately. All refusals to allow access of Credentialed Providers to patients
will be retrospectively reviewed with law enforcement.
Weapons should not be handled by a Provider unless necessary to ensure a safe patient care
environment. If weapons must be handled, the Provider must wear gloves, clearly document the items
original/new location, and inform on-scene Law Enforcement.
Never use anything (phones, sink, bathroom, towels, sheets, blankets, pillows, etc.) from an incident
scene.
Victims of assault should be strongly discouraged against cleaning up prior to arrival of Law
Enforcement or transport.
As always, the focus must remain on patient care, not obtaining patient demographics. Patient
information should be obtained from on-scene Law Enforcement, not from items in or around the
patients location. If demographics are not available, the patient should be named John Doe or Jane
Doe with an estimated age range.
Any ligature used in a suicide attempt should be left as intact as possible and should be cut rather than
untied. All cuts made should be in an area well away from knots.
Containers of any substance which may have been ingested in a suicide attempt should be left in the
position found unless they need to be taken to the hospital. If the container must be touched, use
gloved hands and limit handling to a minimum in order to preserve any fingerprints that may be present.
Disposable items used during resuscitation efforts are to be left in place. Sharps used during the
resuscitation should be stored in an appropriate container with the container being left in the area.
Intravenous lines, endotracheal tubes and all other disposable equipment used, successfully or
unsuccessfully, are to remain in place and/or on-scene.
Pronouncement times should be obtained as outlined in the Initiation and Termination of
Cardiopulmonary Resuscitation section of Professional Practice.
Providers are not to cover a body, even if requested to do so by Law Enforcement. A top sheet may be
provided to the officer on-scene. All efforts should be made to protect the dignity of the patient and
block the public view of the body.
Once a pronouncement time is obtained, the body becomes the property of the Medical Examiner. It
may not be touched or altered in any way without authorization from the Medical Examiners Office.
It is acceptable to share Patient Care information with appropriate on-scene Law Enforcement if the
patient has been Pronounced Dead. Crime scene management where no resuscitation is initiated:
Any Responder, who is not properly credentialed to seek pronouncements of an obvious Dead on
Scene (DOS), should immediately leave the area the same way entry was made without touching
anything.
When confirmation of death is required, only one properly Credentialed Provider should make entry to
the area.

Crime scene management with unsuccessful resuscitation:
Once resuscitation efforts have ceased and a pronouncement has been obtained, Providers should
immediately vacate the area.
The Medical Examiner must be able to differentiate between punctures originating from resuscitation
efforts and those present prior to arrival. All unsuccessful intravenous or pleural decompression
attempts should be marked on the body by circling with a marker or pen.
Crime scene management with patient transport:

Clothing, jewelry or other objects removed from the patient should be left on-scene. Clearly document
any items left and inform on-scene Law Enforcement of the items original and current locations.
If the patient has been placed on a sheet, notify the receiving facility that the sheet and all personal
effects may be considered evidence.
If law enforcement is not on-scene prior to transport, the first response agency is to remain on-scene,
out of the crime scene perimeter, until arrival of law enforcement. An effort should be made to keep all
individuals out of the area.
Mandatory Blood Draw Policy
It is the intent of District Attorney Generals Office, Anderson County EMS, and the law enforcement
agencies serving Anderson County (specifically the Anderson County Sheriffs Office, Clinton Police
Department, Lake City Police Department, Norris Police Department, Oak Ridge Police Department,
Oliver Springs Police Department and the Tennessee Highway Patrol) to establish a standardized
policy that gives direction and guidance to employees of all agencies involved in compliance of the
mandatory blood draw law as set forth by T.C.A. 55-10-406. Blood draws will not be conducted on
any DOA. UT Forensics will handle all DOA blood draw requests.
Scope: This policy applies to requests generated by Law Enforcement.
Implementation: Local Law Enforcement in the course of enforcing T.C.A. 55-10-406 will require
blood to be drawn from persons charged with DUI. Anderson County EMS will assist with the blood
draw portion of this enforcement. The implementation of this process is as follows:
1. At no time shall performance of blood draws be allowed to interfere with the Anderson
County EMS mission of Life Safety or primary mission as the only ambulance provider in
Anderson County. The Shift Supervisor has authority to refuse or delay a blood draw
request based on the status of the EMS system and its ability to meet our primary mission.
2. At no time shall performance of blood draws under T.C.A. 55-10-406 be performed if the
safety of the EMS employee is not certain. The Anderson County EMS employee may
refuse to perform the requested blood draw if the employee is not satisfied the procedure
can be done without endangering the safety of the employee of the person the blood is to be
drawn from.
3. No blood draw shall be conducted without prior approval from the Shift Supervisor, Deputy
Director of Operations or the Director.
4. Requests for blood draw assistance will come from law enforcement.

5. Law enforcement shall bring the subject of the blood draw request to the Anderson County
EMS unit. The only time for deviation from this policy will be allowed is if the subject is
combative. Then the person may be taken by law enforcement to the Anderson County
Detention Facility for proper restraint.
6. The law enforcement agent will provide the Anderson County EMS employee with a
Request for Mandatory Blood Draw form. No blood draw shall be performed without the
written request form. The written request must be filled out in its entirety and signed. The
law enforcement agent shall retain a copy of the completed request in the investigation file.
7. The requesting law enforcement department/agency shall provide Anderson County EMS
with an in-date, Tennessee Bureau of Investigation blood alcohol test kit and a copy of the
written request form.
8. The Anderson County EMS employee shall read the Blood Specimen Collection
Instructions outlined on the back of the Alcohol/Toxicology Request form. The employee
shall comply with these instructions.
9. The law enforcement agent shall observe the blood draw and verify that each step of the
Blood Specimen Collection Instructions was followed. Both the law enforcement agent and
the Anderson County EMS employee shall sign the Blood Specimen Collection Instructions
to indicate compliance with the instructions.
10. In performance of the blood draw the Anderson County EMS employee shall use all
conventional medical steps and aseptic techniques. An employee who has not been
instructed on the appropriate way to perform a blood draw is not allowed to perform the
blood draw. Only two attempts are to be made on the peripheral arm of the subject. If there
is no success after two attempts Anderson County EMS employees will discontinue their
efforts.
11. Each blood draw requires a patient care report to be completed. The law enforcement
agency requesting the blood draw is to sign the preliminary report. The report completed by
the Anderson County EMS employee is to be submitted for review to the QI officer.
12. In addition, ACEMS may draw blood on MVA patients that we transport to the ED.
ACEMS administration may make exceptions for the DAs Office and law enforcement
high profile cases. At no time will drawing blood be allowed to interfere with patient care.

Patient Care Reporting Requirements
Guiding Principles of Documentation for All Organizations Using Any Paper Form or
Automated Charting
At a minimum, all patient care documentation by any Credentialed Provider in the System shall:
Be truthful, accurate, objective, pertinent, legible, and complete with appropriate spelling, abbreviations
and grammar.
Reflect our patients chief complaint and a complete history or sequence of events that led to their
current request or need for care.
Detail our assessment of the nature of the patients complaints and the rationale for that assessment.
Reflect our initial physical findings, a complete set of initial vital signs, all details of abnormal findings
considered important to an accurate assessment and significant changes important to patient care.
Reflect our ongoing monitoring of abnormal findings.
Summarize all assessments, interventions and the results of the interventions with appropriate detail so
that the reader may fully understand and recreate the events.
Include an explanation for why an intuitively indicated and appropriate assessment, intervention, or
action that is part of our Clinical Operating Guidelines did NOT occur.
Clearly describe the circumstances and findings associated with any complex call or out-of-the-ordinary
situations.
Documentation of patient encounter terminates immediately after patient report given to accepting
nurse or physician in emergency department or physician office
Be available in an acceptable time period after our patient encounter for further questioning.
Remain confidential and share information only with legally acceptable entities.
Minimal Data Elements Required for First Responder Patient Care Report Documentation
The Anderson County Emergency Medical Services System Medical Director is responsible for designating the
minimum data required for patient care reporting. The following lists the minimum data to be collected on all
patient encounters.
Date and time of incident
Location of incident
Responders and incident number
Patient name (John Doe/Jane Doe if unknown)
Gender
Chief complaint
Patient assessment (including Trauma Category as applicable)
Available witness account of incident
Patient treatment provided
Transporting unit and location of transport (if immediately available)
Refusal of treatment (if immediately available)
Data may be collected and stored in whatever manner each individual organization deems most suitable for
their needs. It is each organizations responsibility to ensure that collection and storage of patient care
information is compliant with HIPAA guidelines and that the information is readily available for review as may be
required by the Healthcare Quality Committee.

Clinical Review Process
As much as we dont like it, in any practice of medicine, it is understood that errors will occasionally occur. In
order to improve as a System, be a responsible member of the medical community, and be accountable to the
citizens we serve, it is essential that these incidents be promptly, and thoroughly reviewed.
The purpose of the review is to attempt to determine why the error occurred and address those things that we
can change as a System to prevent further similar errors from occurring.
As a Credentialed Provider in the ACEMS system, and as part of that privilege to participate in care within the
System, all Providers agree to report clinical errors through the appropriate organizational channels and/or the
Designated Medical Officer. The Designated Medical Officer will facilitate the collection of data and review of
the incident.
All Providers involved in reviewing errors and evaluating care are committed to an educational (non-punitive)
approach to correcting circumstances that led to a medical error as well as all the members of the Healthcare
Quality Committee.
Clinical Review Process

The Clinical Review Process is designed to investigate all questions regarding clinical care issues. The process
assures that the ACEMS System Director, Medical Director and appointed designees are aware of and can act
on current issues as they arise in order to provide timely feedback, education and track clinical performance.
System Impact
All system Credentialed Providers are expected, as part of their privilege to practice within the Anderson County
EMS System, to actively support and participate in the Clinical Review Process.
Philosophy
The goal of the Anderson County EMS System Clinical Review Process is to protect the public that we serve by
assuring appropriate medical care. We recognize that in any practice of medicine performed by humans,
errors will occasionally occur. We are committed to looking at all clinical issues as a system and require that
anyone engaging in medical care participate in the Clinical Review Process. The process is structured to be fair
and objective with an emphasis on education as the means to improve personal and collective performance.
Our collective desire is to foster an environment where the self reporting of medical concerns and incidents is
not only encouraged but expected. This process is initiated and administered by the Healthcare Quality
Committee and is compliant with the intent of the Medical Practice Act.
Anderson County EMS System Healthcare Quality Committee

Anderson County EMS System Healthcare Quality Committee will be established. The purpose of the
committee is to assure the consistent application of the Clinical Review Process as well as to look at system
clinical issues from a system perspective in order to identify trends that may need to be addressed as part of
a comprehensive quality improvement process. The Committee will meet quarterly to discuss clinical issues
and review outcomes for consistency. Members of the committee will be appointed by the EMS Director
and Medical Director. All minutes, notes, or verbal communications that occur in or on behalf of the
Committee are kept confidential and in line with the intent of Medical Practice Act.

Designated Medical Officer
The Designated Medical Officer acts on behalf of the committee and as the EMS Directors and Medical
Directors designee to receive, assess, and mitigate clinical issues. Any request for information by a
Designated Medical Officer is to be considered a request from the EMS Director and/or Medical Director.
Steps in the Clinical Review Process

Contact with a Designated Medical Officer/Medical Director
This is the first step in the process. The Designated Medical Officer is a member of the Healthcare
Quality Committee and acts at the direction of the committee. The Designated Medical
Officer/Medical Director is available by pager/cell phone 24 hours a day and is the first point of
contact anytime an issue with potential medical involvement is identified. This is the only way to
assure the integrity of the process is protected by the Medical Practice Act. Contact with the
Designated Medical Officer or Medical Director should occur as soon as practical after an incident
has occurred. Circumstances that should be reported to the Designated Medical
Officer/Medical Director may include events such as:
Those that could potentially have an adverse impact on patient care, or on the System
as a whole (any medical error, regardless of severity)
A Provider operating outside the scope of their Credentials or qualifications.
A Provider failing to initiate care appropriate to the patient condition and their level of
Credentialing.
A Provider delivering patient care while impaired by the use of drugs or alcohol.
A Provider providing patient care that is in conflict with the System Clinical Operating
Guidelines.
A Provider refusing to accompany a patient to the hospital, if so requested, and is
reasonably able to comply with the request.
Needle and/or surgical cricothyrotomy are attempted.
A DOS pronouncement time is refused by a physician.
Cardiac and/or respiratory arrest occurs during or after:
Sedative or analgesic administration.
Pharmacologically Assisted Intubations (PAI)
Synchronized cardioversion.
Physical or chemical restraint.
Role of Departmental or Agency Supervisory Personnel in the Inquiry
Supervisory personnel are responsible for notifying the Designated Medical Officer any time there is
a question surrounding medical care or decision-making. Supervisory personnel may be directed by
the Designated Medical Officer/Medical Director to gather incident reports or information about the
issue in question. In order to protect the confidentially and discoverability of the event or concern a
supervisor must not initiate requests for medical incident reports unless directed by a Designated
Medical Officer. A supervisor may participate in the Peer Review Process when their employee is
involved in an issue. They are responsible for maintaining confidentiality in all Clinical Reviews.
Investigation
The investigation of a Clinical Inquiry is performed by a Designated Medical Officer who is a
member of the Healthcare Quality Committee. The Designated Medical Officer will report findings
and/or outcomes back to the committee. The following items may be reviewed (as available) in the
course of the investigation:
Review of the initial concern or questions
Review of the patient care record
Review of the computer aided dispatch (CAD) record
Interview with the crew involved
Interview with other responders, bystanders, patient/family or hospital staff
Hospital reports or autopsy results
Any other relevant information source

Determination of Magnitude
Action or care appears appropriate or minor deviation from acceptable
If it is determined, after review of the issue by the Designated Medical Officer, that the
Providers actions were appropriate or a minor deviation occurred, the Designated Medical
Officer will deliver appropriate feedback and document accordingly.
Action or care appears to deviate significantly from expectations
If the outcome of the review reveals a Provider has deficiencies in an area, an Education
Plan may be created in consultation with the EMS Director and/or Medical Director to
assure the deficient areas are appropriately addressed.
When development of an Education Plan is appropriate the Designated Medical
Officer, Healthcare Quality Committee, and the appropriate supervisory staff from
the representative department will develop and administrate the Education Plan.
If a Provider fails to participate in or is unsuccessful in the Education Plan, the
individual may be decredentialed, or level of Credentials changed. These
outcomes are severe and only necessary if the Provider refuses to participate in re-
education or repeated attempts to assist the Provider in overcoming deficiencies
have proven unsuccessful.
Peer Review Process
The Peer Review Process is a tool used to look at clinical issues in a fair and objective way. Peers
from each agency involved will participate in the review of an incident. Peer Review may be initiated
to better understand the complexities of an incident. The following criteria apply to peer selection:
No less than two personnel with similar Credentials and tenure to give the perspective
of someone with similar experience and training.
At least one experienced Provider, Training Officer or Senior Training Officer to provide
the systems medical expectations perspective.
Peer reviews may be conducted in any or all of the following situations at the discretion of the
Designated Medical Officer/Medical Director in conjunction with members of the Healthcare Quality
Committee:
An incident with multi-agency involvement where it may be useful to get all parties
together in order to discuss the incident
A Provider specifically requests a peer review
Incidents of significant or unusual magnitude
Peer review will be conducted when any of the five (5) potential Decredentialing issues has been
identified:
1. Falsification of Patient Care Documentation: The Provider intentionally provided
false information on a patient care record
2. Intentional Harm to a Patient: A Provider deliberately harmed a patient
3. Intentionally Withholding Care From a Patient: A Provider intentionally
withholds appropriate care from a patient
4. Providing Care Under the Influence of Drugs or Alcohol: A Provider performs
care under the influence of any illicit substance
5. Failure to Remediate: A Provider either refuses to or is unsuccessful in a re-
education process
Possible outcome of a peer review
Appropriate feedback
Development of a formal Education Plan
Referral to non-clinical, agency specific processes
Suspension or revocation of Credentials to practice
Closure of Inquiry
Once all documentation and feedback is delivered, and all requirements (if any) are met, the issue
will be closed and kept in a permanent and confidential file.

Final Words on Professional Practice
Professional practice is just what the name implies...Professional.
We all have a powerful responsibility to care for our patients in a compassionate, scientifically sound, and
operationally appropriate way. If something feels wrong, it probably is. When the going gets tough, the scene
gets complex, the environment becomes challenging or emotions run high, remember to always focus on whats
best for our patients.
Our patients and our community cant call 9-1-2. We have an obligation to do our absolute best to care for them
in a humane, clinically sophisticated fashion. Its our privilege

Section Two
Core Principle Provider Safety & Well-being
Introduction (Looking out for #1)
Face it. We work in a hazardous environment.
One of the most basic and important principles in EMS is protection of ourselves and our colleagues. The
environment we work in puts us at risk for infectious disease exposure, trauma related to motor vehicle crashes
(particularly during lights & siren driving), musculoskeletal strains & sprains, trauma related to violence,
cardiovascular events (cardiac events are the number one cause of work-related fatalities in the Fire Service
nationally) and the psychological stressors of being in the business were in.
Making sure a scene is secure is the first step in minimizing Provider risk. The Provider should perform an initial
scene survey to determine any readily apparent hazards that require additional resources. The Provider must
make an evaluation each and every time they approach a scene. There is a balance between the need for
immediate patient access and Provider and patient safety. Once on-scene, Providers must continually evaluate
the situation and make judgments accordingly. Examples of scenes requiring caution include but are not limited
to the following:
Downed power lines
Fuel spills
Unstable vehicles
Water hazards
Crowds (large, unruly, threatening)
Weapons involved
Our best weapon against the hazards we all face is awareness and prevention. Its also one of the toughest
messages for us to digest. Were in the business of being prepared for the unexpected and this Core Principle
is targeted at looking out for #1.
Infection Control
Adherence to infection control principles is the responsibility of each Provider. All EMS Providers must be
aware of well-known infectious agents (Hepatitis B, influenza, etc.), as well as emerging new pathogens (Avian
Flu, SARS, etc.) that present challenges to medicine and risks to Providers. A personal commitment to
employing basic infection control measures on every single incident will provide the simplest and best protection
against infectious diseases. Make it a habit!

Basic Protection Guidelines and Immunizations
The infection triad requires a portal of entry, an adequate amount of the infectious agent, and a susceptible
host (thats you) in order for a person to actually become infected. Through the engineering of safer equipment
and the use of Personal Protective Equipment (PPE), we can prevent portals of entry and reduce the amount of
materials to which you may be exposed.
Although it sounds simplistic and obvious, individuals that are well nourished, rested, and physically fit have
immune systems that are more responsive and better prepared to mount an effective fight against invading
pathogens. Taking care of ourselves decreases our long-term morbidity and allows us to recover more quickly
should we become infected.
In any health care environment, Providers can expect to be routinely exposed to infectious agents.
Immunizations are an extremely important weapon against infection from many of the more common agents.
Keeping current on appropriate immunizations protects you, protects patients from becoming infected by you,
and decreases overall disease transmission (this is a concept in public health known as herd immunity). As
always, you should consult with your regular physician regarding your health care and immunization status. For
healthcare workers, the currently available recommended immunizations (or documented immunity) include:
Hepatitis B
Measles
Mumps
Rubella
Varicella
Tetanus
Diphtheria
Pertussis
Influenza (seasonal)
Hepatitis A (particularly for Providers routinely involved in water rescue operations)
Attention to ongoing hand washing, especially during the cold and flu season, is very important. Each truck
should have several bottles of waterless hand washing solution. Contact with contaminated surfaces
provides a ready way for you to become infected and for you to infect others. Hands should be washed after
each patient contact, gloves should be changed and all equipment cleaned. Waterless, alcohol-based hand
cleaners are an acceptable alternative to soap and water provided there is no gross organic material present.
To be effective, hand washing with soap and water needs to be performed for a minimum of twenty (20)
seconds, using a vigorous rubbing together of all surfaces of lathered hands followed by thorough rinsing under
a stream of water. If soap and water are not available at the scene, a waterless hand wash/wipe should be
used before boarding the vehicle. Upon return to the station, all Providers should wash their hands with soap
and water.
Additionally, it is important to conduct a self-check of your skin (particularly hands and exposed surfaces) prior
to any potential patient contact. Identify scrapes, wounds, or other non-intact surfaces and cover all open and
scabbed wounds with bandages. The integrity of any bandages should be monitored during your shift to ensure
the continuation of their protection.
Personal Protective Equipment (PPE)
PPE is designed to stop the transmission chain of an infectious agent by preventing potentially infectious
microorganisms from contaminating a Providers skin, mucous membrane, or clothing, and subsequently being
transmitted to others. While PPE reduces the risk, it does not completely eliminate the possibility of infection,
and is only effective if chosen and used correctly.

