Clark County Emt-I

Front 1

ABDOMINAL PAIN, BACK PAIN,
FLANK PAIN (Non-Traumatic)

Back 1

BLS:
1. Initiate General Patient Care.
ILS:
2. If patient is greater than 35 years of age, a female in her childbearing years, or suffering from nausea/vomiting, attempt Vascular Access.
3. If vital signs and patient’s condition indicate hypoperfusion, administer initial fluid challenge of 500 ml NS. If patient’s condition does not improve, administer additional challenges as needed, not to exceed 2,000 ml.
Pediatric fluid bolus is 20 ml/kg. May repeat as clinically indicated to a maximum of 60 ml/kg.

Front 2

ACUTE CORONARY SYNDROME (SUSPECTED)

Back 2

BLS:
1. Initiate General Patient Care.
2. Assess and treat for shock if indicated.
3. If the patient has a known history of coronary artery disease, assist the patient in administering his or her own Nitroglycerin exactly as prescribed IF initial SYSTOLIC blood pressure is greater than 100 mmHg, and pulse is greater than 60 bpm. May be repeated every 5 minutes if ischemic discomfort persists, and blood pressure and pulse remain stable. Maximum three doses total (patient AND EMT-B assisted).
4. Administer Acetylsalicylic Acid (Aspirin) 324 mg (four – 81 mg chewable tablets) PO, if not contraindicated.
ILS:
5. If airway is not manageable by BLS methods, consider use of a Supraglottic Airway Device as indicated by patient condition.
6. Attempt Vascular Access.
7. If vital signs and patient’s condition indicate hypoperfusion, administer initial fluid challenge of 500 ml NS. If patient’s condition does not improve, administer additional challenges as needed, not to exceed 2,000 ml.

Front 3

ALLERGY / ANAPHYLAXIS

Back 3

BLS:
1. Initiate General Patient Care.
2. Assess for signs and symptoms of allergic reaction.
3. For allergic reaction WITH WHEEZING, assist the patient in administering their own Bronchodilator Metered Dose Inhaler exactly as prescribed.
4. For severe allergic reaction involving ANGIOEDEMA/STRIDOR and/or SHOCK, assist the patient in administering their own Epinephrine Auto-Injector exactly as prescribed.
ILS:
5. If airway is not manageable by BLS methods, consider use of a Supraglottic Airway Device as indicated by patient condition.
6. Attempt Vascular Access.
7. If vital signs and patient’s condition indicate hypoperfusion, administer initial fluid challenge of 500 ml NS. If patient’s condition does not improve, administer additional challenges as needed, not to exceed 2,000 ml.
Pediatric fluid bolus is 20 ml/kg. May repeat as clinically indicated to a maximum of 60 ml/kg.
8. Administer Diphenhydramine (Benadryl) 50 mg IV/IM.

Front 4

ALLERGY / ANAPHYLAXIS part 2

Back 4

Pediatric Benadryl dose is 1.0 mg/kg IV/IM, not to exceed 50 mg.
9. For allergic reaction WITH WHEEZING, administer Albuterol (Proventil) 2.5 mg in 3.0 ml via nebulizer. Continue treatments until clinical condition improves.
10. For severe allergic reaction involving ANGIOEDEMA/STRIDOR and/or SHOCK, administer Epinephrine 0.5 mg 1:1,000 IM every 15 minutes as indicated by patient condition for a total maximum dose of 1.5 mg. If the patient’s condition is so critical that imminent circulatory collapse is likely, administer Epinephrine 0.5 mg 1:10,000 IV.
Pediatric Epinephrine dose is 0.01 mg/kg 1:1,000 IM or every 15 minutes as indicated by patient condition with a maximum single dose of 0.3 mg. May repeat x 2 for a total maximum dose of 0.9 mg. If the patient’s condition is so critical that imminent circulatory collapse is likely, administer Epinephrine 0.01 mg/kg 1:10,000 IV/IO.

Front 5

ALTERED MENTAL STATUS BLS

Back 5

BLS:
1. Initiate General Patient Care.
2. If the patient is seizing:
a. DO NOT RESTRAIN.
b. Protect patient from further injury.
3. When seizure activity has stopped, identify and treat injuries.
4. If patient is a known diabetic administer Glucose between the gum and cheek, if gag reflex is present.

Front 6

ALTERED MENTAL STATUS Part 2

Back 6

7. Consider Vascular Access.
8. If patient has respiratory depression AND is unresponsive, administer Naloxone
(Narcan) 1.0 – 2.0 mg IN/IM/IV. If no change in patient’s status or patient is slow
to respond, administer Naloxone (Narcan) 2.0 mg IN/IM/IV, titrated to effect to a
total maximum dose of 10 mg.
Pediatric Narcan dose is 0.1 mg/kg IN/IM/IV, not to exceed the adult dose.
9. If vital signs and patient’s condition indicate hypoperfusion, administer initial fluid
challenge of 500 ml NS. If patient’s condition does not improve, administer
additional challenges as needed, not to exceed 2,000 ml.
Pediatric fluid bolus is 20 ml/kg. May repeat as clinically indicated to a maximum
of 60 ml/kg.