Remember, PPE should always be readily available, not just carried in the vehicle for those surprise
circumstances where the possibility of exposure exists.
There are instances that the selection of appropriate PPE should be obvious and regarded by all Providers as
standard practice. These include:
Anytime patient contact is made, gloves are to be worn. The EMS System has adopted the use of latex
free materials whenever possible and certainly in all cases where a patient or Provider suffers from latex
sensitivity.
During any type of airway management procedure, or other situation that fluid splash contact with the
Providers face is a possibility, the protection of mucous membrane is crucial. Effective mucous
membrane protection may be afforded by use of the combination eye shield and mask apparatus, or
N95 mask in conjunction with department issued or approved eyewear (goggles).
Whenever the possibility exists that a patients bodily fluids could be splashed onto a Provider, gowns
should be utilized.
There are times when the selection of proper PPE, especially respiratory protection, is not so obvious and must
be made based on how a disease is spread. In these situations, the difficulty in determining the appropriate
level of protection is that a truly informed decision usually cant be made until a patient assessment is completed
and/or a history is obtained. By then, its too late! For that reason, a patient exhibiting any of the following signs
or symptoms should be a signal to Providers, that in addition to gloves and, possibly a gown, some level of
respiratory protection is required:
Productive cough (with or without blood)
Fever and chills with coughing
Night sweats
Dramatic (>10%) unexplained weight loss
Fatigue (in the presence of other symptoms)
Hemoptysis (coughing up blood)
Nuchal rigidity (stiff neck)
Chest and upper torso rash
In determining the type of respiratory protection needed, remember that only the N95 mask will afford protection
against disease spread via airborne particles (i.e., tuberculosis), while the combination eye shield and mask
apparatus is appropriate protection against disease spread through larger droplets (i.e., meningitis). In either
case, protection is only afforded if the mask is worn properly.
For a patient exhibiting signs and/or symptoms of a disease spread via airborne particles, the N95 mask
should be donned prior to entering an enclosed area that the patient may have contaminated
When caring for a patient with signs and symptoms of a disease spread through larger droplets, the N95
mask or combination eye shield and mask should be donned as soon as possible, and worn anytime the
Provider is within five (5) feet of the patient.
When airborne or droplet precautions are appropriate, the additional step of placing a non-rebreather
mask with supplemental oxygen on the patient should be employed. This will limit the amount of
aerosolized agent emitted. An N95 mask should never be used on a patient as it could inhibit
his/her respiratory function.
If the patient needs to expectorate, every attempt to should be made to capture the sputum in a tissue
or 4X4, and dispose of properly.
When in doubt, maximal rather than minimal PPE should be selected.

Sharps Hazards
The greatest risk for an occupational exposure to blood occurs with the use of needles and other sharp
utensils. The most common occupational blood exposure occurs when needles are recapped. Needles
that have contact with human tissue will not be recapped, resheathed, bent, broken, or separated from
disposable syringes.
Used needles and other sharps shall be disposed of in approved sharps containers.
Providers should ensure that no sharp is used in a manner inconsistent with its intended purpose or
attempt to circumvent the safety features of the device.
See Crime Scene Preservation (in Professional Practice section) regarding used sharps at a potential
crime scene.
Cleaning and Disinfection of Equipment and Work Areas
Remember how important it is to keep all medical equipment clean and free from infectious agents. The
essential part of cleaning and disinfecting equipment is ensuring the removal of all accumulated organic material
(the big stuff). Failure to remove organic material provides a continuing breeding ground for organisms. After
the removal of the organic material, disinfecting can take place.
Be thorough with your cleaning and consider using your PPE eyewear if you need to do heavy cleaning that
may result in splashing. Remember to clean any surface that your gloved hand may have contacted. After
applying your disinfectant, permit the equipment to air dry. Wiping dry the wet disinfected surface will negate
the effects of the agent and render it useless. Upon completion of the cleaning, make sure you wash your
hands (do you hear your mothers voice?).
Exposure Follow-up
The purpose of PPE, and always using sound infection control practices, is to reduce or eliminate the potential
for infection. On occasion, a Provider is exposed to blood, bodily fluids, or airborne particles, and appropriate
action must be taken. Many of these actions are time-dependent so its important to initiate the reporting and
follow up process as soon as possible. Besides adherence to sound infection control practices, the most
important thing you can do to ensure your health and well-being is to educate yourself. Become knowledgeable
about infectious diseases, and the exposure reporting and follow-up process for your organization. Knowledge
of the process specific to your organization ensures the right people are notified in a timely manner should post-
exposure testing, follow-up, and documentation be required. Following are general guidelines to be followed
should you experience, or suspect that you have experienced, an exposure to blood or other infectious material:
Withdraw from patient care as soon as it is appropriate. This is usually at the completion of care but
may need to occur sooner in some cases.
Take self-care steps and cleanse the wound (or irrigate the membranes) with the appropriate solution
immediately after any exposure to a patients bodily fluids. Dont attempt to milk any needle stick
injuries. This does not appear to be useful in removing source patient material.
Exposures require immediate intervention. Report any suspected exposure to communicable diseases to the
appropriate designated individual in your department as quickly as possible. Questions and consultation
regarding post exposure actions should be immediately directed to your Medical Director. Consultation
may reveal that medical evaluation of the exposure, testing, follow-up, and/or additional documentation is
necessary. In the case of a blood exposure due to needle stick (or other sharps), spray to mucous membrane,
or patient blood contacting non-intact skin, the Provider should immediately travel, or be transported to, the
closest appropriate facility for evaluation.

Motor Vehicle Crashes Lights & Siren Driving
Unfortunately, one of our greatest occupational challenges is motor vehicle crashes resulting in injury or death
to EMS Providers, patients and other vehicle occupants. In a study published in 2002, the general public had a
motor vehicle fatality rate of 2/100,000. EMS Providers, on the other hand, had a motor vehicle crash fatality
rate of 9.6/100,000 (almost 5 times the incidence of the general public). In 2001, a researcher (Kahn) published
the summary results of characteristics associated with fatal ambulance crashes over a ten year period.
The characteristics most commonly associated with fatalities included:

Between noon 1800 (39%)
Improved roadways (99%)
Straight road (86%)
Dry pavement (69%)
Clear weather (77%)
Intersection (53%)
Striking (81%)
Another vehicle (80%)
Angle (56%)
An important part of that study was that serious injuries and fatalities were much more likely to occur to
unrestrained occupants in the back of the ambulance.
According to 2004 data from the National Fire Protection Agency (NFPA), of the 103 reported firefighter deaths,
the largest proportion, 34% (35 deaths) occurred while responding to or returning from alarms. There were 29
deaths reported during operations at fire incidents. The proportion of deaths occurring while responding to or
returning from alarms continues to be close to its highest point ever. Of the 35 response related deaths, 17
firefighters died from injuries directly related to vehicle crashes. The failure to wear seat belts and speeding
continue to be listed as the major contributing factors in crash related deaths.
The bottom line is that Lights & Siren driving is a necessary part of our response to our patients but poses a
significant mortality hazard to us. Always use appropriate caution!!!!
Violence Against Providers
On occasion, the very nature of EMS places us in violent environments. It is important to remember that our
first obligation on any medical scene is to assure a secure environment for ourselves. It is acceptable, and
expected, that EMS Providers not place themselves in any situation that has a high likelihood of causing harm to
the Provider (that just makes more patients).
Staging and Retreat
The dynamic environment in which we operate presents many challenges. Dangerous situations may be
brought on by unplanned and often tragic events. During these times we must remember to provide for our own
safety as well as the safety of our fellow public safety responders and the general public. In these situations,
Providers should use their best judgment to either stage at a distance from the patient, or retreat from the scene
if immediate danger exists. In ALL circumstances, Law Enforcement should be part of the scene
management.

Psychological Stress & Burnout
It should come as no surprise that multiple studies have demonstrated high rates of psychological stress in
emergency health care providers. Not only are acute events stressful (for example a particularly difficult
resuscitation involving the death of a child), but chronic stress takes a long-term toll on both our physical and
mental well-being.
Of immediate concern is impaired job performance. Excessive stress and/or inadequate coping strategies are
associated with poor situational reasoning and judgment, tunnel vision, impaired driving skills, impulsiveness,
injuries, and poor communication with patients and others on-scene.
Obviously, lack of sleep, lack of exercise, addiction, and relationship and financial stress can overwhelm ones
ability to cope effectively. Likewise, managing those lifestyle habits can improve work performance, as well as
general happiness and fulfillment,
Chronic stress is also associated with increased risk of health problems, such as: hypertension, back pain,
peptic ulcer disease and decreased immunological response. Studies have also demonstrated a significant
increase in the divorce rate of individuals who work night shifts (dont get any ideas).
An added challenge for Public Safety Providers as a group is that we dont like to be perceived as impaired by
emotional or psychological stress. There is also a substantial increased risk of long term tobacco, alcohol and
drug use (see Deadly Sins in Professional Practice). Addictive behaviors (include food, gambling, sex/love to
the list) often begin as fun coping habits, to blow off steam, but can with time, become harmful career-ending
problems.
While its certainly beyond the scope of our Clinical Operating Guidelines to address all the approaches to this
daunting career hazard, its a critical part of our Core Principles for this System. Were all in this together, and
we have an obligation as professionals to keep an eye on each other and to support each other in obtaining help
before things spin out of control. We owe it to our patients, our loved ones, and ourselves to practice excellent
stress management in our personal and professional lives.

Section Two
Core Principle Airway, Breathing, and Circulation
(Perfusion & Resuscitation)
With any patient, on any scene, with any complaint or physical finding, our initial priority (on a secure scene, of
course) is the determination of life status. Perfusion is a physiological term that refers to the process of nutritive
delivery of arterial blood to a capillary bed in the biological tissue. In other words, delivering oxygenated blood
to all the organs and tissues so they can function effectively. From a practical perspective, in order to have
adequate perfusion, the body must have an adequate airway (in order to move air in and out of the lungs
appropriately), appropriate ventilations (again to effectively take in oxygen and eliminate carbon dioxide) and
adequate circulation (the movement of blood from the lungs to the tissues and back again). This concept is the
well-known ABCs of medicine.
The Perfusion & Resuscitation Core Principle is perhaps the most important Core Principle for critically
ill or injured patients. Every patient must have their life status assessed immediately on our contact. In most
cases, this is easily done with a simple verbal interaction when the patient responds appropriately to questions.
In some circumstances however, the ABCs are either individually impaired or all are in need of support.
An important concept in this Core Principle is that we now better understand the very important relationship
between Airway, Breathing & Circulation. Actions to address one may have a dramatic impact on the other. For
that reason, all principles of Airway, Breathing and Circulatory support are contained in a single Core Principle
with specific discussions regarding each individual concept.
In conjunction to the guidelines located here within this book, as approved by the medical director, it is accepted
practice to follow AHA, ACLS, PALS, and PHTLS guidelines when providing pre-hospital emergency care to our
patients.

Airway Adequacy (The A)
Important Concepts in Airway Management
The assessment and management of a patients airway is the crucial initial priority in all circumstances.
Usually, this is easily accomplished when faced with a talking, breathing, and coherent patient. Other times it is
more difficult to determine if the patients airway is compromised, ventilatory rate inadequate, or air exchange is
poor. Additionally, there may be circumstances when airway adequacy may become rapidly compromised
secondary to a disease or injury (i.e., thermal burns to the face or anaphylaxis). When these conditions exist, an
airway management approach must be determined rapidly and early intubation must be considered a priority.
The purpose of establishing an adequate airway (or protecting an airway from compromise) is to allow
appropriate movement of air to maintain oxygenation and to facilitate elimination of CO 2. There is a significant
risk of hypoventilation and hypoxia with any airway intervention. This risk is often overlooked in the heat
of the battle. Sometimes, during the actual procedure, healthcare providers lose sight of the need for basic
airway and ventilatory management. As procedural attempts continue, the patients oxygenation status
drastically decreases and their CO 2 dramatically rises. Both of these conditions are associated with significant
potential to worsen patient outcome.
Hypoxia has been shown to decrease survival from prehospital trauma, especially in head injury. Similarly,
increases in CO2 as a result of little or no ventilation (for example during the time an advanced airway is being
attempted) also decreases survival and worsens outcome in head injury patients. If the process of establishing
an airway is prolonged (as much as 90 seconds), we may actually make the patients outcome worse, even
though the airway is established.
If attempts at advanced airway placement are difficult or prolonged, an assessment of the adequacy of BLS
airway management must be made. It is better to maintain a BLS airway than make repeated or prolonged
attempts to establish an advanced airway. All Providers on scene should be aware of periods of no
ventilation (during airway management, transport or other circumstances) and make an effort to correct the
situation immediately.
Airway Management Approach
Our approach to airway management is extremely important. The best decision on how to manage an airway
can be reached by answering the following questions:
Is the airway being adequately maintained?
Is there a need to clear the airway?
Is the airway being protected against aspiration?
Is oxygenation adequate?
Is ventilation adequate?
Is there a condition present, or is there a therapy required that mandates airway adjuncts?
Do I have the tools to correct this problem?
Do I have the skills to correct this problem?
Airway procedures should be implemented starting with the least and progressing to the most invasive:
Manual maneuver (chin lift, jaw thrust, etc.)
BLS adjuncts (NPA, OPA)
Nasal intubation (if appropriate) CONTRAINDICATED if severe head injury noted
Orotracheal intubation (laryngoscopic or digital as appropriate)
Rescue airway (Combitube, etc)

If the patients airway cannot be maintained (i.e., inadequate ventilation), the Provider should immediately
consider airway maneuvers (within their scope of practice) as listed above. If unable to establish an
advanced airway, return to BLS maneuvers while evaluating the need for a rescue airway. If still unable
to maintain adequate ventilation and/or airway protection, proceed to placement of the Combitube or other
rescue airway.
Common Sense Approach to Facilitate Difficult Airway Management

Reposition the patients airway,
Consider laryngeal manipulation
Change your position
Change the blade
Change the provider who is intubating (this is often overlooked as a significantly useful approach)
Re-evaluate the need for an advanced airway versus expedited transport of patient to definitive care
with BLS airway management
Once the airway is established, secure it

Confirming and Monitoring Appropriate Advanced Airway Placement
Esophageal Intubation detectors and End Tidal CO2 or waveform capnography (preferred) are MANDATORY
for all intubations. The appropriate range should be between 35-45 mmHg unless herniation is suspected.
Additionally, it is important to continuously monitor airway placements for changes related to movement or
obstruction. It is essential that all advanced airway attempts, as well as confirmation of placement, be
documented in the Patient Care Record (PCR) with copies of all monitoring equipment printouts (O2 saturation
and ETCO2 with waveforms) when available.
Confirmation of an appropriately placed advanced airway is multi-faceted and should include:

Visualizing the placement,
Auscultating for breath sounds over both lungs and epigastrium,
Observing for equal chest rise and fall,
Monitoring pulse oximetry,
Monitoring changes in vital signs, especially skin color,
Monitoring ETCO2
Once an advanced airway has been established, management of the tube or catheter should be of the highest
priority during any patient movement
An appropriately sized cervical collar should be applied immediately following successful placement and
securing of the tube or catheter
No exceptions
If patient is to be transported, they should be placed on a backboard and secured
Adult and pediatric patients
The only exception would be patients who cannot tolerate a supine position (i.e. awake patient in
respiratory distress, patient with pulmonary edema, etc.)
The BVM is to be disconnected from the tube during any transitional movement including
Log-rolling patient onto a backboard
Moving patient onto a stretcher
Loading and unloading from ambulance or helicopter
Transfer to the hospital stretcher
The tube is to be reassessed following any patient movement
Appropriate demonstration of persistent ETCO2 is the most reliable indicator of tube placement in our
assessment toolbox. All advanced airway placement must be confirmed by ETCO 2 (color metric and/or
capnographic when available). Additionally, it is important to continuously monitor tube placement for any
changes related to movement or obstruction. Loss of ETCO 2 is an immediate indicator of significant change,
whether it is loss of tube placement or loss of perfusion. ALL changes in ETCO 2 must be immediately
evaluated to determine the reason for change.

Tools of the Trade Airway Management
Suctioning Device for clearing fluids or debris from the airway.

Oropharyngeal Airway (OPA) to facilitate a patent airway. Used only for unconscious patients
without a gag reflex.
Nasal Pharyngeal Airway (NPA) to facilitate a patent airway. Appropriate for use in conscious
patients.
Endotracheal Intubation advanced airway management. Definitive airway that protects patients
from aspiration. Can be accomplished either orally or nasally.
Beck Airway Airflow Monitor (Baam) - Nasotracheal intubation is an essential skill that allows a
flexible approach to airway management. In order for nasotracheal intubation to be successful it
requires patient respiratory effort and air exchange.
Combitube and King LT used as a rescue airway device in patients that require advanced airway
management but are unable to be successfully intubated. Provides protection against aspiration.
Laryngeal Mask Airway (LMA) used as a rescue airway device in pediatric patients that require
advanced airway management but are unable to be successfully intubated.

Appropriate Ventilation (The B in Breathing)
Introduction
After it has been confirmed that the patient has a patent airway, the next step is to assess ventilation and
oxygenation status. An initial assessment of respiratory rate and depth, skin color, and mental status will give a
quick picture of whether the patient is breathing and oxygenating adequately.
Your physical assessment, and pulse oximetry provide a very accurate picture of how well the patient is being
ventilated and oxygenated.
It is crucial that all Providers take responsibility for assessing adequate oxygenation and ventilation in every
patient. This can be accomplished by monitoring:
Respiratory rate and depth,
Skin color,
Capillary refill,
Lung sounds,
Work of breathing,
Patient position (i.e. Tripod),
Pulse oximetry monitoring
Oxygenation and Ventilation the Important Relationship
Ventilation is the mechanical aspect of breathing in which O 2 moves into the lungs and CO2 (normal by-product
of metabolism) moves out of the lungs. Proper ventilation requires both adequate tidal volume (500-600 cc for
an adult male) and respiratory rate.
Oxygenation is defined as the addition of oxygen to any system, including the human body. With ventilation
serving as the mechanical means of adding oxygen to the body, the patient must have sufficient oxygen
available, and the ability for that oxygen to be utilized (O2/CO2 exchange). While ventilatory rate and depth are
the key components, there are other factors that can affect whether or not the patient is being adequately
oxygenated. Even if ventilation rate and depth are adequate, every patient must be evaluated for the need to
have supplemental oxygen delivered and the most appropriate means for that to occur. Considerations in
determining a patients need for supplemental oxygen include:
Level of consciousness
Ventilation rate and depth
Mental status
Circulatory status
Skin color
Chief complaint
Previous history
Type of incident
A condition related to a patients breathing depth and rate that can create uncertainty for Providers is
hyperventilation. Because the patient is breathing at an excessive rate and/or depth, he/she expels too much
CO2. The lack of adequate CO2 causes a drop in the acid levels of arterial blood resulting in a condition called
alkalosis. Simply, the buildup of excess base in the bodys fluids. It is the alkalosis that causes many of the
symptoms commonly associated with hyperventilation including anxiety, dizziness, numbness, tingling in the
hands, feet, and lips, and a sense of difficulty breathing.

Hyperventilation can occur as a response to serious illness or, in a healthy person, as a response to
psychological stress. In either case, the key is thorough assessment to identify treatable conditions. All patients
suffering from hyperventilation should be given supplemental oxygen, calm reassurance in a professional
manner in an effort to normalize their respiratory rate and depth, and be offered transport to the hospital.
When inadequate oxygenation is recognized, it is essential that steps be taken to immediately supplement the
patients oxygen intake. Remember our primary treatment goals for patients suffering from inadequate
oxygenation include:
Preventing or correcting hypoxia
Normalizing CO2
Minimizing the effects of secondary injuries
Decreasing airway resistance
Once it is determined that supplemental oxygen is required, the question would be how much? A truly correct
answer can only be reached by thoroughly evaluating your patients condition and considering the following
guidelines
Nasal cannula at 2-6 L/min for patients suffering from minor injury or illnesses where lower liter flow is
appropriate.
Non-rebreather at 10-15 L/min for patients presenting with altered mental status, obvious difficulty
breathing, poor skin color, poor circulatory status, etc.
Bag-valve-mask at 15 L/min or greater for patients with inadequate ventilation rate and/or depth
Ventilation Rate and Depth
A common pitfall in ventilation is to over-ventilate the patient by providing too much volume or too fast a rate.
The physics that allow us to move air in and out of the lungs can also have a major impact on blood circulation
(one more important inter-relationship between the ABCs). When a normally breathing patient takes in a breath,
intrathoracic pressure decreases, allowing air to be sucked in due to the resulting pressure differential. This is
in contrast to patients that are ventilated with positive pressure (whether intubated, Bag-Valve-Mask or Mouth-
to-Mask). In these patients, we INCREASE intrathoracic pressure as we inflate the lungs. In this case, the
heart itself is squeezed and doesnt fill as well or move blood forward as well. Overly aggressive ventilation
will have a dramatically adverse effect on circulation. If we dont pay attention to rate and depth, we may
actually harm the patients circulation, drop their blood pressure, and decrease perfusion.
Ventilation depth and rate is variable and driven by the patients condition. We must be mindful of the volume
and rate at which we are ventilating the patient. The majority of adult patients should be ventilated at a rate of
12 breaths per minute (see below). Studies have shown that excessive ventilation rates significantly decreased
coronary perfusion pressures and ultimately patient survivability. This is particularly true in cases of cardiac
arrest. Each ventilation should be sufficient to create adequate chest rise and be delivered over one second.
In the absence of ETCO2 and pulse oximetry, rescue breathing (patients with a pulse) should be performed at
the following rates
Age Group Ventilatory Rate

Birth 4 to 5 days old 4060 bpm
4 to 5 days old 8 years 12-20 bpm
old
Greater than 8 years 10-12 bpm

Patients with obstructive airway diseases and evidence of bronchospasm (wheezing) must be ventilated very
carefully. These patients have a difficult time eliminating the volume of air we push into their lungs because
they have increased airway resistance. Aggressive ventilation rates or volumes may increase the risk for
pneumothorax and decreased cardiac output (because of the increase in intrathoracic pressure). These
patients require longer expiratory times due to their bronchospasm. Each ventilation should be sufficient to
create adequate chest rise and allow for an exhalation of three to four seconds.
Ventilation in Head Injuries
When treating a patient with a suspected head injury, it is important to find a balance between providing
effective brain perfusion (delivering oxygenated blood to the brain) and not allowing for an increase in
intracranial pressure (ICP). CO2 is a potent vasodilator. As CO2 levels rise, the resulting hypoxia and
hypercarbia result in brain tissue swelling and increased ICP. Studies have shown that when a patient is
hyperventilated, the cerebral arteries constrict, decreasing cerebral perfusion. We know that decreasing blood
flow to the acutely injured brain is potentially harmful and increases mortality.
In order to ventilate patients in a manner that mitigates rises in ICP, but still provides generous oxygenation of
brain tissue (very, very important in early traumatic brain injury), it is critical that we play close attention to our
ventilatory rates. The adult patient with suspected head injury should be ventilated at 16 breaths per minute.
The pediatric patient with suspected head injury should be ventilated 25% above the recommended ventilatory
rate. If ETCO2 is available, ventilation should be targeted at keeping the ETCO 2 range between 32-35 mmHg.
Herniation syndrome is the one circumstance in which hyperventilation is indicated (these patients unfortunately
have a very high mortality). Initial signs/symptoms of herniation include:
Precipitous rise in systolic blood pressure
Precipitous decrease in heart rate
Unequal pupils
Declining mental status
As ICP rises, the brain has nowhere to go except to herniate (push through) the tentorium and/or foramen
magnum. The chances of patient recovery or survival decrease significantly when cerebral herniation begins. If
signs and symptoms of herniation are present, immediate hyperventilation at 20-24 breaths per minute is
indicated. If ETCO2 is available, an ETCO2 of 30mmHg or lower is desirable. The theory is that hyperventilation
will rapidly drop the CO2 which results in a constriction of the blood vessels, decreased blood flow to the brain,
thereby reducing ICP.
Pneumothorax
Pneumothorax is the result of an injury that produces air in the pleural space and creates a collapsed lung. A
pneumothorax may be open or closed as a result of trauma or a congenital abnormality. While each of these
has unique characteristics, they present with similar signs and symptoms:
Shortness of breath
Tachypnea
Chest pain that increases on inspiration and movement
Diminished or absent breath sounds on the affected side
Hyper-resonance to percussion on the affected side

Open Pneumothorax
An open pneumothorax exists when air enters the pleural space during inspiration but is unable to leave on
expiration, raising the intrathoracic pressure. This injury is easily noticeable by the Provider who exposes and
thoroughly assesses the chest. Signs of an open pneumothorax or sucking chest wound may include a sucking
or bubbling sound as air moves in and out of the pleural space. Management of this injury is directed at
covering the hole with an occlusive dressing larger than the wound and taping on 3 sides. In theory, this allows
air to escape on exhalation through the un-taped side, reducing the intrathoracic pressure. Regardless of
dressings, these wounds may occlude on their own creating a tension pneumothorax. It is important to
continually reassess (including breath sounds).
Closed Pneumothorax
A closed pneumothorax is frequently caused from blunt trauma or congenital abnormalities and not treated in
the prehospital environment unless signs of a tension pneumothorax develop.
Tension Pneumothorax
Tension pneumothorax, a life-threatening condition, results when increased pressure in the pleural space
collapses the lung on the affected side and forces the mediastinum to the opposite side. This patient will
present with:
Extreme anxiety
Cyanosis
Tachypnea
Diminished or absent lung sounds on the affected side
Tachycardia
Late signs
jugular vein distension (JVD)
narrowing pulse pressures
hypotension
tracheal deviation
The treatment for a tension pneumothorax is immediate needle decompression to relieve the rising pressure.
Remember, as intrathoracic pressure rises, blood pressure will fall. Hypotension is a very late and ominous sign
in tension pneumothorax.
Tension pneumothorax is a clinical diagnosis. The treatment decision should be based on the following criteria:
Physical findings: decreased or absent breath sounds on one side
Rapidly progressive deterioration (one of the more useful signs)
Evidence of hypoperfusion
Presence of any late signs
In traumatically arrested patients, bilateral needle decompression may be considered for patients with significant
chest trauma.

Tools of the Trade- Breathing
Pulse Oximetry - a useful tool to estimate patient oxygenation. An Oxygen Saturation (SaO 2) reading of 95%
or above is a good indication that oxygenation is adequate. SaO 2 readings below 90% indicate hypoxia and
would be an indication to look for causes of impaired oxygenation, ventilation and/or perfusion.
End-tidal carbon dioxide (ETCO2) detectors - devices that measure the concentration of exhaled carbon
dioxide are extremely useful in airway management. These devices are most commonly used to assess proper
placement of an endotracheal tube.
ETCO2 Monitoring Capnography - direct measurement of the concentration of carbon dioxide in an exhaled
breath. ETCO2 is very useful in both the intubated and non-intubated patient for determining ventilation
adequacy and perfusion. A patient with normal cardiac and pulmonary function will have an ETCO2 level
between 35-45mmHg.
Nebulized Medications - inhaled medications provide an excellent therapy for acute bronchospasm in the
prehospital setting. These agents are generally effective, safe, and easy to use. Application of bronchodilating
drugs directly into the lungs allows a much lower dosage, thus minimizing effects.
Pleural Decompression - tension pneumothorax is a life-threatening problem. The definitive prehospital

treatment is rapid decompression of the affected side of the chest by emergency needle decompression. Once
the tension pneumothorax has been relieved, close monitoring of the patient is necessary in case of
redevelopment of the pneumothorax. The classic signs of a tension pneumothorax are progressive shortness of
breath, absence of breath sounds on the affected side, distended neck veins, cyanosis, hypotension, and
tracheal deviation (a late sign) away from the affected side.
CPAP - Continuous Positive Airway Pressure devices are used in patients that require advanced airway
management and, without the device may deteriorate rapidly. This device is a bridge to airway management that
often suspends the need for invasive airway placement, provides a more comfortable way to breathe and
decreased hospital length of stay.
Gastric Tube Insertion - gastric tubes are of limited use in the prehospital environment. Their use should be
limited to adult and pediatric resuscitation, gastric decompression after endotracheal intubation, and when
requested by On-Line Medical Control. If the nasal route is unavailable, the orogastric route may be used.

Circulation (The C)
Adequate perfusion depends on the ability of the circulatory system to function properly. Whether our patient is
suffering from a rate problem, a pump problem, or a volume problem, it is crucial to determine WHY the
patients circulation is impaired, the best approach to managing the problem and some estimate of a target end-
point indicating that we have done all we can to help maintain adequate perfusion.
As we know, there are a myriad of reasons why a patient could be suffering from rate, pump, or volume
problems leading to a hypoperfused state. The discussion of how we manage these problems will be very
broad-based and is intended to serve as guidelines for all providers. For more information on how to manage
the specific causes of these problems, please refer to the particular topics within the COGs
To ensure consistency in the assessment and treatment of patients that may be suffering circulatory system
problems, the following definitions will apply:
Tachycardia
Resting heart rate greater than 100 bpm in adults
Bradycardia
Resting heart rate less than 50 bpm in adults
A childs heart rate should be evaluated based on age and condition. The heart rate of an anxious,
sick, or injured child should be rapid. A heart rate less than 60 bpm coupled with signs of poor
perfusion in children <8 years of age is an ominous sign.
Hypertension
Consistent resting blood pressure greater than or equal to 140/90 mmHg in adults
Hypotension
Consistent resting blood pressure less than 100/60 mmHg in adults with associated signs and
symptoms of hypoperfusion.
o As described later in this section, the goal in treating patients suffering from non-
compressible bleeding is to maintain a systolic BP of 70 mmHg. This is referred to as
permissive hypotension.
o Trauma Patient Categories define a Category 1 trauma patient as one with a systolic blood
pressure of <90 mmHg.
With associated signs and symptoms, a BP of <70mmHg + (age in years x 2) is considered
hypotensive in a child.
General Management of Hypoperfusion
Baseline assessment findings will reveal perfusion status as evidenced by skin color and condition, pulse rate
and location and capillary refill.
While other assessment findings should be the keys to early identification of a hypoperfused state, blood
pressure assessment is a useful tool to guide fluid resuscitation.
Regardless of the cause, it is important that all hypoperfused patients be placed in a position that best supports
central circulation without compromising respiratory status. This should be a modified Trendelenburg position
(with or without the torso raised) with appropriate precautions related to airway management and potential
spinal cord injury. In addition, all of these patients should receive high flow oxygen.
In cases of external hemorrhage (usually compressible bleeding), application of direct pressure and other basic
techniques to control bleeding should be immediately initiated.

Hypoperfused patients are at risk for hypothermia (the obvious exception being heat-related dehydration
resulting in hypoperfusion). This is partly due to the amount of time the patient is exposed to the elements after
clothing has been stripped during assessment, and is especially true of patients receiving large quantities of
fluid. Special attention should be given to seeing that hypoperfused patients are kept warm during evaluation,
extrication, treatment and/or transport as hypothermia can lead to cardiac abnormalities and dysrhythmias.
It is important to continuously monitor blood pressure and evidence of end organ perfusion during the entire
patient encounter. Maintenance of perfusion in an actively bleeding trauma patient is an extremely dynamic
situation requiring constant reassessment and changes in therapy.
There are three unique conditions/situations of hypoperfusion that require special attention:
Traumatic brain injury (TBI)
Congestive heart failure (CHF)
Hypotension secondary to trauma with a significant delay in arrival at a receiving facility.
In TBI and CHF, trying to restore perfusion by using IV fluids may lead to volume over load (in TBI creating
cerebral edema and in CHF worsening pulmonary edema). Limited fluid resuscitation (250-500 mL bolus)
should be followed by use of pressors (Dobutamine and/or Dopamine as appropriate) to maintain perfusion.
Fluid Resuscitation
Fluid resuscitation should begin with crystalloid solutions:

Ringers Lactate in trauma
Normal saline 0.9% in non-trauma situations
In instances of hypoperfusion related to fluid losses (i.e., compressible bleeding, severe dehydration), the goal is
to maintain adequate perfusion as evidenced by skin color and condition, pulse rate and location, capillary refill,
and improvement in BP.
In non-compressible bleeding (bleeding unable to be stopped in the field) regardless of the cause, permissive
hypotension (where restrictive fluid resuscitation increases systemic pressure without reaching normotension) is
preferred. In this case, the decrease in blood pressure may assist in the formation of clots. With permissive
hypotension, the goal in the adult patient is simply maintenance of a SBP of 70mmHg. Aggressive fluid
resuscitation to increase blood pressure could pop clots that may have formed.
For the pediatric patient, the ultimate goal of fluid resuscitation is to maintain vital end-organ function as
evidenced by skin color and condition, pulse rate and location, capillary refill, and improvement in BP while
avoiding complications of inadequate or excessive therapy.
It is important to remember that it takes 3mL of fluid to replace 1mL of blood lost because 2/3 of infused fluid will
leave the vascular space within an hour.
While it is a good principle to begin with 20mL/kg of fluid as a starting point, the final amount will vary depending
on the situation.
Large bore IV catheters should be chosen for trauma patients. In cases of severe hypotension or shock and the
inability to rapidly establish vascular access, intraosseous access should be established in both adult and
pediatric patients.
The effectiveness of fluid resuscitation can be monitored by utilizing ETCO 2 monitoring. When a patient
becomes hypovolemic, the ETCO2 should be lower than normal due to a reduction in cardiac output and
perfusion. Theoretically, as fluid resuscitation begins and cardiac output increases, the ETCO 2 should rise. It is

an ominous sign if the ETCO2 remains low even after aggressive fluid resuscitation. As always with all patients
receiving aggressive fluid therapy, volume status should be carefully monitored by physical examination for
evidence of fluid over load (pulmonary edema, etc.).
Guidelines for Medication Administration
Medications should be administered as designed
The establishment of intraosseous vascular access should be limited to those patients in extremis, as an
alternative when no other vascular access is readily available. Medications and fluid therapy normally given IV
may also be administered IO in this circumstance. For IO administration, Lidocaine should be administered
SLOWLY through the attached pre-primed extension set prior to IO bolus or flush on an alert patient; or with
evidence of pain directly related to the IO infusion in the pediatric patient. Refer to Appendix A-C-9 or A-C-10 for
dosing parameters.
The endotracheal route is the least preferable route for medication administration and is limited to Naloxone,
Atropine, Epinephrine, and Lidocaine. For the proper dosing of medications administered via ET tube, please
refer to the applicable PCG and/or Appendix A-C-6.
There are instances when pediatric dose calculations could exceed the Adult single or total dose. The maximum
Adult Single or Total dose shall not be exceeded when administering medications to pediatric patients.
Circulatory Support During Arrest (Non-Traumatic)
Patients in cardiac arrest have no circulation, no perfusion and are obviously in need of immediate circulatory
support. In these cases, external cardiac compressions provide forward blood flow. While chest compressions
provide some degree of flow, its only 25-33% of normal cardiac output. Every effort should be made to effect
Return of Spontaneous Circulation (ROSC). To that end, there are some very important principles that must be
focused on during resuscitative efforts.
Proper ventilation rates and depth

Although previously discussed in the Ventilation portion of this Core Principle, its importance in relation to
chest compressions cannot be over emphasized. Studies have repeatedly shown that over-ventilating a
patient increases intrathoracic pressure, reducing venous return to the heart during compressions.
Reduced venous return leads to diminished cardiac output and decreased coronary and cerebral perfusion.
Newborn (birth to 4-5 days old)
Apnea, gasping breaths, central cyanosis (acrocyanosis is usually a normal finding), and/or a heart
rate <100 bpm, are all indicators that ventilations are required
Assisted ventilations should be delivered at the rate of 40-60 per minute
After 30 seconds, reevaluate. The primary measure of adequate ventilations is prompt
improvement in the heart rate.
Infant or child (4-5 days old to 8 years old)
Rescue breathing (patient has a pulse)
o 12 to 20 breaths per minute
Ventilations with chest compressions
o Single rescuer / No advanced airway in place
- 30 compressions and 2 ventilations per cycle
o Two rescuers / No advanced airway in place

o One or two rescuers / Advanced airway in place
- Ventilations at 8-10 breaths per minute
- Compressions are not interrupted for delivery of ventilations
Adult (8 years old and older)
Rescue breathing (patient has a pulse)
o 10-12 breaths per minute
Ventilations with chest compressions
o 30 compressions and 2 ventilations per cycle (single or two rescuers)
Effective compressions
Push hard and push fast is the motto
No matter the age group, allow the chest to completely recoil following each compression and allow
approximate equal compression and relaxation times
Interruptions in chest compressions leads to a reduction in coronary artery perfusion pressure and must be
minimized.
Newborn (birth to 4-5 days old)
Compressions are indicated for an infant with a heart rate <60 bpm despite 30 seconds of adequate
ventilations with supplemental oxygen
The 2 thumb-encircling hands technique is recommended to compress the lower third of the
sternum approximately 1/3 the anterior-posterior diameter of the chest
The compression to ventilation ratio is 3:1
o There should be 90 compressions and 30 breaths (120 events) per minute
Compressions and ventilations should continue until heart rate is >60 bpm with ventilations
continuing as needed after that.
Infant or child (4-5 days old to 8 years old)
Compressions are indicated for an infant or child (4-5 days old to 8 years old) with a heart rate <60
bpm (and/or signs of poor perfusion) despite 30 seconds of adequate ventilations with supplemental
oxygen
Compressions should be performed just below the nipple line, at the rate of 100 per minute in an
infant or child
Single rescuer / No advanced airway in place
o Two fingers to compress the chest
o 30 compressions and 2 ventilations per cycle
Two rescuers / No advanced airway in place
o If possible based on infant size, the 2 thumb-encircling hands technique is recommended
o 15 compressions and 2 ventilations per cycle
- Compressions are not interrupted for delivery of ventilations
Adult (8 years old and older)
Compressions are performed at the nipple line
o 2 hands to depress the sternum 2-2.4 inches
o Compressions are delivered at the rate of 100-120 per minute
o Single or two rescuers / No advanced airway in place
- Compressions are not interrupted for delivery of ventilations.

Proper sequencing of defibrillation and compressions
Depending on the circumstances (witnessed or non-witnessed arrest), there is a significant difference in
whether immediate application of an available AED is appropriate or, if CPR should be performed prior to
AED application.
For purposes of clarification, a witness is defined as a trained healthcare Provider, i.e., other System
Credentialed Provider, nurse, physician, etc.
In cases of Non-Witnessed Arrest (DISCOVERED) With No Rescuer CPR
Perform 5 cycles (approximately 2 minutes) of compressions/ventilations at a ratio of 30:2 for the
single rescuer and 15:2 if two rescuers are present
In Cases of Witnessed Arrest
Immediately apply defibrillator/AED and defibrillate as indicated followed by appropriate CPR
In cases where the adequacy of compressions provided prior to the arrival of System Providers is in
question or bystander CPR, 5 cycles (approximately 2 minutes) compressions/ventilations should be
provided prior to defibrillation attempts
AED Pad guidelines
Patient >55 lbs- Adult pads
Patient <55 lbs- Pediatric pads (application of the AED is not indicated in the newborn)
Uncertain if patient requires adult pads or pediatric pads- Adult pads
No pediatric pads available- Adult pads may be used (anterior-posterior application may be
required)
Removal of the AED in favor of a manual monitor/defibrillator is appropriate for
Therapy that is only available with the manual monitor/defibrillator
VF/VT that does not convert despite multiple AED shocks
Patient transport
The measurement of ETCO2 has become a valuable monitoring tool in arrest management. Studies have
demonstrated that ETCO2 can accurately predict ROSC and is a positive prognosticator for survival from cardiac
arrest. In one study, those patients that were delivered to the ED with ETCO 2 greater than 15mmHg had a 90
percent chance of ROSC. Those that had ETCO 2 less than 15 mmHg had almost zero chance of ROSC. It has
also been shown that ETCO2 rose dramatically well before a pulse was detected which can be a useful tool in
determining ROSC.
Circulatory Support During Arrest (Traumatic)
If the patient is a candidate for resuscitation (see Initiation and Termination of CPR in Professional Practice
section), airway management, ventilations and chest compressions should be initiated. There are specific
guidelines important to management of the traumatically arrested patient:
Resuscitation attempts should be carried out while transporting the patient to the closest appropriate
facility. Rapid transport of these patients should be initiated; this is not a stay and play situation.
Consider bilateral needle decompression in patients with significant chest trauma.
Patients in VF or pulseless ventricular tachycardia (PVT) should be defibrillated with an AED or manual
defibrillator. It is important to note that without circulating blood volume defibrillation is usually
unsuccessful.

Tools of the Trade- Circulation Management Adjuncts
Electrocardiograph (ECG) - a graphic representation of the hearts electrical activity generated by

depolarization and repolarization of the atria and ventricles. It is a valuable diagnostic tool for identifying a
number of cardiac abnormalities, including abnormal heart rates and rhythms, abnormal conduction pathways,
hypertrophy or atrophy of portions of the heart, and the approximate location of ischemic or infracted cardiac
muscle.
EZ-IO - if a patient presents in shock, the peripheral veins have often collapsed (usually the result of blood or
fluid loss, lack of vascular tone, respiratory complications or cardiac failure). Gaining vascular access with the
patient in this condition can be extremely difficult. The IO space is considered a Non-Collapsible vein.
Alternate Venous Access - with advancements in home health care, an increasing number of patients are
being released to their homes with implanted venous access devices. These include double, triple, multi-lumen
and implanted medication ports. This is in addition to the existing population of patients with implanted AV
fistulas and AV-grafts used in dialysis. Q-Ports (Portacath) should be used as the primary access, in those
patients who have them, for intravenous therapy, unless contraindicated (i.e. infection, malfunction etc.)
AED the AED delivers a low-energy biphasic waveform, in which the direction of the current is reversed
midway through the pulse.
Cardioversion - a properly connected defibrillator/monitor placed in synchronization (sync) mode searches for
the peak of the QRS complex (or R-wave deflection) and delivers the shock a few milliseconds after the highest
part of the R-wave.
Emergent Cardiac Pacing - in transcutaneous pacing the heart is stimulated with externally applied cutaneous
electrodes that deliver an electrical impulse. This impulse is conducted across the intact chest wall to hopefully
stimulate myocardial activity.
Manual Defibrillation - rapid defibrillation is the most important intervention in ventricular fibrillation or pulseless
VT. This procedure involves the placement of two electrodes (hand-held paddles or hands-off electrodes) on the
patients chest.
Endotracheal Medication Administration - because of the large surface area of the alveoli and vast blood
supply of the pulmonary capillary beds that return blood to the left heart, drugs administered through the trachea
are rapidly absorbed and delivered to the heart for distribution.
IM Medication Administration - intramuscular (IM) injection is the most commonly used route of parenteral
medication administration. The drug is injected into the muscle tissue, from which it is absorbed into the blood
stream.
Intraosseous Infusion (manual device) - intraosseous infusion is a temporary means of intravenous access in
both children and adults, to be replaced with conventional venous access as soon as possible.
Intravenous Fluid Therapy - intravenous therapy is the introduction of fluids and other substances into the
venous side of the circulatory system. It is used to replace blood loss through hemorrhage, for electrolyte or fluid
replacement, and for introduction of medications into the vascular system.