Front 7

BEHAVIORAL EMERGENCIES

Back 7

BLS:
1. Initiate General Patient Care.
2. Consider medical causes of the patient’s behavior
a. Hypoxia
b. Intoxication/overdose
c. Hypoglycemia
3. Implement SAFER model.
a. Stabilize the situation by containing and lowering the stimuli.
b. Assess and acknowledge the crisis.
c. Facilitate the identification and activation of resources (chaplain, family, friends, or police).
d. Encourage patient to use resources and take actions in his/her best interest.
e. Recovery or referral - leave patient in care of responsible person or professional, or transport to appropriate facility.
4. If it is in the best interest of the patient and does not place EMS personnel in danger of physical harm, soft restraints may be applied to the wrists and ankles prior to transport. The reasons for restraint must be clearly documented on the PCR.

Front 8

BURNS( when to go to burn unit)

Back 8

Patients meeting the following criteria shall be transported to the Burn Center (UMC Adult Trauma Center or UMC Pediatric E.D.):
(1) Second and/or third degree burns >20% bsa
(2) Second and/or third degree burns >10% bsa in patients under 10 or over 50 years of age
(3) Burns of the face, hands, feet, or perineum
(4) Electrical burns (including lightning)
(5) Chemical burns
(6) Circumferential burns
(7) Suspected inhalation injury

Front 9

Burns Protocol

Back 9

BLS:
1. Initiate General Patient Care.
2. Stop the burning process with water or saline.
3. Remove smoldering clothing and jewelry.
4. Continually monitor the airway for evidence of obstruction.
5. Cover the burned area with a dry sterile dressing. DO NOT use any type of ointment, lotion or antiseptic.
6. Estimate involved body surface area (BSA) using the “Rule of Nines.”
ILS:
7. If airway is not manageable by BLS methods, consider use of the Supraglottic Airway Device as indicated by patient condition.
8. Attempt Vascular Access, if indicated by patient condition.
9. If vital signs and patient’s condition indicate hypoperfusion, OR there is greater than 10% BSA involved, administer initial fluid challenge of 500 ml NS. If patient’s condition does not improve, administer additional challenges as needed, not to exceed 2,000 ml.
Pediatric fluid bolus is 20 ml/kg. May repeat as clinically indicated to a maximum of 60 ml/kg.

Front 10

CARDIAC ARREST
(ADULT CCC CPR)
BLS

Back 10

1. Initiate General Patient Care.
2. Establish unresponsiveness, pulselessness, and apnea.
3. Does patient meet the criteria of the Prehospital Death Determination protocol?
4. Does the patient meet the criteria of the Do Not Resuscitate protocol?
5. WITNESSED ARREST BY EMS, begin Continuous Chest Compressions(CCC)at a rate of at least 100/min while preparing for AED use and defibrillate if prompted. Then immediately resume CCC. The depth of compressions should be at least 2 inches.
6.UNWITNESSED ARREST, immediately begin CCC for 2 minutes while applying and preparing AED for analysis.
7.Have additional rescuer insert Nasopharyngeal Airway (NPA)/Oropharyngeal Airway (OPA) and place Non-Rebreather (NRB) mask on patient at 10-15 lpm.
8.If after 4 minutes of CCC CPR, if no advanced airway has been placed, initiate BVM ventilation at 8-10 bpm. Waveform capnography may be attached between the mask and BVM to monitor the effectiveness of CPR and possible return of spontaneous

Front 11

CARDIAC ARREST
Adult CCC CPR
ILS

Back 11

9. Analyze rhythm, defibrillate if prompted, AND immediately resume CCC for 2 minutes. Repeat analysis every two minutes.
CARDIAC ARREST
(ADULT CCC CPR)
ALERT
CCC CPR is only to be considered for the non-traumatic cardiac arrest patient.
ALERT
Quality compressions are the single most important action to be taken, followed by timely defibrillation. Interruptions in chest compressions are to be avoided.
TREATMENT
34
10. If the patient has return of spontaneous circulation ensure adequate oxygenation and ventilation.
ILS:
11. If airway is not manageable by BLS methods, consider use of the Supraglottic Airway Device.
12. Attempt Vascular Access.
13. If patient has return of spontaneous circulation and vital signs indicate hypoperfusion, check lung fields, and if clear, administer initial fluid challenge of 500 ml NS. If patient’s condition does not improve, check lung fields. If clear, administer an additional 500 ml NS.