Pressure Infusion Bag - may be considered for use in any environment where awkward patient position,
physical location, or IV/IO placement does not allow for adequate gravity flow of IV fluid. The device is designed
for use during rapid fluid infusion only. It is not appropriate when a specific drip rate is required.
Pneumatic Anti-Shock Garment (PASG) - in very specific and limited circumstances, PASG garments may be
useful in maintaining perfusion when patient arrival at definitive care may be prolonged. Examples include
prolonged extrication from a wilderness or confined space environment. In these circumstances, the benefits of
circulatory support must be balanced by the potential for worsening non-compressible hemorrhage. While not
always practical, OLMC should be attempted prior to use of PASG in these situations.
Subcutaneous Medication Administration - SQ injection is one of the simpler forms of drug administration
that indeed may be lifesaving in cases of severe asthma or allergic reaction.

Section Two
Core Principle Disability
Introduction
Once a patient has been stabilized (meaning their respiratory and perfusion status is established), it is
important to continue our assessment to determine whether or not there is any neurological impairment, and if
so, WHY the patient has that abnormality. In broad terms, this describes a patients disability.
Nervous System Dysfunction
Injuries to the Central Nervous System are classified as being either primary or secondary. Primary injuries
refers to tissue damage occurring at the time of the event, such as tissue destruction as a direct result of stroke,
blunt head trauma, or trauma to the spinal cord. Secondary injuries may occur minutes to days after the
incident and refer to the tissue damage that can result from the hypoxia, hypercarbia, hypotension or increased
intracranial pressure that can occur secondary to the actual event. While we are unable to directly change the
effects of primary injury, our goal is to minimize the impact of secondary injury by maintaining adequate cerebral
perfusion through management of the airway, ventilation and oxygenation, and circulation.
Although the brain accounts for only 2% of total body weight, it accounts for 15% of cardiac output and 20% of
oxygen requirements. If the brain is deprived of oxygen, unconsciousness will result within 5 to 10 seconds. If
totally deprived of oxygen, irreversible brain death can occur within 4 to 6 minutes. These facts underscore that
continuous, quality CPR during cardiac arrest is crucial for a patient to survive neurologically intact.
Causes for Nervous System Dysfunction
The multiple causes for impaired neurological function may be grouped into two general categories: metabolic
and structural abnormalities.
Metabolic Abnormalities
Hypercarbia and/or Hypoxia the build up of CO2 and/or the lack of adequate available oxygen may
result in secondary tissue injury and neurological impairment
Hypotension the lack of perfusion to vital organs which in turn leads to a decrease in available
nutrients and the build up of toxins
Diabetic states the brain requires glucose to function but cannot store it. Low blood sugar impairs
cognitive function
Metabolite build up usually due to malfunctioning organs.
Poisoning and overdose various toxins may impair mental status

Hypothermia or Hyperthermia extremes in temperature depresses metabolism and slows nerve
conductions
Mild hypothermia = 93-97 degrees
o mild alteration in awareness and clouded thoughts
Moderate hypothermia = 8292 degrees
o body metabolism and heart rate drops 50%
o pupils non-reactive to light
o patient is unconscious
Deep hypothermia = 6181 degrees
o cardio-respiratory arrest
o muscle reflexes absent
Profound hypothermia = 61 degrees and below
o unlikely chance of survival
Hyperthermia with associated altered mental status
o usually occurs at a temperature of 105 degrees and higher
o risk for cardiac arrest secondary to metabolic acidosis, electrolyte disturbance and
hypotension
Sepsis severe illness caused by an overwhelming infection of the bloodstream by toxin- producing
bacteria
Sometimes the treatment of the infection results in the release of toxins which in turn attack the
body and destroy tissue leading to further infection and complications
Structural Abnormalities
Stroke
Stroke is the leading cause of brain injury in adults and the third leading cause of death in the United States.
Approximately 75% of all strokes can be classified as ischemic (strokes caused by the occlusion of an artery
supplying oxygen and other essential nutrients to the brain) as opposed to hemorrhagic. This makes the vast
majority of stroke patients candidates for fibrinolytic agents and endovascular procedures.
The major arteries that supply blood to the brain are the carotid, which perfuse the front of the brain, and
vertebral arteries, which perfuse the back of the brain. Patients with stroke caused by occlusion of carotid
arteries present with one sided deficits (classic, one-sided weakness or paralysis) while vertebral artery
occlusions present with bilateral deficits (like passing out, for example).
The risk factors of stroke include

Hypertension
Diabetes
Congestive heart failure
Atrial fibrillation
Carotid or other artery disease
High blood cholesterol
Alcohol and drug abuse
Very recent developments in stroke therapy including fibrinolytic agents and endovascular procedures have
shown great promise when started within a short period of time from the onset of signs and symptoms. Early
recognition, rapid transport to a designated stroke center and early notification of the stroke team all directly
affect the patients final outcome and chances for recovery. Every provider has the responsibility for conducting
an appropriate evaluation and facilitating rapid transport when a patient presents with new onset neurological
deficits.

Traumatic Brain Injury (TBI)
TBI is defined as an injury to the brain caused by an external physical force, resulting in total or partial functional
disability and/or psychosocial impairment that adversely affects performance. The term applies to open or
closed head injuries. Most frequently, TBI results from falls, especially in younger and older populations,
followed by motor vehicle crashes, then assaults.
Increased intracranial pressure is the leading cause of mortality/morbidity following TBI. The brain, being
enclosed in the skull, is not able to compensate for sudden increases in pressure either by fluid (i.e., bleeding in
cranial vault), or sudden changes in blood flow (vasodilation/vasoconstriction). As ICP rises, the brain has
nowhere to go except to herniate (push through) the tentorium and/or foramen magnum. The chances of patient
recovery or survival decrease significantly when cerebral herniation begins. No matter the cause, the final
common pathway is the same: brain death.
Spinal Cord Injury

Spinal cord injuries can result from a myriad of mechanisms. However, motor vehicle accidents, falls,
penetrating trauma and sports injuries are the most common causes. Spinal cord injuries can be classified as
either complete or incomplete cord injuries. A complete cord injury results in loss of motor and sensory function
below the level of injury. These injuries have a poor prognosis and little chance for recovery of function.
Incomplete cord injuries damage the cord, but preserve some motor or sensory function below the level of
injury. These injuries have a slightly better prognosis with the expectation of at least some recovery of function.
Nervous System Assessment
Assessment/Stroke
Due to the time critical nature of delivering fibrinolytic agents and endovascular procedures to suspected stroke
patients, it is the responsibility of all Providers to immediately evaluate any patient presenting with new onset
neurological deficits using the Los Angeles Prehospital Stroke Scale (LAPSS).
Assessment/Traumatic Brain Injury
For the traumatically injured, neurologically impaired patient, a rapid assessment is crucial. A complete
neurological assessment is the most important tool in identifying neurological pathology. Components of a
complete neurological exam include:
Vital Signs
Glasgow Coma Scale
Pupil Assessment
Glucose Assessment

Neurological Exam Components
Heart rate and Blood Pressure

Brain injury causes brain ischemia which initially results in stimulation of the sympathetic nervous system (fight
of flight) causing vasoconstriction and tachycardia. If ischemia and/or the increase in intracranial pressure is
allowed to continue, the brain can no longer compensate and begins to herniate downward through the foramen
magnum (the biggest hole in your head), compressing the brain stem. This herniation syndrome is evidenced by
hypertension, bradycardia and irregular respiratory patterns. Herniation syndrome is a true life threatening
emergency. If the process is allowed to continue, the sympathetic nervous system is no longer able to override
the parasympathetic nervous system and profound hypotension and bradycardia ensues, leading to brain death.
Respiratory Rate and Patterns

Breathing is controlled by the medulla and pons and is partially regulated by the concentration of carbon dioxide
(hydrogen ions). Increasing C02 levels in a normal patient should lead to an increased respiratory rate and
depth and cerebral vasodilatation. Conversely, lower C0 2 levels should lead to a decreased respiratory rate and
depth and cerebral vasoconstriction.
Respiratory patterns are indicative of intracranial pathology. Slower respiratory rates with periods of apnea
indicate brain stem injury.
Glasgow Coma Scale (GCS)

Level of consciousness is the most sensitive indicator of nervous system dysfunction. The GCS is the most
effective tool for assessing level of consciousness. All Providers are responsible for assessing and
documenting GCS scores on any patient with indications of trauma related neurological impairment.
Glasgow Coma Score

Eye Opening (E) Verbal Response (V) Motor Response (M)
4=Spontaneous 5=Normal conversation 6=Normal
3=To voice 4=Disoriented conversation 5=Localizes to pain
2=To pain 3=Words, but not coherent 4=Withdraws to pain
1=None 2=No words......only sounds 3=Decorticate posture
1=None 2=Decerebrate
1=None
Total = E+V+M
Decorticate posturing
Decorticate posture is an abnormal posturing indicated by rigidity, flexion of the arms, clenched fists, and
extended legs. The arms are bent inward toward the body with the wrists and fingers bent and held on the
chest. Presence of this type of posturing implies severe damage to the brain with immediate need for medical
attention.
Decerebrate posturing
Decerebrate posture is an abnormal body posture indicated by rigid extension of the arms and legs, downward
pointing of the toes, and backward arching of the head. A severe injury to the brain at the level of the brainstem
is the usual cause

Pupil Assessment
When assessing the pupils, it is important to note that there is constant competition between the sympathetic
(fight or flight) and the parasympathetic system. In general, pupil response indicates which of these systems is
currently dominant. The sympathetic system causes the pupil to dilate while the parasympathetic system
constricts the pupil. Deviations from normal, such as non-reactive or unequal size, give indications to the
Provider about potential brain abnormalities.
Glucose Assessment
Patients exhibiting any level of altered mental status (i.e. Stroke or Traumatic Brain Injury) should have their
blood glucose level assessed in order to either eliminate Hypoglycemia as the cause or identify it as a
contributing factor.
Assessment/Spinal Cord Injury
For any patient involved in an incident that has the potential to result in spinal cord injury, it is the responsibility
of all Providers to apply the System Spinal Restriction Algorithm to determine whether or not the patient
should be placed in a C-collar and on a spine board.
See spinal immobilization algorhythm
Treatment for Nervous System Impairment
Head Injury
The treatment of brain injury, whether traumatic or the result of stroke, should be focused on maintaining
appropriate brain perfusion. As with all patients we evaluate and treat, our focus should be:
Airway Must be secured early and monitored continuously
Breathing If patient respiratory rate and depth are adequate, deliver high flow oxygen. If assisted
ventilations are required, be mindful of ventilation rate and depth. A ventilation rate that is too fast or
too slow can worsen the injury.
The adult patient with suspected head injury should be ventilated at 16 breaths per minute. The pediatric
patient with suspected head injury should be ventilated 25% above the recommended ventilatory rate.
Patients requiring assisted ventilations due to the possibility of having suffered a stroke should be ventilated at
the rate of 12 breaths per minute.
If capnography is available during treatment of either a stroke or head injury patient, ventilate to maintain EtC0 2
32-35 mmHg.
Impending brain herniation as a result of stroke or traumatic injury, as evidenced by hypertension, bradycardia
and an irregular respiratory pattern, is a true life threatening emergency. The immediate short term treatment
for these patients is aggressive hyperventilation at a rate of 20-24 bpm. If ETC02 is available, ventilate until
the ETC02 is less than 30 mmHg. Although this patient population has very high mortality rate, hyperventilation
and rapid transport will give them a slightly better chance of survival.
Circulation fluid resuscitation to maintain a systolic blood pressure of at least 100 mmHg in
adults.
Positioning The best position for patients with brain injuries is with the head midline and elevated
30 degrees. This angle facilitates drainage through the jugular veins. This can be accomplished in
patients on a backboard simply by raising the head of the board.

Spinal Cord Injury
Patient spinal motion restriction is paramount. Treatment considerations include:

Airway ensure patent airway. Jaw thrust should be performed if airway manipulation is needed to
open the airway.
Breathing be prepared to assist with ventilations especially patients with high cervical neck
injuries. If intubation is required, it may be necessary to loosen the cervical collar to allow for jaw
movement. One provider should maintain manual cervical immobilization throughout.
Circulation be prepared to treat symptoms associated with spinal shock. Evidence of spinal
shock includes:
Patients who are generally warm and flushed below the level of injury due to vasodilatation and
venous pooling
Hypotension with a low diastolic pressure due to the loss of vascular tone of the vessels
Relative bradycardia, particularly with thoracic spine injuries, due to parasympathetic system
activating the vagus nerve
Thermoregulation be aware that patients suffering from spinal shock are highly susceptible to
hypothermia. Be sure to maintain patient warmth.
Pregnancy - Patients in need of Spinal Motion Restriction that are >20 weeks gestation should be
packaged normally and the backboard tilted approximately 15 degrees, left side down
Tools of the Trade Disability Management Adjuncts
Glucometer (Blood Glucose Assessment)
Physical Restraint/Transport Against Patient Will

An EMS System has an obligation to treat and transport certain patients who may be suffering from an
illness or injury that impairs their ability to make an informed decision.

Section Two
Core Principle Patient Comfort
Introduction
One of the most important objectives of any emergency healthcare provider is relief of pain. Patients have
significant concerns about pain and want relief quickly (as we would want if we were injured or ill).
Historically, EMS Providers (and EMS Systems) have not concentrated on pain relief as a significant component
of patient care.
The establishment of Patient Comfort as a Core Principle emphasizes our commitment to always focus on
relieving pain, both by behavioral and technical means. Pain may also be emotional (people dont usually plan
their emergencies).
Patient Interactions
As Anderson County Emergency Service Providers, it is our obligation to provide for both our patients physical
and psychological well being. This begins with the demeanor and approach of each provider in the System. All
interactions should be professional and caring. Patients in these circumstances rely heavily on the advice and
care we provide and trust that it is given in their best interest. This is a responsibility we all take seriously and a
trust that it part of a unique patient relationship.
We exist to do the best job we can to solve our patients problems.
Pain
Reactions to Pain
A small degree of anxiety can actually raise the tolerance level of pain. However, studies have shown that
increases in anxiety actually lower the pain tolerance in most people. Environment has also been shown to
have an affect on a patients reaction to pain. Individual pain perception and response to pain is based on three
major factors:
The interpretation of the severity of the initial injury.
Past experiences with pain create a memory of past events. Repeated exposure to painful experiences
lowers a patients threshold.
Events surrounding the injury.

Pain Assessment
Patients experience a variety of insults that may result in discomfort. It is our responsibility to manage this
discomfort whenever possible while we appropriately treat underlying illness or injury. Remember the power of
focusing on the patient and listening to their responses to your interventions.
Non-Verbal Cues to Pain
Tachycardia
Tachypnea
Sweating
Blood Pressure Increases
Decreased SaO2
Nausea/Vomiting
Flushing or Pallor
Shivering
Increased muscle tension, position changes or immobility
Guidelines for Pharmacological Pain Management
Vascular access should be initiated prior to administration when safely able to do so.
Naloxone should be available anytime an opiate is administered for rapid reversal.
The intramuscular route is indicated only when vascular access is unobtainable.
A baseline blood pressure or radial pulse (age appropriate) should be assessed prior to analgesia and should
be reassessed every 5 minutes, or as appropriate.
ETCO2 monitoring is essential when administering narcotic analgesics. It is not only a great tool to assess
effectiveness, but also provides and an early warning of potential complications. Analgesics should be titrated
to the patients perception of pain and the ETCO2 readings/waveform. Indications that adequate sedation/pain
relief has been achieved:
Deeper and slower respiratory rate (evident by elongated waveform)
Slowly rising carbon dioxide level due to the respiratory rate and depth
Patient reports decrease in pain
Sleepy or alteration in awareness
Constant monitoring of patient condition utilizing all available tools including EKG, ETCO2, SaO2, and vital signs
is critical.
Any patient that has been given a medication for the relief of pain and/or anxiety will have a printed strip of the
vitals and ETCO2 (when available) prior to and post administration. This will become a permanent part of the
Patient Care Record (PCR). A code summary will be attached to both the original PCR and the Clinical Practice
copy with the name of the patient and the date written on the strip.

Tools of the Trade Patient Comfort
Non-Pharmacological
Provide a calm and controlled interaction. When the environment surrounding the patient is controlled it
helps to relieves anxiety and provides initial pain relief. Examples include: dimming lights, quiet room
and soft spoken voice.
Explanation of procedures and calm re-assurance.
Providing relaxation techniques, distractions and guided imagery
Splint and stabilize fractures/dislocations. By limiting the spinal reflex, tissue and muscle metabolism is
slowed preventing spasms that increase pain reception and transmission.
Minimizing tissue damage prevention and protection of the environment to reduce further injury
thereby reducing the perception of pain by receptors.
Use of cold and heat packs.
Pad backboards including padding the natural voids created by the curvature of the spine.
Allow patients to remain in the position that is most comfortable, thus minimizing anxiety and reducing
pain transmission.
Kendrick Traction Device (KTD) has improved the ability to provide femoral traction. The traction pole
length quickly adjusts for both adult and pediatric application. The need for patient rollover or
unnecessary leg elevation has been eliminated.
SAM Sling - The SAM Sling is a force-controlled circumferential pelvic belt designed to provide safe
and effective reduction and/or stabilization of potential pelvic fractures.
Pharmacological
Medication should only be used for anxiety when severe enough to impede appropriate patient care and
impair safety or worsen physiology. Remember that almost all patients experience some anxiety
associated with acute illness or injury that does not require medication.
Patient Care Guidelines that contain these drugs include titrate to effect dosing. It is critical that
attention be paid to onset of action for each.
Morphine: is the drug of choice for ischemic chest pain/acute myocardial infarction. It reduces preload,
thus reducing the workload of the injured heart. Morphine is a respiratory depressant that may cause
hypotension. It also may stimulate the vomit center in the brain (consider antiemetic). Onset of action
of IV Morphine is approximately 5 minutes.
Fentanyl: works best if given to burn patients and trauma patients. It should be used to treat acute pain
only. Fentanyl is a respiratory depressant that may cause hypotension. Onset of action of IV Fentanyl
is approximately 2 minutes.
Midazolam: has an amnestic effect; however it has no analgesic properties. Significant dose-related
respiratory depression can be associated with rapid Midazolam use, especially when combined with
narcotics. Extreme caution should be observed when combining these medications. Onset of action of
IV Midazolam is approximately 1-5 minutes.
Diazepam: has an amnestic effect; however it has no analgesic properties. Significant dose-related
respiratory depression can be associated with rapid Diazepam use, especially when combined with
narcotics. Extreme caution should be observed when combining these medications. Onset of action of
IV Diazepam is approximately 5-7 minutes.

Medical
Patient Care
Guidelines &
Standing Orders

EMERGENCY INTUBATION
EMT-B /FIRST RESPONDER/ALL PROVIDERS

Scene and patient management per Core Principles
Focused history and physical exam
Develop and implement treatment plan based on assessment findings, resources, and training
ADULT PEDIATRIC (<37 kg)

A-EMT PROVIDER A-EMT PROVIDER
EMT-PARAMEDIC PROVIDER EMT-PARAMEDIC PROVIDER
Advanced airway, vascular access and fluid therapy per Advanced airway, vascular access and fluid therapy per
Resuscitation and Perfusion Core Principle Resuscitation and Perfusion Core Principle
Pre-oxygenation with appropriate device Pre-oxygenation with appropriate device
Sedate the patient Atropine 0.01mg/kg (if less than 5 years old)
Etomidate 0.3 mg/kg IV over 30-60 sec Morphine 0.1 mg/kg IV (younger than 10 years)
and consider Sedate the patient
Fentanyl up to 2 mcg/kg (per dose) (max total of Etomidate 0.3 mg/kg injected over 30-60 sec (10
400 mcg) (Preferred) IV titrated to effect for pain years and older)
related to trauma without evidence of Versed 0.1 0.4 mg/kg IV push over 30 sec
hypoperfusion (younger than 10 years)
Intubate with appropriate tube, confirm placement, May repeat in 3 minutes if inadequate response
secure tube Intubate with appropriate tube (16+ age/4), confirm
Ventilate and maintain proper oxygenation placement, secure tube
Post-intubation sedation Ventilate and maintain proper oxygenation
Diazepam 520 mg (5 mg increments) titrated to Post-intubation sedation
effect, IV. Consider for severe musculoskeletal Fentanyl up to 2 mcg/kg (per dose) (max total of
injuries with anxiety and SBP >100 mmHg or 200 mcg) IV titrated to effect for pain related to
peripheral pulses present trauma, without evidence of hypoperfusion
-OR-
Midazolam 2.510 mg (2.5 mg increments) IV, Diazepam 0.10.3 mg/kg (per dose) IV titrated to
SBP >100 mmHg. effect. Consider for severe musculoskeletal injuries
with anxiety and SBP >70 + (age in years x 2)
Post-intubation monitoring mmHg or peripheral pulses present
Continuous ETCO2 monitoring o Max total for <5 yrs: 5 mg
Continuous EKG monitoring o Max total for >5 yrs: 10 mg
If hypotension develops please see -OR-
HYPOTENSION/HYPOPERFUSION guidelines Midazolam 0.05-0.2 mg/kg (per dose) (max total
(page 65) of 5 mg) IV, or IM titrated to effect with SBP >70 +
(age in years x 2) mmHg or peripheral pulses
present
Post-intubation monitoring
Continuous ETCO2 monitoring
Continuous EKG monitoring
If hypotension develops please see
HYPOTENSION/HYPOPERFUSION guidelines
(page 65)

ETOMIDATE DOSAGE 0.3 MG/KG
LBS KG 0.3 MG
75 34.09 10
80 36.36 10
85 38.64 11
90 40.91 12
95 43.18 13
100 45.45 13
105 47.73 14
110 50 15
115 52.27 15
120 54.55 16
125 56.82 17
130 59.09 18
135 61.36 18
140 63.64 19
145 65.91 19
150 68.18 20
155 70.45 21
160 72.73 22
165 75 22
170 77.27 23
175 79.55 24
180 81.82 25
185 84.09 25
190 86.36 26
195 88.63 26
200 90.91 27
205 93.18 28
210 95.45 28
215 97.73 29
220 100 30
225 102.27 31
230 104.55 31
235 106.82 32
240 109.1 33
245 111.36 33
250 113.64 34
255 115.91 35
260 118.18 35
265 120.46 36
270 122.73 37
275 125 37
280 127.27 38
285 129.55 39
290 131.82 39
295 134.09 40
300 136.36 41

ALLERGIC REACTION/ANAPHYLAXIS
EMT-B / FIRST RESPONDER/ALL PROVIDERS

Safely and rapidly eliminate the source of exposure as required
Administer Oxygen for difficulty breathing
Severe distress = 15 lpm via Non Rebreather Mask
Moderate mild distress = 2-6 lpm via Nasal Cannula
Cold pack to bite or sting site as necessary

Assist patients with prescribed Epipen (0.3 mg) IM for Assist patients with prescribed Epipen Jr. (0.15 mg) IM
severe respiratory distress and/or shock from for severe respiratory distress and/or shock from
anaphylaxis anaphylaxis
Epinephrine (1:1000) 0.3-0.5 mg IM for patient in Epinephrine (1:1000) 0 .01 mg/kg (max of .15mg) IM
extremis or anaphylaxis for patient in extremis or anaphylaxis
May repeat every 20 minutes to max total of 1.2 May repeat every 20 minutes x 3
mg if needed
Albuterol 2.5-7.5 mg (2.5 mg increments) via Albuterol 2.5-7.5 mg (2.5 mg increments) via
nebulization for bronchospasm/wheezing until nebulization for bronchospasm/wheezing until
symptoms subside symptoms subside
Patient respiratory status must be reassessed after Patient respiratory status must be reassessed after
each 2.5 mg to determine need for additional each 2.5 mg to determine need for additional
dosing. dosing.

Continuous ECG and O2 monitoring Continuous ECG and O2 monitoring
Diphenhydramine 2550 mg PO for mild to moderate Diphenhydramine 1 mg/kg (max single dose of 50
allergic reaction mg) IV (preferred) or IM for moderate to severe allergic
Diphenhydramine 50 mg IV (preferred) or IM for reaction or anaphylaxis
severe allergic reaction or anaphylaxis Methylprednisolone 2 mg/kg (max single dose of
Methylprednisolone 125 mg IV over 1 minute 125 mg) IV over 1 minute

ALTERNATIVE VASCULAR ACCESS
EMT-B /FIRST RESPONDER /ALL PROVIDERS

EMT- PARAMEDIC PROVIDER EMT- PARAMEDIC PROVIDER

Q-PORT (Portacath) Q-Port (Portacath)
To be the primary access for patients who have them, Same as Adult
unless the patient chooses not to have it accessed.
Maintain a sterile field while accessing the patients
Portacath. IO
Use Iodine and Alcohol to cleanse the site, alcohol For use in:
must be used last. o Emergency situation when peripheral
Withdrawal 10cc of blood from Portacath prior to access is unsuccessful and venous
flushing with fluid, this is done to remove the anti- access is necessary.
clotting agent used to maintain the patency of the Contraindicated in suspected fractures or
Portacath. previous attempts to the same extremity
If there is resistance when attempting to flush the Bone Injection Gun (red)
Portacath do not force the flush or utilize the o Proper placement:
Portacath as this may be indicative of a clot. Locate the Tibial Tuberosity
Use the tagaderm to cover the site. Go approximately 1-2cm toward
the inner leg (medially)
Go approximately 1-2cm toward
IO the foot (distally)
For use in an emergency situation when peripheral Pain management should be
access is unavailable Lidocaine 0.5 mg/kg slow IO
Contraindicated in suspected fractures or previous push.
attempts to the same extremity
Utilize the Bone Injection Gun (blue) XJ
o Proper placement: To be done as a last resort when other
Locate the Tibial Tuberosity attempts to access a peripheral site or IO
Go approximately 2cm toward inner leg have failed
(medially) IV used should be similar to that of a
Go approximately 2cm toward the knee peripheral venous access
(proximally) Choose a site about the middle of the vein
Pain Management for IO placement is Some mild pressure can be applied to the
Lidocaine 50 mgs slow IO push proximal part of the vein to help with
identifying the vein during access, or place
the patient in trendelenberg position. Use
XJ the index and middle finger to apply mild
To be done when other attempts to access a peripheral proximal pressure and the thumb to hold the
site have failed skin taught at the distal point of the vein, this
will help when introducing the catheter into
Use a large bore IV (18-14 gauge)
the vein
Choose a site about the middle of the vein
Access the vein going toward the heart.
Some mild pressure can be applied to the proximal
After obtaining a flash advance the catheter
part of the vein to help with identifying the vein during
and remove the needle when ready to apply
access, or place the patient in trendelenberg position.
the IV tubing and fluids. Secure in place.
Use the index and middle finger to apply mild proximal
pressure and the thumb to hold the skin taught at the
distal point of the vein, this will help when introducing
the catheter into the vein. Dialysis Shunt
Access the vein going toward the heart. Contact Online Medical Control

After obtaining a flash advance the catheter and
remove the needle when ready to apply the IV tubing
and fluids. Secure in place.
Dialysis Shunt PICC Lines

Contact Online Medical Control Should be primary access when available
Access is the same as that of an INT
PICC Lines
Should be primary access when available
Access is the same as accessing an INT
EZ IO Procedure
Insertion locations: Adult/Pediatric: Distal tibia, Proximal
tibia, Proximal humeral
Sizes: Adult 25mm (40 kg and over),Pediatric 15mm (3-39 kg)
Adult 45mm (40 kg and over with excessive tissue)
Procedure:
1. Locate appropriate insertion site and prepare using
aseptic technique
2. Prepare the EZ-IO driver and appropriate needle set
3. Stabilize site and insert appropriate needle set
4. Remove driver from needle set while stabilizing catheter
hub
5. Remove stylet from catheter
6. Confirm placement, Connect primed EZ-Connect
7. Slowly administer appropriate dose of Lidocaine 2%
(Preservative Free) IO to alert pts
8. Syringe bolus (flush) the EZ-IO catheter with the
appropriate amount of normal saline.
9. Begin infusion, utilize pressure (pressure bag or infusion
pump) for continuous infusions
10. Dress site, secure tubing and apply wristband as
directed, monitor site and pt

ENVIRONMENTAL TEMPERATURE EMERGENCIES
Heat Related
Remove patient from environment, when possible
Body temperature assessment
Severe muscle cramps may be relieved by
o Patient gently stretching the muscle
Temperature elevation/patient with no altered mental status
o Slow cooling with ice packs, wet towels, and/or fans to areas in the vicinity of carotid, femoral, brachial arteries
If patient is alert and not nauseated, rehydration with water or balanced electrolyte solution
Temperature elevation/patient with altered mental status (heat stroke)
o Aggressive cooling to unclothed patient utilizing fine mist water spray and fans in conjunction with ice packs to
groin and axilla
o Aggressive cooling should be stopped if shivering begins
Cold Related
Protect patient from further heat loss (application of blankets, warm environment, etc.).
Suspicion of cardiac arrest in cold environment, utilize 30-45 seconds to confirm pulselessness.
In the absence of a confirmed temperature, provider should initiate standard resuscitative efforts as necessary.
Body temperature assessment
Develop and implement treatment plan based on assessment findings, resources, and training.
Confirmation of body temperature <86 degrees F.
o No active external rewarming (no heat, forced hot air, warm packs, etc.)
o Limit defibrillation attempts to 3
Confirmation of body temperature 86-93 degrees F., warm packs to neck, armpits, and groin
Body temperature >93 degrees, warm with blankets, warm environment, etc.
Both

Advanced airway, vascular access and fluid therapy per Same as adult
Resuscitation and Perfusion Core Principle
If available, use warmed fluids for hypothermic
patients.
Blood glucose assessment.
Continuous ECG & O2 monitoring Same as adult
Obtain 12-lead ECG if time and patient condition
permits
Cold emergencies
Withhold antiarrythmic until temperature
>86 degrees F

FEVER
EMT-B/FIRST RESPONDER/ALL PROVIDERS

Remove any excessive clothing or blankets

EMT-IV PROVIDER EMT-IV PROVIDER
Obtain temperature, ideally using an oral When possible assess temperature rectally, an oral and
thermometer, tympanic is acceptable tympanic temperature are acceptable
When obtaining a tympanic temperature make When obtaining a tympanic temperature make sure
that you slightly pull the ear down for a clearer path
sure that you slightly pull the ear up and back
to the tympanic membrane.
for a clearer path to the tympanic membrane.
Vascular access and fluid therapy per Resuscitation
Vascular access and fluid therapy per Resuscitation and Perfusion Core Principle
and Perfusion Core Principle
If temperature is 100.4*F administer: If temperature is 100.4*F administer :

Tylenol Tylenol (Preferred medication)
o 500 mg PO o 15 mg/kg PO
-OR- -OR-
Motrin Motrin
o 800 mg PO o 10 mg/kg PO

GLUCOSE ABNORMALITIES
HYPOGLYCEMIA/HYPERGLYCEMIA
FIRST RESPONDER /ALL PROVIDERS
Hypoglycemia is defined as blood glucose level <50 mg/dl with any degree of altered mentation
Hypoglycemic patient with altered mentation - insulin pump in place
o Care is directed at treating hypoglycemia first, then stopping administration of insulin
o Turn off insulin pump if able
o If no one familiar with the device is available to assist, disconnect pump from patient by:
Using quick-release where tubing enters dressing on patients skin
-OR-
Completely removing the dressing, thereby removing the subcutaneous needle and catheter from under
patients skin
When mental status returns to normal, patient should be strongly encouraged to eat.
EMT- B
. If patient is known diabetic and is conscious with an intact gag reflex, administer on tube of instant
Glucose and reassess

A- EMT PROVIDER A-EMT PROVIDER
Vascular access and fluid therapy per Resuscitation Vascular access and fluid per Resuscitation and
and Perfusion Core Principle Perfusion Core Principle
Blood glucose assessment Blood glucose assessment (preferably via heel stick)
Oral glucose 7.5 grams (pediatric) to 15 grams Normal Saline 20 mL/kg IV over 3060 minutes for
(adult) if patient able to protect airway hyperglycemic patient (BS >300 mg/dL) with signs of
Repeat in 15 minutes as appropriate hypoperfusion and no evidence of pulmonary edema
Dextrose 50% 25 grams IV titrate to effect for Newborn up to 3 kg

hypoglycemia. May repeat as necessary Dextrose 10% 5 mL/kg IV titrate to effect for
hypoglycemia
To mix: Add 1 mL Dextrose 50% to 4 mL of NS
Normal Saline 1000 mL IV over 3060 minutes for
hyperglycemic patient (BS >300 mg/dL) with signs of Infants and children >3 kg to 37 kg
hypoperfusion and no evidence of pulmonary edema Dextrose 25% 2 mL/kg IV titrate to effect for
hypoglycemia
To Mix: Add 25 mL of Dextrose 50% to 25 mL
Glucagon 1 mg IM with no IV access in hypoglycemic
NS
patients (if formally trained)
Glucagon 0.1 mg/kg (max dose of 1 mg) IM with

no IV access in hypoglycemic patients (if formally
trained)
Thiamine 100 mg IV (preferred) or IM for hypoglycemia
with evidence of malnourishment or chronic alcohol
abuse
When possible administer prior to Dextrose

HEADACHE
EMT-B/ FIRST RESPONDER/ALL PROVIDERS


EMT-IV PROVIDER EMT-IV PROVIDER
Assess blood glucose level Assess blood glucose level
Establish if the current headache is a typical migraine Establish if the current headache is a typical migraine
headache for the patient or not headache for the patient or not
LAPSS is MANDATORY on all Acute Severe LAPSS is MANDATORY on all Acute Severe
headaches absent of any significant history headaches absent of any significant history

If IV access is obtained skip to the Toradol and Tylenol
Phenergan administration. 15 mg/kg PO
Tylenol 500 mg PO
-OR-
Motrin 800 mg PO
If no improvement within 30 minutes give Toradol

and Phenergan.
Toradol (<65 years old)
o 30 mg IV
o 60 mg IM
Phenergan
o 12.5 mgs IM

HYPOTENSION / HYPOPERFUSION
(NON-TRAUMATIC)
EMT-B/ FIRST RESPONDER /ALL PROVIDERS

Consider assessing for orthostatic changes
Modified Trendelenburg position (with or without the torso raised) with appropriate precautions related to airway
management and potential spinal cord injury.
Ensure patient warmth

A-EMT PROVIDER A-EMT- PROVIDER
Vascular access and fluid therapy per Resuscitation Same as adult
Dopamine 520 mcg/kg/min IV infusion per chart on Dopamine 520 mcg/kg/min IV infusion per chart
page 65. Titrated to maintain a SBP >100 mmHg on page 65. Titrated to maintain a SBP >70 + (age
in years x 2) mmHg

DOPAMINE DRIP RATES 1600 mcg / cc
LBS KG 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
75 34.09 1 2 4 5 6 8 9 10 12 13 14 15 17 18 19 20 22 23 24 26
80 36.36 1 3 4 5 7 8 10 11 12 14 15 16 18 19 20 22 23 25 26 27
85 38.64 1 3 4 6 7 9 10 12 13 14 16 17 19 20 22 23 25 26 28 29
90 40.91 2 3 5 6 8 9 11 12 14 15 17 18 20 22 23 25 26 28 29 31
95 43.18 2 3 5 6 8 10 11 13 15 16 18 19 21 23 24 26 28 29 31 32
100 45.45 2 3 5 7 9 10 12 14 15 17 19 21 22 24 26 27 29 31 32 34
105 47.73 2 4 5 7 9 11 13 14 16 18 20 22 23 25 27 29 30 32 34 36
110 50 2 4 6 8 9 11 13 15 17 18 21 23 24 26 28 30 32 34 36 38
115 52.27 2 4 6 8 10 12 14 16 18 20 22 24 26 27 29 31 33 35 37 39
120 54.55 2 4 6 8 10 12 14 16 18 20 23 25 27 29 31 33 35 37 39 41
125 56.82 2 4 6 9 11 13 15 17 19 21 23 26 28 30 32 34 36 38 41 43
130 59.09 2 4 7 9 11 13 16 18 20 22 24 27 29 31 33 36 38 40 42 44
135 61.36 2 5 7 9 12 14 16 18 21 23 25 28 30 32 35 37 39 41 44 46
140 63.64 2 5 7 10 12 14 17 19 21 24 26 29 31 33 36 38 41 43 45 48
145 65.91 2 5 7 10 12 15 17 20 22 25 27 30 32 35 37 40 42 45 47 49
150 68.18 3 5 8 10 13 15 18 20 23 26 28 31 33 35 38 41 44 46 49 51
155 70.45 3 5 8 11 13 16 18 21 24 26 29 32 34 37 40 42 45 48 50 53
160 72.73 3 5 8 11 14 16 19 22 25 27 30 33 36 38 41 44 46 49 52 55
165 75 3 6 8 11 14 17 20 23 25 28 31 34 37 39 42 45 48 51 53 56
170 77.27 3 6 9 12 15 17 20 23 26 29 32 35 38 41 44 46 49 52 55 58
175 79.55 3 6 9 12 15 18 21 25 27 30 33 36 39 42 45 48 51 54 57 60
180 81.82 3 6 9 12 15 18 21 25 28 31 34 37 40 43 46 49 52 55 58 61
185 84.09 3 6 10 13 16 19 22 25 28 32 35 38 41 44 47 50 54 57 60 63
190 86.36 3 7 10 13 16 19 23 26 29 32 36 39 42 45 49 52 55 58 62 65
195 88.63 3 7 10 13 17 20 23 27 30 33 37 39 43 47 50 53 57 60 63 67
200 90.91 3 7 10 14 17 20 24 27 31 34 38 41 44 48 51 55 58 61 65 68
205 93.18 3 7 10 14 17 21 24 28 31 35 38 42 45 49 52 56 59 63 66 70
210 95.45 4 7 11 14 18 21 25 29 32 36 39 43 47 50 54 57 61 64 68 72
215 97.73 4 7 11 15 18 22 26 29 33 37 40 44 48 51 55 59 62 66 70 73
220 100 4 8 11 15 19 23 26 30 34 38 41 45 49 53 56 60 64 68 71 75
225 102.3 4 8 12 15 19 23 27 31 35 38 42 46 50 54 58 61 65 69 73 77
230 104.6 4 8 12 16 20 24 27 31 35 39 43 47 51 55 59 63 67 71 75 78
235 106.8 4 8 12 16 20 24 28 32 36 40 44 48 52 56 60 64 68 72 76 80
240 109.1 4 8 12 16 20 25 29 33 37 41 45 49 53 57 61 66 70 74 78 82
245 111.4 4 8 13 17 21 25 29 33 38 42 46 50 54 58 63 67 71 75 79 84
250 113.6 4 9 13 17 21 26 30 34 38 43 47 51 55 60 64 68 73 77 81 85
255 115.9 4 9 13 17 22 26 30 35 39 43 48 52 57 61 65 70 74 78 83 87
260 118.2 4 9 13 18 22 27 31 35 40 44 49 53 58 62 67 71 75 80 84 89
265 120.5 5 9 14 18 23 27 32 36 41 45 50 54 59 63 68 72 77 81 86 90
270 122.7 5 9 14 18 23 28 32 37 41 46 51 55 60 64 69 74 78 83 87 92
275 125 5 9 14 19 23 28 33 38 42 47 52 56 61 66 70 75 80 84 89 94
280 127.3 5 10 14 19 24 29 33 38 43 48 53 57 62 67 72 76 81 86 91 96
285 129.6 5 10 15 19 24 29 34 39 44 49 53 58 63 68 73 78 83 88 92 97
290 131.8 5 10 15 20 25 30 35 40 44 49 54 59 64 69 74 79 84 89 94 99
295 134.1 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 81 86 91 96 101
300 136.4 5 10 15 20 26 31 36 41 46 51 56 61 67 72 77 82 87 92 97 102

NAUSEA / VOMITING
EMT-B FIRST RESPONDER /ALL PROVIDERS

Nothing by mouth
Upright or lateral recumbent positioning

Vascular access and fluid therapy per Resuscitation and Same as adult
Perfusion Core Principle
Blood glucose assessment.
Ondansetron Zofran (drug of choice) 4 8 mg Oral Ondansetron Zofran (drug of choice)
Dissolving Tablet 4 years 4 mg Oral Dissolving Tablet
Ondansetron Zofran (drug of choice) 4 mg IV if < 4 years 2 mg Oral Dissolving Tablet
access available < 2 years - call medical control
0.15 mg/kg IV, max of 4mgs
If patient is allergic to Zofran, Promethazine is alternate
medication
If patient is allergic to Zofran, Promethazine is
Promethazine 12.5 mg IM if SBP >100 or peripheral
alternate medication
pulses present and no vascular access
Promethazine 0.25 mg/kg (max dose of 12.5
mg) IM for patients >2 years of age if SBP >70 +
(age in years x 2) mmHg or peripheral pulses
present and no vascular access

OBSTETRICAL EMERGENCIES

Attempt to attain sanitary environment
Do not perform pelvic exam
If crowning is present develop and implement treatment plan based on assessment findings, resources, and training
Normal delivery procedures
o Attempt to prevent explosive delivery
o As delivery occurs, suction mouth, then nose
o If membrane is still intact as head delivers
- Instruct the mother to stop pushing
- Gently tear open membrane and immediately suction mouth, then nose
o Keep newborn warm and dry
o Keep newborn at level of vagina until cord is cut
- Once cord pulsations cease, place one clamp 6 inches away from baby, place second clamp 9 inches away
from baby, cut cord between the clamps
o Allow infant to nurse
- In multiple births, do not allow babies to nurse until all have been delivered
o APGAR score at 1 minute and again at 5 minutes
- Special situations
o Significant hemorrhage following delivery or delayed placenta delivery
- Unless multiple birth is anticipated, begin fundal massage
- Refer to Resuscitation and Perfusion Core Principle
Nuchal cord
o Attempt to slip cord over the head
o If cord is too tight to remove, immediately clamp in two places and cut between clamps
Prolapsed cord or limb presentation
o With maintaining a pulsatile cord as the objective, two fingers of gloved hand into vagina to raise presenting
portion of newborn off the cord.
o If possible, place mother in Trendelenburg position. Otherwise, knee-chest.
o Keep cord moistened with sterile saline.
o Continue to keep pressure off cord throughout transport
Breech presentation
o Position mother with her buttocks at edge of bed, legs flexed
o Support body as it delivers
o As the head passes the pubis, apply gentle upward pressure until the mouth appears over the perineum.
Immediately suction mouth, then nose.
o If head does not deliver, but newborn is attempting to breath, place gloved hand into the vagina, palm toward
newborns face, forming a V with the index and middle finger on either side of the nose. Push the vaginal wall
from the face. Maintain position throughout transport.
Shoulder dystocia
o Position mother with buttocks off the edge of the bed and thighs flexed upward as much as possible.
o Apply firm, open hand pressure above the symphysis pubis
o If delivery does not occur, maintain airway patency as best as possible, immediately transport
Stillborn/abortion
o All products of conception should be carefully collected and transported with the mother to the hospital.
Anything other than transport should be coordinated with on-line medical consultation and/or law enforcement.

Vascular access and fluid therapy with Lactated Ringers per

Magnesium Sulfate 50% 4 gms added to 250 mL NS infused
wide open for active seizures secondary to presumed eclampsia
until seizure stops or 4 gms is reached
Diazepam 520 mg (5 mg max increments) IV titrated to
effect for active seizures non-responsive to magnesium therapy
or for patients with seizure history not related to pregnancy and
SBP >100 mmHg or peripheral pulses present
In the event of uterine inversion, make one attempt to put the
uterus back into place. Using the palm of the hand, push the
fundus of the inverted uterus toward the vagina. If unsuccessful,
cover uterus with moistened sterile gauze.
APGAR Scale
Component of Score of 0 Score of 1 Score of 2

Acronym
Appearance blue all over white at extremities pink all over

Skin color: body pink
Pulse Absent slow fast

Heart rate:
Grimace no response to grimacing when crying and

Reflex response: stimulation stimulated coughing
Activity Limp some bending or active movement

Muscle tone: stretching of limbs
Respiration Absent weak or irregular good and

Breathing: baby is crying

OBSTRUCTIVE AIRWAY DISEASE
EMT-B/FIRST RESPONDER /ALL PROVIDERS

Focused history and physical exam:
Determine whether the patient has sensitivity to peanuts and/or soy

Assist with administration of prescribed metered dose Assist with administration of prescribed metered dose
inhaler or nebulized medication per dosing inhaler or nebulized medication per dosing instructions
instructions if responder nebulized medication is if responder nebulized medication is unavailable. If
unavailable. If MDI dosing instructions are not MDI dosing instructions are not available, give second
available, give second dose at 20 minutes if needed. dose at 20 minutes if needed.
Albuterol 2.5-7.5 mg (2.5 mg increments) via Normal Saline 3mls nebulized for thick mucus
nebulization for bronchospasm/wheezing until secretions in the airway associated with RSV
symptoms subside.
Patient respiratory status must be reassessed Albuterol 2.5-7.5 mg (2.5 mg increments) via
after each 2.5 mg to determine need for nebulization for bronchospasm/wheezing until
additional dosing. symptoms subside
Advanced airway, vascular access and fluid therapy Patient respiratory status must be reassessed
per Resuscitation and Perfusion Core Principle after each 2.5 mg to determine need for additional
dosing.
Advanced airway, vascular access and fluid therapy
per Resuscitation and Perfusion Core Principle

Ipratropium Bromide 0.5 mg mixed with Albuterol Ipratropium Bromide 0.5 mg mixed with Albuterol
2.5 mg nebulized for bronchospasm/wheezing 2.5 mg nebulized for bronchospasm/wheezing
Methylprednisolone 125 mg IV over 1 minute Patient >10 kg - 0.5 mg
Patient <10 kg - 0.25 mg (1/2 unit dose)
CPAP if appropriately trained and equipped without
Methylprednisolone 2 mg/kg (max dose of 125 mg)
history of severe asthma
IV over 1 minute
Racemic Epinephrine 11.25 mgs in 0.5 ml
Racemic Epinephrine 11.25 mgs in 0.5 ml solution
solution (2.25% solution) nebulized for
(2.25% solution) nebulized for
bronchospasms/wheezing bronchitis and subglottic
bronchospasms/wheezing bronchitis and subglottic
edema associated with croup
edema associated with croup
NO REPEAT DOSE RECOMMENDED
NO REPEAT DOSE RECOMMENDED

OVERDOSE


Advanced airway, vascular access and fluid therapy Advanced airway, vascular access and fluid therapy
per Resuscitation and Perfusion Core Principle per Resuscitation and Perfusion Core Principles
Blood glucose assessment. Blood glucose assessment (preferably via heel stick).
Identify potential underlying causes. Identify potential underlying causes.
Obtain 12-lead ECG if time and patient condition Obtain 12-lead ECG if time and patient condition
permit. permits
Naloxone Naloxone
0.42 mg (per dose) IV,IN for suspected narcotic 0.1 mg/kg (per dose) IV, IM, IN or intra nasal for
overdose. Titrate to effect, no maximum dose. suspected narcotic overdose. Titrate to effect,
0.8 mg IM (per dose) Titrate to effect, no no maximum dose.
maximum dose. For suspected narcotic overdose ET administration may be considered in
when vascular access is unavailable narcotic associated cardiac arrest
ET administration may be considered in Diphenhydramine
narcotic associated cardiac arrest 1 mg/kg (max single dose of 50 mg) IV
Diphenhydramine (preferred) or IM for patient with evidence of
50 mg IV (preferred) or IM for patient with dystonic reaction
evidence of dystonic reaction Sodium bicarbonate 1 mEq/kg slow IV push for
Sodium bicarbonate 1 mEq/kg slow IV push for tricyclic antidepressant overdose with sustained HR
tricyclic antidepressant overdose with sustained HR >120 bpm, QRS >0.10, hypotension unresponsive to
>120 bpm, QRS >0.10, hypotension unresponsive to fluids, or ventricular dysrhythmias
fluids, or ventricular dysrhythmias Dopamine 5-20 mcg/kg/min IV infusion per Chart in
Dopamine 520 mcg/kg/min IV infusion per Chart in Appendix titrated to maintain SBP of >70 + (age in
Appendix titrated to maintain SBP of >100 mmHg for years x 2) mmHg for tricyclic antidepressant
tricyclic antidepressant overdose with hypotension overdose with hypotension unresponsive to fluids or
unresponsive to fluids or sodium bicarbonate therapy sodium bicarbonate therapy
Calcium Gluconate 1-2 grams IV over 5 minutes for Calcium Gluconate 20 mg/kg (per dose) (max total
calcium channel blocker or beta blocker overdose of 2 grams) IV over 5 minutes for calcium channel
Contact Medical Control for further doses blocker or beta blocker overdose
Diazepam 520 mg (5 mg max increments) IV Contact Medical Control for further doses
titrated to effect for hypersympathetic state from
amphetamine, cocaine or PCP use
Condition usually presents with sustained HR
>120 bpm and HTN

PAIN/ANXIETY MANAGEMENT


A-EMTPROVIDER A-EMT IV PROVIDER
Continuous O2 monitoring Continuous O2 monitoring
Apply ice pack and elevation of affected area if Apply ice pack and elevation of affected area if
applicable applicable
Toradol 30 mg IV/ 60 mg IM (<65 years old) Fentanyl up to 2 mcg/kg (per dose) (max total of
-OR- 200 mcg) DRUG OF CHOICE IV or IM titrated to
Fentanyl up to 2 mcg/kg (per dose) (max total of effect for pain related to trauma, without evidence of
400 mcg) DRUG OF CHOICE IV or IM titrated to hypoperfusion
effect for pain related to trauma without evidence of -OR-
hypoperfusion Morphine 0.1 mg/kg IV or IM IV or IM access needs
-OR- to be attempted
Diazepam 520 mg (5 mg increments) IV or IM, -OR-
titrated to effect. Consider for severe musculoskeletal Diazepam 0.10.3 mg/kg (per dose) IV or IM titrated
injuries with anxiety and SBP >100 mmHg or peripheral to effect. Consider for severe musculoskeletal injuries
pulses present with anxiety and SBP >70 + (age in years x 2) mmHg
-OR- or peripheral pulses present
Morphine 5-10 mg (2 mg increments) IV or IM, Max total for <5 yrs: 5 mg
titrated to effect for pain related to trauma without Max total for >5 yrs: 10 mg
evidence of hypoperfusion, and SBP >100 mmHg.
Pain related to IO use
Acute Coronary Syndrome chest pain Lidocaine 0.5 mg/kg administered slowly
Morphine Sulfate 220 mg (4 mg max
increments) IV titrated to effect for persistent ACS
chest pain following nitroglycerin therapy if SBP
remains >100 mmHg
Diazepam 520 mg (5 mg max increments) IV
titrated to effect for significant anxiety unrelieved by
Morphine if SBP >100 mmHg
Pain related to IO use
Lidocaine 50 mg administered SLOWLY through
attached pre-primed extension set prior to IO bolus
or flush on alert patient

REACTIVE AIRWAY DISEASE

Focused history and physical exam:
Determine whether the patient has sensitivity to peanuts and/or soy

Assist with administration of prescribed metered Same as adult
dose inhaler or nebulized medication per dosing Advanced airway, vascular access and fluid therapy per
instructions if responder nebulized medication is Resuscitation and Perfusion Core Principle
unavailable. If MDI dosing instructions are not Normal Saline 3mls nebulized for thick mucus
available, give second dose at 20 minutes if needed. secretions in the airway associated with RSV
Albuterol 2.5-7.5 mg (2.5 mg increments) via
nebulization for bronchospasm/wheezing until
Albuterol 2.5-7.5 mg (2.5 mg increments) via
symptoms subside.
nebulization for bronchospasm/wheezing until
Patient respiratory status must be reassessed symptoms subside.
after each 2.5 mg to determine need for
Patient respiratory status must be reassessed after
additional dosing.
each 2.5 mg to determine need for additional
Advanced airway, vascular access and fluid therapy dosing.

Ipratropium Bromide 0.5 mg mixed with Albuterol Ipratropium Bromide 0.5 mg mixed with Albuterol
2.5 mg nebulized for bronchospasm/wheezing 2.5 mg nebulized for bronchospasm/wheezing
Methylprednisolone 125 mg IV over 1 minute for Patient >10 kg - 0.5 mg
bronchospasm Patient <10 kg - 0.25 mg (1/2 unit dose)
Methylprednisolone 2 mg/kg (max dose of 125 mg)
IV over 1 minute for bronchospasm

SEIZURES

As appropriate, determine possibility of pregnancy
Ensure patients experiencing febrile seizures are not excessively dressed or bundled
Patients <12 months old with seizure activity. The parent(s) should be strongly urged to have the child transported
by EMS and/or evaluated by a Physician.

Assist patient with their magnet stimulation device Same as adult
(Vagus Nerve Stimulator) once every 3-5 minutes, up to Advanced airway, vascular access and fluid
3 times. therapy per Resuscitation and Perfusion Core
Blood glucose assessment. Principle
Advanced airway, vascular access and fluid therapy per Blood glucose assessment (preferably via heel
Resuscitation and Perfusion Core Principle stick).

Continuous O2 monitoring Continuous O2 monitoring
Diazepam 520 mg (5 mg increments) IV or IM for Acetaminophen 15 mg/kg (max dose of 1 gm)
active seizures with SBP >100 mmHg PO for patient with temperature >102
Seizures refractory to Diazepam and SBP >100 mmHg or Diazepam 0.10.3 mg/kg (per dose) IV or IM for
peripheral pulses present active seizures with SBP of >70 + (age in years x
Midazolam 2.510 mg (2.5 mg increments) IV 2) mmHg or peripheral pulses present.
(preferred) Max total for <5 yrs: 5 mg
-OR- Max total for >5 yrs: 10 mg
Midazolam 5 mg IM for seizure activity when unable Seizures refractory to Diazepam or unable to
to establish IV obtain IV and SBP >70 + (age in years x 2) mmHg
Magnesium Sulfate 50% 4 gms added to 250 mL NS or peripheral pulses present
infused wide open for active seizures secondary to Midazolam 0.2 mg/kg (per dose) (max total
presumed eclampsia until seizure stops or 4 gms is of 5 mg) IV, IM or intra nasal titrated to effect
reached

STROKE


Apply LAPSS criterion during assessment.
Blood glucose check.
Advanced airway, vascular access and fluid therapy per
If possible, IV therapy should include no smaller than
an 18 gauge catheter in the AC
Continuous ECG and O2 monitoring On-line medical consultation
permits
If patient presentation and history suggestive of stroke,
early notification and rapid transport to nearest facility
Lidocaine 1.5 mg/kg IV for patients with evidence of
increased ICP requiring intubation
Administered 3 minutes prior to intubation (if time
allows), to help blunt ICP rise during intubation

SUBMERSION/DROWNING
EMT-B / FIRST RESPONDER /ALL PROVIDERS

Safely and appropriately remove patient from the water
Body temperature assessment if conditions are such as to induce hypothermia
Place patient supine
Remove wet clothing
Ensure patient warmth
The Scuba Divers Dive Computer or Dive Log Book should be transported with the patient

Albuterol 2.57.5 mg (2.5 mg increments) nebulized Same as adult
for bronchospasm/wheezing until symptoms subside.
dosing.

Dopamine 520 mcg/kg/min IV infusion per Chart on Dopamine 520 mcg/kg/min IV infusion per Chart
pg. 65 for hypoperfusion. Titrated to maintain a SBP on pg. 65 for hypoperfusion. Titrated to maintain a
>100 mmHg SBP >70 + (age in years x 2) mmHg

TOXIC EXPOSURE- CARBON MONOXIDE
EMT-B FIRST RESPONDER /ALL PROVIDERS

Safely and rapidly remove patient from source of exposure
Environmental CO levels if equipment is available
Estimation of exposure time
Be cautious of pulse oximetry readings
Develop and implement treatment plan based on, assessment findings, resources, and training

Advanced airway management , vascular access and Same as adult
fluid therapy per Resuscitation and Perfusion Core
Principle
Early notification to receiving ED of potential CO Early notification to receiving ED of potential CO
poisoning poisoning
Dopamine 520 mcg/kg/min IV infusion per Chart on Transport to East TN Childrens Hospital
pg. 65 for hypotension. Titrated to maintain a SBP Dopamine 520 mcg/kg/min IV infusion per Chart
>100 mmHg on pg.65 for hypoperfusion. Titrated to maintain a
SBP >70 + (age in years x 2) mmHg

TOXIC EXPOSURE CYANIDE -

If properly trained and equipped, safely and rapidly remove patient from the source of exposure
Request HazMat response as appropriate
Be alert for exposure related
Acute dyspnea/tachypnea without cyanosis
Nausea/vomiting
Seizures
Hyper or hypotension
High flow oxygen immediately and continuously
Be cautious of pulse oximetry readings

Advanced airway, vascular access and fluid therapy Same as adult
permits permits
Dopamine 520 mcg/kg/min IV infusion per Chart Dopamine 520 mcg/kg/min IV infusion per Chart on
on pg. 65 for hypoperfusion. Titrated to maintain a pg.65 for hypoperfusion. Titrated to maintain a SBP
SBP >100 mmHg >70 + (age in years x 2) mmHg

TOXIC EXPOSURE - HYDROFLUORIC ACID

Skin Exposure
o Immediate irrigation. Clothing, jewelry etc., is removed as irrigation is taking place.
o Soak burned skin in magnesium hydroxide antacid preparations (milk of magnesia, Mylanta, Maalox).
Eye Exposure
o Continuous rinsing for a minimum of 15 minutes or until a calcium ocular solution is available.
Ingestion Conscious/Alert Patient Only
o If patient is able to swallow, administer high amounts of any calcium or magnesium based antacid (milk of
magnesia, Mylanta, Maalox). In the absence of these products, have patient drink approximately 8-16 oz. of
water

Continuous ECG and O2 monitoring Same as adult
permits
Dermal exposure
Topical solution
Mix 10 mL calcium gluconate 10% with 30 gms
of water-soluble gel
Dermal exposure with persistent pain after 30 minutes
of calcium gluconate gel application
0.5 ml/cm(2) burn of 10% calcium gluconate by
SC infiltration
Ocular Exposure
Mix 10 mL calcium gluconate 10% with 1000 mL
of LR
Irrigate affected eye(s) with 500 mL of solution
Inhalation exposure with pulmonary edema
Mix 1 mL calcium gluconate 10% with 3mL NS
and nebulize solution

TOXIC EXPOSURE - ORGANOPHOSPHATES/NERVE AGENTS
EMT-B / FIRST RESPONDER /ALL PROVIDERS

If properly trained and equipped, safely and rapidly remove patient from the source of exposure
Request HazMat response as appropriate
Be alert for S.L.U.D.G.E. presentation
o Salivation
o Lacrimation
o Urination
o Defecation
o Gastrointestinal cramping
o Emesis
Immediate irrigation.
Clothing, jewelry etc., is removed as irrigation is taking place

permits permits
Atropine sulfate 2 mg rapid IV (preferred) repeated Atropine sulfate 0.05 mg/kg rapid IV (preferred)
every 15 minutes until atropinized repeated every 15 minutes until atropinized
-OR- -OR-
Atropine sulfate 2 mg IM repeated every 15 minutes Atropine sulfate 1 mg IM repeated every 15 minutes
until atropinized until atropinized
Pralidoxime 600 mg IM single dose should be given Pralidoxime 600 mg IM single dose should be given
any time Atropine is administered for this PCG. any time Atropine is administered for this PCG.

VIOLENT PATIENT / CHEMICAL SEDATION

Tasered patient- Prior to touching any patient that has been subdued using a Taser, ensure law enforcement has
disconnected the wires from the hand held unit.
Blood glucose assessment
Tasered patient- Determine the patients condition prior to and after Taser discharge
Tasered patient
o Removal of Taser probe by System Providers
Credentialed Providers may remove probes that are not embedded in the face, neck, groin, breast, or
spinal area
To remove probes
- Place one hand on the patient in the area where the probe is embedded and stabilize the skin
surrounding the puncture site. Place other hand firmly around the probe.
- In one fluid motion pull the probe straight out from the puncture site
- Repeat procedure with second probe
- Removed probes should be handled and disposed of in a designated sharps container
o The following patients should be transported to an Emergency Department for evaluation
- Patient with probes embedded in the face, neck, groin, breast, or spinal area
- Patient with significant cardiac history
- Patient having ingested stimulants such as Phencyclidine/PCP, cocaine, etc.
- Patients exhibiting bizarre behavior or with persistently elevated vital signs
Pepper Spray exposure
o Ocular irrigation, medial to lateral, with copious amounts of water

Albuterol 2.5-7.5 mg (2.5 mg increments) via Same as adult
nebulization for bronchospasm/wheezing for respiratory
irritant sprayed patients.
dosing
Intravenous access should be accomplished prior to
chemical restraint whenever possible. If not
possible due to safety concerns, obtain as soon as
possible after chemical sedation.
Continuous EKG monitoring Continuous EKG monitoring
Midazolam 5 mg IM with SBP >100 mmHg or Midazolam 0.05-0.2 mg/kg (per dose) (max total
peripheral pulses present of 5 mg) IV, IM or intra nasal titrated to effect if
May repeat X 1 dose SBP >70 + (age in years x 2) mmHg or peripheral
-OR- pulses present
Midazolam 2.510 mg (2.5 mg increments) IV titrated
to effect if SBP >100 mmHg or peripheral pulses
present

Addisonian Crisis
ABC and vital signs

Vascular access and fluid therapy per Resuscitation and Vascular access and fluid therapy per Resuscitation and
Perfusion Core Principle Perfusion Core Principle
Normal Saline 1 L bolus Normal Saline 20 mg/kg bolus IV or IO (1 Liter max)
Monitor Monitor
Methylprednisolone 125 mg IV or IO Methylprednisolone 2 mg/kg IV, IM or IO (max 125
mg)

Cardiac
Patient
Care
Guidelines & Standing

Orders

ACUTE CORONARY SYNDROMES (ACS)
ACUTE MYOCARDIAL INFARCTION
Ask patient to describe the pain utilizing the O-P-Q-R-S-T mnemonic
Determine whether the patient (male or female) has taken erectile dysfunction medications such as Viagra, Levitra
or Cialis within the last 24 hours.
Develop and implement treatment plan based on assessment findings, resources, and training.
High flow O2 via Non Rebreather 15lpm if tolerated, if not use Nasal Cannula up to 6lpm
EMT-B
Give Aspirin (325mg of chewable non-enteric coated if patient has not self-administered in the last 24
hours.)
Aspirin 324 mgs (baby chewable) or Adult 325 mg, instruct On-line medical consultation
patient to chew Aspirin prior to swallowing.
Nitroglycerin 0.4 mg (every 5 minutes) (max of 3 doses) SL
as long as symptoms persist and SBP >100 mmHg
Do not administer nitroglycerin if patient (male or female) has
taken erectile dysfunction medications within 24 hours.
Vascular access and fluid therapy per Resuscitation and
IV access prior to nitrates is preferred if possible

Obtain 12-lead ECG early in treatment, ideally during the initial On-line medical consultation
assessment.
If ST segment elevation and history suggestive of MI, early
notification and rapid transport to designated STEMI Center
(STEMI ALERT)
When possible, obtain 12-lead prior to nitroglycerin therapy
Normal Saline 2501000 mL IV over 15 minutes to increase

preload if signs of right sided MI are present
Morphine Sulfate 220 mg (4 mg max increments) IV titrated

to effect for persistent pain following nitroglycerin therapy if SBP
remains >100 mmHg
Diazepam 520 mg (5 mg max increments) IV titrated to effect

for significant anxiety unrelieved by Morphine if SBP >100
mmHg or ACS and hypersympathetic state from amphetamine,
cocaine or PCP use
Usually presents with sustained HR >120 bpm and HTN

ASYSTOLE / AGONAL
(HR <10 bpm)

See Cardiac Arrest Universal Management Guideline

Advanced airway, vascular access and fluid Same as adult
therapy per Resuscitation and Perfusion Core
Principle
ADVANCED PROVIDER ADVANCED PROVIDER
CPR CPR
Begin simultaneous therapy if arrest is from Begin simultaneous therapy if arrest is from known
known treatable cause treatable cause
AND AND
Epinephrine Epinephrine
0.01 mg/kg (1:10,000) IV or IO push
1 mg (1:10,000) IV or IO push
0.1 mg/kg (1:1,000) via ETT if no IV or IO access
2-2.5 mg via ETT if no vascular access
Repeat every 3-5 minutes as long as patient remains
Repeat every 3-5 minutes as long as patient
pulseless
remains pulseless
o May repeat initial dose or increase to 0.1 mg/kg
(1:1,000) (IV, IO, ET)
Sodium Bicarb
1 mEq/kg IV or IO push if down time After 20 minutes of resuscitative efforts, contact medical
exceeds 15 minutes. control for notification/update and possible discontinue of
efforts.
After 20 minutes of resuscitative efforts, contact
medical control for notification/update and
possible discontinue of efforts.

BRADYCARDIA
(Symptomatic)

Initial Scene and Patient Management per System Core Principles
Modified Trendelenburg position (with or without the torso raised) with appropriate precautions related to airway
management and potential spinal cord injury
Ensure patient warmth for hypotension
Pediatric patient (<8 year old)
o Aggressive oxygenation with high flow oxygen and assisted ventilations with a BVM as indicated.
o Persistent heart rate <60/minute and/or signs of poor perfusion following aggressive oxygenation and
ventilation, begin chest compression

Vascular access and fluid therapy per Resuscitation and

Same as adult

SYMPTOMATIC BRADYCARDIA IF BRADYCARDIA IS SEVERE AND CLINICAL
CONDITION IS LIFE-THREATENING
Atropine 0.5 - 1.0 mg rapid IV bolus administered prior
to, and in conjunction with, TCP in any patient in imminent Epinephrine
danger of a bradyasystolic arrest. IV/IO- 0.01 mg/kg (1:10,000 = 0.1 mL/kg),
Repeat as needed every 3 minutes, to a maximum repeat every 3-5 minutes at same dose
total dose of 0.03-0.04 mg/kg. Endotracheal- 0.1 mg/kg (1:1,000) flushed
Midazolam 2.510 mg (2.5 mg increments) IV with SBP with 2-3 ml NS while vascular access is
>100 mmHg or peripheral pulses present if needed for established
sedation prior to pacing of the conscious patient. Atropine
-OR- IV/IO- 0.02 mg/kg
Midazolam 5 mg IM when unable to establish IV o Minimum single dose- 0.1 mg
Use of sedation is left to the discretion of the Provider o Max single dose
and is based on patients hemodynamic status, mental Child- 0.5 mg
status, and severity of bradycardia. Adolescent- 1.0 mg
Avoid sedation in severe hypotension (SBP <70 o May repeat once to a max total dose of
mmHg) unless absolutely necessary Child- 1 mg
Transcutaneous pacing (TCP) at an initial rate of 80 Adolescent- 2 mg
beats per minute as first line-therapy on any patient Endotracheal- 0.02 mg/kg diluted to a
requiring heart rate acceleration. minimum volume of 3 to 5 mL (use a 1:1,000
Refer to Emergent Cardiac Pacing procedure for solution)
energy amounts and pacing steps
Dopamine 5-20 mcg/kg/min IV infusion per Chart
Dopamine 5-20 mcg/kg/min as a catecholamine infusion on page 65. Titrated to maintain a SBP >70 +
per Chart on page 65 for persistent hypotension (age in years x 2) mmHg
unresponsive to Atropine, TCP, or both. Titrated to
maintain a SBP >100 mm Hg.

CARDIAC ARREST UNIVERSAL MANAGEMENT

Assess for evidence that resuscitation should not be attempted
Spinal motion restriction per algorithm (as indicated)
Airway, ventilations, compressions, and defibrillation per Resuscitation and Perfusion Core Principle
Patient warmth
Assess blood glucose level
Pregnancy >20 weeks gestation
Place wedge-shaped cushion or multiple pillows under patients right hip
Advanced airway (combitube) per Resuscitation Core Principle (if appropriately trained and have annual documented
retraining)

Vascular access and fluid therapy per Perfusion

Same as adult
Core Principle
EMT-PARAMEDIC PROVIDER EMT PARAMEDIC PROVIDER

Continuous ECG monitoring Continuous ECG monitoring
Apply patient therapy pads Apply patient therapy pads
MONITOR FAILURE MONITOR FAILURE

NO ECG AVAILABLE ON-SCENE NO ECG AVAILABLE ON-SCENE
Request backup unless total package and transport Request backup unless total package and transport
time is less than backup arrival time is less than backup arrival
1 mg (1:10,000) IV or IO push 0.01 mg/kg (1:10,000) IV or IO push
o Consider 3-5 mg if arrest is from beta 0.1 mg/kg (1:1,000) via ET while vascular access is
blocker overdose or anaphylaxis established
2-2.5 mg via ET if no vascular access Repeat every 3-5 minutes as long as patient
Repeat every 3-5 minutes as long as patient remains pulseless
remains pulseless o May repeat initial dose or increase to 0.1
mg/kg (1:1,000) (IV, IO, ET)
PEA WITH BLUNT AND/OR PENETRATING
TRUNCAL TRAUMA PEA WITH BLUNT AND/OR PENETRATING TRUNCAL
(PEA + diminished or absent lung sounds + poor BVM TRAUMA
compliance and/or ventilation) (PEA + diminished or absent lung sounds + poor BVM
Immediate needle decompression compliance and/or ventilation)
Immediate needle decompression
medical control for notification/update and possible After 20 minutes of resuscitative efforts, contact medical
discontinue of efforts. control for notification/update and possible discontinue
of efforts.

CONGESTIVE HEART FAILURE/PULMONARY EDEMA

Determine whether the patient (male or female) has taken erectile dysfunction medications such as Viagra, Levitra
or Cialis within the last 24 hours

A-EMT PROVIDER A-EMT- PROVIDER
Assist patient with prescribed nitroglycerin SL every 5 Contact On-Line Medical Control
minutes, up to 3 doses, as long as symptoms persist and
SBP >100 mmHg
Do not administer nitroglycerin if the patient (male or
female) has taken erectile dysfunction medications
within the last 24 hours.
Albuterol 2.5 mg nebulized only for patient with
significant bronchospasm/wheezing
IV access prior to nitrates is preferred if possible
Limit fluid bolus to 250500 mL NS
CPAP If appropriately trained and equipped. Contact On-Line Medical Control
Obtain 12-lead
If ST segment elevation and history suggestive of MI,
early notification and rapid transport to designated
STEMI Center (STEMI ALERT)
When possible, obtain prior to nitroglycerin therapy
Nitroglycerin 0.4 mg (every 5 minutes) (max of 3

doses) SL if symptoms persist and SBP >100 mmHg
Furosemide 40 mg IV for patient not prescribed daily

furosemide if SBP >100 mmHg or IV two (2) times
patients oral daily dose up to maximum of 120 mg if SBP
>100 mmHg
-OR-
Bumex 1-2mg IV if the patient is in renal failure or is

already taking Bumex.
Morphine Sulfate 220 mg (4 mg max increments) IV

titrated to effect to produce peripheral vasodilation for
reduction of preload and afterload pressures on the heart
if SBP remains >100 mmHg
Dopamine 520 mcg/kg/min IV infusion for

hypoperfusion per chart on page 65. Titrated to maintain
a SBP of >100 mmHg

DETERMINATION OF DEATH
AND PRONOUNCEMENT PROCESS
Scene and patient management per System Core Principles
Per General Crime Scene Management Principles as appropriate
Initiation of CPR is not indicated in pulseless, apneic patient in the presence of
Obvious death
Decomposition
Rigor Mortis
Obvious mortal wounds (massive burn injuries, severe traumatic injuries with obvious signs of organ destruction
such as brain, thoracic contents, etc)
Severe extremity damage, including amputation, should not be considered an obvious mortal wound
without coexistent injury/illness
Patient submersion of greater than 20 minutes from arrival of the first public safety entity until the patient is in a
position for resuscitative efforts to be initiated
Out of Hospital Do Not Resuscitate (DNR) Directive
Valid Out-Of-Hospital Do Not Resuscitate Written Order or Device from any (US) State
A valid licensed physician on scene or by telephone orders no resuscitation efforts
Following determination of obvious death
Document according to System and Agency protocols
Termination of BLS resuscitative efforts
Resuscitation efforts may be discontinued in the following circumstances:
A valid Out of Hospital Do Not Resuscitate (DNR) Directive is discovered after resuscitative efforts were initiated
Resuscitation efforts initiated when criteria to not resuscitate were present
Once resuscitative efforts have been terminated, the Provider should
Call ATCEMS Communications via radio to reduce responding transport unit to Code 1.
Document according to System and Agency protocols

A-EMT A-EMT
Obvious dependent lividity Same as adult
Must contact online Medical Control
See above Criteria Same as adult
Must contact online Medical Control
KEY POINTS/CONSIDERATIONS
There will always be patients and circumstances that deserve special consideration (pediatric drowning, for
instance).

HYPERKALEMIC ARREST
(Presumed)

See Cardiac Arrest Universal Management Guideline. Establish if the patient has missed his/her dialysis treatment.

Continuous ECG monitoring Continuous ECG monitoring
Obtain a 12-Lead ECG, if pulses return and Obtain a 12-Lead ECG, if pulses return and patient
patient condition allows condition allows
IMMEDIATE MEMBRANE STABILIZATION IMMEDIATE MEMBRANE STABILIZATION

Calcium gluconate (first line drug) Calcium gluconate (first line drug)
10-20 mL IV or IO bolus 20 mg/kg IV or IO bolus up to 2 gms
May repeat in 10 minutes if no response is May repeat in 10 minutes if no response is observed
observed
EXTRACELLULAR TO INTRACELLULAR
EXTRACELLULAR TO INTRACELLULAR POTASSIUM SHIFT
POTASSIUM SHIFT Sodium bicarbonate 1 mEq/kg IV/IO push
Sodium bicarbonate 1 mEq/kg IV/IO push Albuterol 2.5 mg via in-line nebulization
Albuterol 2.5 mg via in-line nebulization
After 20 minutes of resuscitative efforts, contact medical
After 20 minutes of resuscitative efforts, contact control for notification/update and possible discontinue of
medical control for notification/update and possible efforts.
discontinue of efforts.

NEWBORN RESUSCITATION

Apnea
Suction (bulb syringe) mouth, then nose
- If power suction is used, negative pressure must be regulated to not exceed 100 mm Hg
Tactile stimulation
Manual airway maneuvers
Ventilations with supplemental oxygen at 40-60/min
Slow or gasping respirations
Heart rate <100
Persistent central cyanosis
Slow to respond
Suction (bulb syringe) mouth, then nose
Ensure neonate is dry and warm
Tactile stimulation
Manual airway maneuvers
Blow-by oxygen
Assisted ventilations with supplemental oxygen at 40-60/min
Heart rate below 60 beats/min
Assisted ventilations with supplemental oxygen at 40-60/min for at least 30 seconds
If no improvement following ventilations, begin chest compressions at a compression/ventilation ratio of 3:1 and a rate
of 120 events per minute
A-EMT PROVIDER
IV or IO NS at a TKO rate to avoid volume overload
Only when required for fluid resuscitation or parenteral medication
IO infusions are only indicated when life-threatening conditions are present
Glucose assessment via heel stick
Oral glucose is not indicated in the newborn
EVIDENCE OF HYPOPERFUSION OR HYPOVOLEMIA

IV or IO NS @ 10 mL/kg syringe bolus over 5-10 min
Additional boluses require physician approval
EMT- PARAMEDIC PROVIDER

Tracheal intubation is indicated when
Merconium aspiration with depressed respirations, decreased muscle tone, or heart rate <100 bpm
BVM ventilation is ineffective
Chest compressions are performed
Tracheal medications are required
Insert a gastric tube in all intubated patients
HEART RATE REMAINS <60 BPM
FOLLOWING CHEST COMPRESSIONS, OXYGENATION, AND VENTILATION
Epinephrine
0.01-0.03 mg/kg (1:10,000) IV or IO
0.1 mg/kg (1:1,000) via ET while vascular access is established
Repeat every 3-5 minutes if heart rate remains <60 bpm
HYPOGLYCEMIA
Dextrose 10% per Glucose Abnormalities, Hypoglycemia/Hyperglycemia Guidelines

POST RESUSCITATION


Obtain 12-lead ECG if time and patient condition Obtain 12-lead ECG if time and patient condition permits
permits Blood glucose assessment
Without previous antiarrhythmic therapy during Without previous antiarrhythmic therapy during arrest
arrest Lidocaine 1 mg/kg IV push, (if not given Lidocaine during
Lidocaine 0.5-1.5 mg/kg IV push, (if not given the arrest), followed by continuous infusion per Chart in
Lidocaine during the arrest), followed by continuous Appendix of 20-50 mcg/kg/min
infusion per Chart in Appendix of 2-4 mg/min With previous antiarrhythmic therapy during arrest
With previous antiarrhythmic therapy during arrest If conversion was from Amiodarone
If conversion was from Amiodarone, bolus 150 mg Closely monitor patient
and closely monitor patient Contact OLMC for guidance
If conversion was from Lidocaine, begin continuous If conversion was from Lidocaine, begin continuous
infusion per Chart in Appendix of 2-4 mg/min infusion per Chart in Appendix of 20-50 mcg/kg/min
Dopamine 520 mcg/kg/min IV infusion per Chart on Dopamine 5-20 mcg/kg/min IV infusion per Chart on page
page 65 for hypoperfusion. Titrated to maintain a SBP 65 for hypoperfusion. Titrated to maintain a SBP >70 + (age
>100 mmHg in years x 2) mmHg
Ice packs placed in axilla and groin Ice packs placed in axilla and groin
POST RESUSCITATION SVT
POST RESUSCITATION SVT
Observe for 2 minutes. If SVT persists or BP drops see
Observe for 2 minutes. If SVT persists or BP drops see
Narrow - Complex Tachycardias Guideline
Narrow - Complex Tachycardias Guideline
INDUCED HYPOTHERMIA
For Induced hypothermia for pediactric patients contact
medical control.
ET tube to capnograph for continuous monitoring. Goal
Is to maintain ETCO2 at 40
Expose patient and apply ice packs to groin and axilla
Versed 0.15 mg/kg (max dose 10 mg), use only for
Severe shivering or if necessary to maintain airway
Iced saline bolus 30 ml/kg (max of 2 liters)
Monitor MAP ([systolic + 2xdiastolic] / 3). Goal of
Therapy is to maintain MAP at 60 or greater.
If MAP less than 60 after iced saline infused, start
Dopamine at 5 mcg/kg/min and titrate to maintain
if the patient arrests during hypothermia induction,
Discontinue the procedure and begin protocol
Appropriate for the rhythm
Notify the ED of protocol initiation as soon as feasible
Elevate HOB to 30 degrees
Document finger stick blood sugar

PULSELESS ELECTRICAL ACTIVITY (PEA)



Principle
EMT PARAMEDIC PROVIDER EMT PARAMEDIC PROVIDER
CPR CPR
AND AND
0.1 mg/kg (1:1,000) via ETT while vascular access is
2-2.5 mg via ETT if no vascular access
established
Repeat every 3-5 minutes as long as patient remains
remains pulseless
pulseless
Sodium Bicarb
(1:1,000) (IV, IO, ET)
1 mEq/kg IV or IO push if down time
exceeds 15 minutes.
control for notification/update and possible discontinue of
After 20 minutes of resuscitative efforts, contact efforts.

TACHYCARDIA NARROW COMPLEX
(with Pulses)
EMT-B/ FIRST RESPONDER/ALL PROVIDERS


Vascular access and fluid therapy per Resuscitation and Same as adult
PROBABLE SUPRAVENTRICULAR TACHYCARDIA PROBABLE SUPRAVENTRICULAR TACHYCARDIA
With POOR Perfusion With POOR Perfusion
Maneuvers to increase vagal tone (valsalva) (QRS duration normal, <0.08 seconds)
If no response to initial vagal maneuvers P waves absent or abnormal
Abrupt rate change to or from normal
Adenosine 6 mg rapid IV bolus followed by rapid 20 mL
Infants: rate usually greater than 220 bpm
flush of NS Children: rate usually greater than 180 bpm
If no response after 1 to 2 minutes Maneuvers to increase vagal tone (valsalva, ice pack
Adenosine 12 mg rapid IV push followed by a rapid 20 to face (CSM),* Trendelenburg etc.)
mL flush of NS If no response to initial vagal maneuvers
If no response from maximal Adenosine doses, the
Adenosine 0.1 mg/kg rapid IV or IO push followed
following may be administer as indicated
by 2-3 mL flush of NS
If no response after 1 to 2 minutes
Midazolam 2.510 mg (2.5 mg increments) IV with
SBP >100 mmHg or peripheral pulses present if needed Adenosine 0.2 mg/kg rapid IV or IO push followed
for sedation prior to cardioversion of the conscious by 2- 3 mL flush of NS
patient. Maximum combined total dose of
-OR- 0.25 mg/kg or 12 mg
Midazolam 5 mg IM when unable to establish IV Consult Medical Control for further doses
Use of sedation is left to the discretion of the Provider Midazolam 0.05-0.2 mg/kg (per dose) (max total
and is based on patients hemodynamic status, of 5 mg) IV, IM, or intra nasal titrated to effect with
mental status, and severity of tachycardia SBP >70 + (age in years x 2) mmHg or peripheral
Avoid sedation in severe hypotension (SBP <70 pulses present if needed for sedation prior to
mmHg) unless absolutely necessary cardioversion of the conscious patient.
Synchronized Cardioversion If time and patient condition allows
Indicated for unstable (i.e., shock, serious signs or Contact OLMC for further doses
symptoms) patients Synchronized Cardioversion
Begin at 50-100 J Indicated immediately in the unstable patient
If no response, increase energy as needed Initial energy dose is 0.5 1 J/kg
If no response and tachydysrhythmia persists,
double energy dose to 2 J/kg
Repeat as needed at 2 J/kg while establishing
contact with OLMC

ATRIAL FIBRILLIATION/ATRIAL FLUTTER
Midazolam 2.510 mg (2.5 mg increments) IV with

SBP >100 mmHg or peripheral pulses present if needed
for sedation prior to cardioversion of the conscious
patient.
Use of sedation is left to the discretion of the Provider
and is based upon patients hemodynamic status,
mental status, and severity of tachycardia.
Avoid sedation in severe hypotension (SBP <70
mmHg) unless absolutely necessary
Synchronized Cardioversion
Indicated for unstable (i.e., shock, serious signs or
symptoms) patients
Begin at 120-200J
If no response, increase energy as needed

VENTRICULAR FIBRILLATION
PULSELESS VENTRICULAR TACHYCARDIA


Principle
EMT PARAMEDIC PROVIDER EMT PARAMEDIC PROVIDER
Defibrillation 200 J biphasic, 360 J monophasic Defibrillation -2 J/kg
PERSISTENT OR RECURRENT VF/VT PRESENT PERSISTENT OR RECURRENT VF/VT PRESENT

2-2.5 mg via ETT if no vascular access 0.1 mg/kg (1:1,000) via ETT while vascular access is
established
remains pulseless Repeat every 3-5 minutes
Resume defibrillation attempts
(1:,000) (IV, IO, ET)
ANTIARRHYTHMICS Resume defibrillation attempts at 4-10 J/kg
(any order of use)
ADDITIONAL ANTIARRHYTHMICS
Treatment pattern is shock, drug, shock, drug,
(any order of use)
shock
Amiodarone 300 mg IV bolus Treatment pattern is shock, drug, shock, drug, shock.
Lidocaine Amiodarone 5 mg/kg rapid IV or IO bolus with 10 mL NS
flush (max dose 300 mg)
1-1.5 mg/kg IV push
May repeat up to 2 times for refractory V-Fib or
May repeat every 3-5 min up to 3 mg/kg
V-tach without a pulse
Magnesium sulfate 50% 1-2 gms slow IV push
Lidocaine
at 1 gm/min for treatment of Torsades
1 mg/kg IV, IO, or ETT
May repeat same dose every 5 minutes until
May repeat every 3-5 minutes up to 3 mg/kg
a maximum of 4 grams is reached
Magnesium sulfate 25-50 mg/kg IV/IO for torsades or
Contact OLMC for further magnesium
hypomagnesemia
therapy
control for notification/update and possible discontinue of
Sodium Bicarb
efforts.
1 mEq/kg IV or IO push if down time
exceeds 15 minutes.


VENTRICULAR TACHYCARDIA OR WIDE-COMPLEX OF UNKNOWN TYPE
(with Pulses)


Same as adult
VENTRICULAR TACHYCARDIA VENTRICULAR TACHYCARDIA
-OR- (QRS duration wide >0.08 seconds)
Implantable cardioverter defibrillator (ICD)
patient with VT Priority Order
(If VT is sustained, or ICD fails to convert rhythm) Amiodarone 5 mg/kg over 20 min
-OR- Do not delay cardioversion to administer
If conversion occurs from Amiodarone, begin
Wide-complex tachycardia of uncertain type infusion per Chart in Appendix
with no serious signs or symptom
(No serious signs or symptoms, hemodynamically stable)
- OR-
Priority Order
Amiodarone 150 mg over 10 min Lidocaine 1 mg/kg IV
May repeat X 1 Do not delay cardioversion to administer
Lidocaine 1-1.5 mg/kg IV push If conversion occurs from Lidocaine, begin
No greater than 50 mg per minute infusion per Chart in Appendix at 20-50
mcg/kg/min
Repeat the following every 5 to 10 minutes
Lidocaine 0.5-0.75 mg/kg IV push Midazolam 0.05-0.2 mg/kg (per dose) (max total
No greater than 50 mg per minute until max dose of of 5 mg)
3 mg/kg is reached, arrhythmia is suppressed, or IV or IM titrated to effect with SBP >70 + (age in
patient becomes unstable. years x 2) mmHg or peripheral pulses present if
If conversion occurs from Lidocaine, begin infusion needed for sedation prior to cardioversion of the
at 2-4 mg per minute conscious patient.
If time and patient condition allows
If no response to max doses of Amiodarone Contact Medical Control for further doses
and Lidocaine
UNSTABLE VENTRICULAR TACHYCARDIA Synchronized Cardioversion
(Serious signs or symptoms) Indicated immediately in the unstable patient
Midazolam 2.510 mg (2.5 mg increments) IV with Initial energy dose is 0.5 - 1 J/kg
SBP >100 mmHg or peripheral pulses present if If no response and tachydysrhythmia persists,
needed for sedation prior to cardioversion of the double energy dose to 2 J/kg
conscious patient. Repeat as needed at 2 J/kg while establishing
-OR- contact with Medical Control
Midazolam 5 mg IM when unable to establish IV
Use of sedation is left to the discretion of the
Provider and is based on patients hemodynamic
status, mental status, and severity of tachycardia.
Avoid sedation in severe hypotension (SBP <70
mmHg) unless absolutely necessary

Synchronized Cardioversion
Begin with 100 J
If no response, increase to 200 J biphasic or 300 J,
and 360 J monophasic
If no response contact OLMC for further guidance
POLYMORPHIC VENTRICULAR TACHYCARDIA

(Torsade de Pointes)
Stable
(Episodic or sustained polymorphic VT, without
serious signs or symptoms)
Magnesium sulfate 50% 1-2 gms

slow IV push at 1 gm/min, if SBP >100 mmHg
May repeat same dose every 5 minutes until a
maximum of 4 grams is reached
Large doses (i.e., up to 8-10 grams) of magnesium
may be required to suppress arrhythmia. Contact
OLMC for further magnesium therapy.
Unstable
(Sustained polymorphic VT with serious signs
or symptoms)
Unsynchronized Defibrillation
Begin with 200 J
Repeat as needed at 200 J biphasic or 300 J and
360 J monophasic
If patient is or becomes pulseless, see Ventricular
Fibrillation / Pulseless Ventricular Tachycardia
Guidelines

Trauma
Patient
Care
Guidelines & Standing

Orders

TRAUMA PATIENT CATERGORIES
It is the responsibility of all Providers to be familiar with criteria associated with each category, properly
designate trauma patients accordingly, and report patient classification as quickly as possible to other
responding resources.
INDICATIONS
Patients having suffered acute traumatic injury
CONTRAINDICATIONS
Trauma Patient criteria are not used to classify patients suffering primarily from medically related conditions.
NOTES/PRECAUTIONS
All Category I and II Trauma patients are to be transported to UT medical Center (closest designated
level I trauma center)
The goal of Anderson County Emergency Services is to have all Category I and II patients off the scene in
less than 10 minutes
LEVEL I
TRAUMA
Critical Patients
TRAUMA ALERT
Category I patients may require immediate, life-saving interventions
1. Glasgow coma score less than 13 associated with trauma

2. Physiologic criteria
Use any one of the following:
Adults
- Systolic Blood Pressure Less than 90 mmHg
- Respiratory Rate Less than 10, or greater than, 29 breaths / minute
Children Less Than 5 Years
- Systolic Blood Pressure Less than 70 + (age in years x 2) mmHg
- Heart Rate Less than 60 or greater than 180
- Respiratory Rate Less than 10 breaths / minute
Children Greater Than 5 Years
- Systolic Blood Pressure Less than 70 + (age in years x 2) mmHg
- Heart Rate Greater than 160
- Respiratory Rate: Less than 10 breaths / minute
3. Respiratory compromise/obstruction and/or intubation
4. Depressed or open skull fracture
5. Flail chest
6. Pelvic fractures
7. Traumatic paralysis
8. Amputation proximal to the wrist or ankle

9. Two (2) or more proximal long bone fractures
10. All penetrating injuries to the head, neck, torso or extremities proximal to elbow or knee
11. Stab wounds with hemodynamic instability (SBP < 90)
12. Burns
a. Inhalation injuries
rd
b. 2nd or 3 degree burns greater than 20% body surface area
Note: Once appropriately designated, Level I patients should not be downgraded to a lesser trauma Level
(II or III), regardless of additional findings or improvement in physiologic status. Transport providers should
provide an initial hospital radio report on all Level I or II trauma as soon as appropriate after loading and
initiation of transport. Early notification allows the receiving physician to activate an internal trauma page (if
needed) prior to patient arrival.

LEVEL II
TRAUMA
Emergent Patients
These patients may require urgent assessment - within 30 minutes - by a trauma surgeon to evaluate for
both actual and potential injuries. Contact Medical direction.
WHEN IN DOUBT TAKE TO A TRAUMA CENTER
1. Motor vehicle collisions with any one of the following:

a. Ejection from moving vehicle
b. Death in the same passenger compartment
c. Auto roll-over greater than 90 degrees rotation
d. Steering wheel damage
e. Auto-pedestrian incident
f. Auto-bicycle collisions
2. Extrication time greater than 20 minutes
3. Motorcycle or watercraft crashes greater than 20 mph
4. Stab wound to head, neck or torso with hemodynamic stability (SBP >90)
5. Any significant traumatic incident in patients less than 5 years or greater than 55 years of age
6. Falls
a. Greater than 10 feet in patients less than 10 yrs., or greater than 55 yrs. of age
b. Greater than 20 feet in other patients
7. Burns
a. Second or third degree burns, greater than 5% or less than 20% body surface area
8. Blunt trauma patients with concomitant medical diseases or processes, including;
a. Immunosuppression (i.e., HIV, TB, chemotherapy treatment for cancer etc.)
b. Coagulopathy (i.e. Hemophilia, Von Willebrands disease, factor IX deficiency)
c. Pregnancy
LEVEL III
TRAUMA
Non-emergent
Patients
Any injured patient not meeting Category I or II definitions is considered a Category III Trauma patient.

AMPUTATIONS
EMT-B/FIRST RESPONDER / ALL PROVIDERS

Direct pressure to control hemorrhage
If amputation is incomplete, splint affected digit or limb in physiologic position
Amputated Body Parts and/or Tissue
o All retrievable tissue should be transported (do not delay transport for tissue retrieval)
o Rinse part(s) with LR (preferred) or NS
o Wrap tissue in sterile gauze moistened with LR (preferred) or NS
o Place tissue into plastic bag or container.
o Place bag / container into separate container filled with ice
o Do not allow tissue to come into direct contact with ice
Tooth Avulsion
o Handle tooth by chewing surface only. Avoid touching the root.
o Rinse with water. Do not scrub, dry, or wrap tooth in tissue or cloth.
o Place tooth in container of (in order of preference)
- Patients Saliva
- Milk
- Normal Saline
- Water

If bleeding is not controlled with pressure, apply
tourniquet device
Transport to Level 1 Trauma Same as adult

TRAUMATIC BRAIN INJURY

Elevate head of spinal board or stretcher 30 degrees
Ventilation rates per Resuscitation and Perfusion Core Principles
In cases of obvious or potential skull fracture, use caution when applying direct pressure to bleeding from nose
Open skull fractures should be covered with non-pressure dry sterile dressings

Vascular access and fluid therapy per Resuscitation Vascular access and fluid therapy per Resuscitation
and Perfusion Core Principle and Perfusion Core Principle
Limit fluid bolus to 250 500 mL NS Limit fluid bolus to 10 mL/kg NS
Utilize Emergency Intubation Protocol if needed. Utilize Emergency Intubation Protocol if needed.
Nasotracheal Intubation is Contraindicated. Nasotracheal Intubation is Contraindicated.
Ventilate to maintain EtC02 less than 30 mmHg when Ventilate to maintain EtC02 less than 30 mmHg when
capnography is available capnography is available
Persistent hypotension unresponsive to fluids Persistent hypotension unresponsive to fluids
Dopamine 520 mcg/kg/min IV infusion per Chart on Dopamine 520 mcg/kg/min IV infusion per Chart on
page 65 for hypoperfusion. Titrated to maintain a page 65 for hypoperfusion. Titrated to maintain a SBP
SBP >100 mmHg >70 + (age in years x 2) mmHg
Goal is to maintain mean arterial Goal is to maintain mean arterial
pressure (MAP) >70 mmHg
pressure (MAP) >70 mmHg

BURNS ELECTRICAL / LIGHTNING

Safely evacuate patient from electrical source
When multiple patients are struck simultaneously by lightning or a high voltage source, those in respiratory and/or
cardiac arrest should be given the highest priority of care, even those who appear dead on initial evaluation.
Identify potential entry and exit wounds
Remove items that may constrict swelling tissue
Be alert to the possibility of impending cardiac arrest.
Spinal motion restriction in the unconscious patient
Dressings
nd rd
o 2 or 3 degree <10% BSA- Wet sterile dressings
nd rd
o 2 or 3 degree >10% BSA- Dry sterile dressings
Maintain patient warmth
For Cat I burned patients, without additional Cat I trauma, consider aeromedical transport from the scene to a designated
burn center
Inhalation injuries
2nd or 3rd degree burns greater than 20% body surface area

Advanced airway, vascular access per Resuscitation Same as adult
If possible, avoid placing IV through burned skin
nd rd
2 or 3 degree burn >10% BSA Fluid therapy
following Parkland Burn Formula
LR 4 mL per kg body weight per % deep burn
during the first 24 hours
o To calculate: multiply 4cc X kg X % burn =
total fluid requirement
o Give half of this amount during the first 8 hours
from the time of injury
Continuous ECG and O2 monitoring Same as adult
permits
If possible, avoid placing electrodes over burned
skin
High voltage electrical injury or direct lightning strike
with significant tissue destruction
Sodium Bicarbonate 1 mEq/kg (maximum of
100 mEq) in 1000 mL NS wide open
Address pain according to Pain Management Protocols.

BURNS THERMAL

Stop the burning process
Early oxygen therapy with high flow O2 is critical
Be alert for the possibility of developing airway compromise
Dressings:
nd rd
o 2 or 3 degree < 10% BSA- Wet sterile dressings
nd rd
o 2 or 3 degree > 10% BSA- Dry sterile dressings
o Maintain patient warmth
For Cat I burned patients, without additional Cat I trauma, consider aeromedical transport from the scene to a designated
burn center
Inhalation injuries
2nd or 3rd degree burns greater than 20% body surface area

Advanced airway, vascular access per Resuscitation Same as adult
If possible, avoid placing IV through burned skin
nd rd
2 or 3 degree burn > 10% BSA Fluid therapy
following Parkland Burn Formula
LR 4 mL per kg body weight per % deep burn
during the first 24 hours
o To calculate: multiply 4cc X kg X % burn =
total fluid requirement
o Give half of this amount during the first 8 hours
from the time of injury
Continuous ETCO2 and O2 monitoring Continuous ETCO2 and O2 monitoring
Continuous ECG monitoring and obtain 12-lead if Continuous ECG monitoring and obtain 12-lead
time and patient condition permits. if time and patient condition permits.
If possible, avoid placing electrodes over burned If possible, avoid placing electrodes over burned
skin skin
Address pain according to Pain Management Protocols Address pain according to Pain Management
Protocols

CRUSH INJURIES


NS 0.9% only
When possible, initiate prior to patient being
freed from object
Constant crush injuries greater than four (4) hours Same as adult
duration
Sodium Bicarbonate 1 mEq/kg (maximum of
100 mEq) in 1000 mL NS wide open.
Address pain according to Pain Management
Protocols

PNEUMOTHORAX
B-EMT/FIRST RESPONDER / ALL PROVIDERS

Cover open chest wounds with occlusive dressing

Suspected Tension Pneumothorax
Same as adult
Immediate needle decompression of affected
side
Traumatic Arrest
Consider bilateral needle decompression based
on mechanism of injury

SKELETAL INJURIES

Uncomplicated fractures/dislocations with adequate circulation should be splinted in a position of function/comfort.
Fractures/dislocations with circulation deficits or severely angulated injuries are treated with one attempt at placing
the extremity in a position of function/comfort. If the attempt is unsuccessful, splint in position found and expedite
transport
Fractures and joint dislocations without palpable distal pulses are true orthopedic emergencies.
For patients with potential pelvic fractures, the treatment of choice is application of the pelvic binder. If unavailable,
a cloth sheet or blanket can be wrapped tightly around the pelvis to stabilize it.
Isolated proximal femur fractures (especially in the elderly) are usually best managed with anatomical splinting
utilizing a scoop stretcher. Traction splints are not appropriate for any proximal femur fractures.
Femoral shaft fractures are immobilized utilizing a traction splint unless one of the situations listed below is present:
o Injuries proximal to, or involving the knee joint
o Injury to the pelvis
o Partial amputation
o Lower leg or ankle injuries
o If use would delay transport of a patient with a life-threatening condition

and Perfusion Principle

If the situation warrants, one additional attempt may Same as adult
be made at repositioning fractures/dislocations with
circulation deficits or severe angulations following
appropriate analgesia
Address pain according to Pain Management
Protocols

SNAKE BITES

Keep patient movement to a minimum
Splint limb and place below heart level

Dopamine 520 mcg/kg/min IV infusion per Chart Dopamine 520 mcg/kg/min IV infusion per Chart on
on page 65 for hypoperfusion. Titrated to maintain page 65 for hypoperfusion. Titrated to maintain a SBP >70
a SBP >100 mmHg + (age in years x 2) mmHg

SOFT TISSUE INJURIES

Cover lacerations or puncture wounds on the neck near the great vessels or trachea with an occlusive dressing
Bleeding from the nose (epistaxis) should be controlled by first having the patient sit and lean forward unless spinal
motion restriction is required. Direct pressure by pinching the fleshy portion of the nostrils may effectively control
bleeding. An alternate method would be the use of a rolled gauze bandage to apply pressure between the upper lip
and gum. The use of appropriate pressure points and/or ice packs (not in direct contact with skin) in combination
with direct pressure may also be effective.
Cover abdominal eviscerations with a moist sterile dressing
o Do not attempt to replace organs
Cover extruded eye or deflated globe with a moist sterile dressing and protective covering
o Do not apply pressure or attempt to replace in socket
o Cover both eyes
Large partially attached avulsions should be replaced over injury site when possible
Impaled objects should be stabilized in place and covered with dry sterile dressings. The exceptions would be:
o Objects through the cheek where there is the possibility of airway compromise
- Objects that would interfere with chest compressions

Anderson County Emergency Services 113 Clinical Operating Guidelines 2014

SPINAL CORD INJURIES

Apply Spinal Motion Restriction Algorithm
Be alert for the possibility of developing airway compromise
Spinal movement restriction per Disability Core Principle
Patients in need of Spinal Motion Restriction that are >20 weeks gestation should be packaged normally and the
backboard tilted approximately 15 degrees, left side down

Dopamine 520 mcg/kg/min IV infusion per Chart on Dopamine 520 mcg/kg/min IV infusion per Chart
page 65 for hypoperfusion. Titrated to maintain a SBP on page 65 for hypoperfusion. Titrated to maintain a
>100 mmHg SBP >70 + (age in years x 2) mmHg
Anderson County Emergency Services 114 Clinical Operating Guidelines 2014

ACEMS Clinical Operating Guidelines (2016)

Hochgeladen von

Dokumentinformationen

Copyright

Verfügbare Formate

Dieses Dokument teilen

Dokument teilen oder einbetten

Freigabeoptionen

Stufen Sie dieses Dokument als nützlich ein?

Sind diese Inhalte unangemessen?

Copyright:

Verfügbare Formate

ACEMS Clinical Operating Guidelines (2016)

Hochgeladen von

Copyright:

Verfügbare Formate

Medical Directors Authorization

Clinical Operating Guidelines 2016

Effective Date of these SOPs: February 2016

Anderson County Emergency Services -1- Clinical Operating Guidelines 2016

Introduction (What is Professional Practice?)

EMS is a practice of medicine. A unique practice at that

Authority for Patient Care/On-Scene Healthcare Providers

Anderson County Emergency Services -2- Clinical Operating Guidelines 2016

Transfer of Care to a Provider of Lesser Credentialing

First Responder Accompanying Ambulance Transport of Critically Injured/Ill Patients

On-Line Medical Consultation (OLMC)

Anderson County Emergency Services -3- Clinical Operating Guidelines 2016

Physician On-Scene/General Guidelines

Patients Personal Physician On-Scene

Intervener Physician On-Scene

Anderson County Emergency Services -4- Clinical Operating Guidelines 2016

Anderson County Emergency Services -5- Clinical Operating Guidelines 2016

What is the Definition of a Patient?

The definition of a patient is any human being that:

To assist in further distinguishing our patients, the following should apply:

The definition of an adult is:

The definition of a minor is:

Anderson County Emergency Services -6- Clinical Operating Guidelines 2016

Patient Consent and Refusal

Anderson County Emergency Services -8- Clinical Operating Guidelines 2016

Anderson County Emergency Services -9- Clinical Operating Guidelines 2016

Restraint/Transport Against Patient Will

Anderson County Emergency Services - 11 - Clinical Operating Guidelines 2016

Initiation of Cardiopulmonary Resuscitation (CPR)

Termination of Resuscitation Efforts Without Online Medical Control

Anderson County Emergency Services - 12 - Clinical Operating Guidelines 2016

Termination of Resuscitation Efforts Utilizing OLMC

Out of Hospital Advanced Directives Pertaining to Resuscitation

Important Points to Remember

Anderson County Emergency Services - 14 - Clinical Operating Guidelines 2016

General principles of crime scene management:

Anderson County Emergency Services - 15 - Clinical Operating Guidelines 2016

Crime scene management with patient transport:

Mandatory Blood Draw Policy

Scope: This policy applies to requests generated by Law Enforcement.

Anderson County Emergency Services - 16 - Clinical Operating Guidelines 2016

Anderson County Emergency Services - 17 - Clinical Operating Guidelines 2016

Anderson County Emergency Services - 18 - Clinical Operating Guidelines 2016

Clinical Review Process

Anderson County EMS System Healthcare Quality Committee

Anderson County Emergency Services - 19 - Clinical Operating Guidelines 2016

Steps in the Clinical Review Process

Anderson County Emergency Services - 20 - Clinical Operating Guidelines 2016

Anderson County Emergency Services - 21 - Clinical Operating Guidelines 2016

Professional practice is just what the name implies...Professional.

Anderson County Emergency Services -22- Clinical Operating Guidelines 2016

Introduction (Looking out for #1)

Face it. We work in a hazardous environment.

Anderson County Emergency Services -23- Clinical Operating Guidelines 2016

Personal Protective Equipment (PPE)

Anderson County Emergency Services -24- Clinical Operating Guidelines 2016

Anderson County Emergency Services -25- Clinical Operating Guidelines 2016

Cleaning and Disinfection of Equipment and Work Areas

Anderson County Emergency Services -26- Clinical Operating Guidelines 2016

The characteristics most commonly associated with fatalities included:

Violence Against Providers

Staging and Retreat

Anderson County Emergency Services -27- Clinical Operating Guidelines 2016

Anderson County Emergency Services -28- Clinical Operating Guidelines 2016