Front 12

OBSTETRICAL / GYNECOLOGICAL
EMERGENCIES BLS

Back 12

BLS:
1. Initiate General Patient Care.
2. If patient presents with vaginal bleeding, determine pregnancy status
a. Any passed tissue or products of conception should be transported with the patient.
3. If patient presents pregnant, with contractions and/or pain, accompanied by bleeding or discharge, crowning during contraction, the feeling of an impending bowel movement, and/or a rock-hard abdomen, prepare for imminent delivery.
a. Normal (head first) presentation
1) Puncture amniotic sac if not already broken
2) Deliver and support the head
3) Suction mouth then nose. If meconium is present, repeat several times
4) Deliver upper shoulder then lower shoulder
5) Deliver remainder of baby
6) Clamp and cut umbilical cord
7) If multiple births, return to step 2 and repeat
8) Deliver placenta
b. Limb presentation
1) Place mother in left lateral recumbent position
c. Breech presentation
1) Deliver body, supporting baby’s weight

Front 13

OBSTETRICAL / GYNECOLOGICAL
EMERGENCIES ILS

Back 13

d. Cord presentation
1) Position mother on elbows and knees, with hips elevated
2) Wrap cord and keep it moist
3) Insert gloved hand to lift baby off the cord
4) Obtain and document cord pulse
ILS:
4. Attempt Vascular Access.
5. If vital signs and patient’s condition indicate hypoperfusion, administer initial fluid challenge of 500 ml NS. If patient’s condition does not improve, administer additional challenges as needed, not to exceed 2,000 ml.

Front 14

OVERDOSE / POISONING

Back 14

1. Initiate General Patient Care.
2. If possible, identify substance and amount ingested or otherwise exposed to. Collect any empty bottles/containers and transport with the patient.
3. If the ingestion occurred within ONE HOUR OF EMS ARRIVAL, administer Activated Charcoal 50 gm PO.
Pediatric Charcoal dose is 1 gm/kg PO. Minimum dose is 10 gm. Maximum dose is 50 gm.
ILS:
4. If airway is not manageable by BLS methods, consider use of the Supraglottic Airway Device as indicated by patient condition.
5. Consider Vascular Access.
6. If patient has respiratory depression AND is unresponsive, administer Naloxone (Narcan) 2.0 mg IN/IM/IV. If no change in patient’s status or patient is slow to respond, administer Naloxone (Narcan) 2.0 mg IN/IM/IV, titrated to effect to a total maximum dose of 10 mg.
Pediatric Narcan dose is 0.1 mg/kg IN/IM/IV, not to exceed the adult dose.
OVERDOSE / POISONING
Narcan is not recommended as part of the initial resuscitation efforts in the newly born.

Front 15

OVERDOSE / POISONING
ILS

Back 15

ALERT
If patient is suspected to have narcotic overdose/hypoglycemia administer Narcan/Glucose prior to Supraglottic Airway Device/intubation.
ALERT
If the ingested / exposed substance poses a hazard or potential risk of contaminating EMS personnel, vehicles, or the receiving facility DO NOT transport the material with the patient.
ALERT
TREATMENT
7. If patient is experiencing a dystonic reaction, administer Diphenhydramine
(Benadryl) 50 mg IV/IM.
Pediatric Benadryl dose is 1.0 mg/kg IV/IM, not to exceed 50 mg.

Front 16

PULMONARY EDEMA / CHF (ADULT)

Back 16

BLS:
1. Initiate General Patient Care.
2. Place patient in position of comfort.
ILS:
3. If airway is not manageable by BLS methods, consider use of the Supraglottic Airway Device as indicated by patient condition.
4. Attempt Vascular Access.

Front 17

RESPIRATORY DISTRESS
WITH BRONCHOSPASM

Back 17

BLS:
1. Initiate General Patient Care.
2. Assist the patient in administering his or her own Bronchodilator Metered Dose
Inhaler exactly as prescribed.
ILS:
3. If airway is not manageable by BLS methods, consider use of the Supraglottic
Airway Device as indicated by patient condition.
4. For severe distress, attempt Vascular Access.
5. Administer Albuterol (Proventil) 2.5 mg in 3.0 ml NS (0.083% solution) for
nebulizer. Continue treatments until clinical condition improves.

Front 18

SHOCK (NON-TRAUMATIC)

Back 18

BLS:
1. Initiate General Patient Care.
ILS:
2. If airway is not manageable by BLS methods, consider use of the Supraglottic Airway Device as indicated by patient condition.
3. Attempt Vascular Access.
4. If lung fields are clear, administer initial fluid challenge of 500 ml NS. Administer additional challenges as needed, to maintain cerebral perfusion, not to exceed 2,000 ml.
Pediatric fluid bolus is 20 ml/kg. May repeat as clinically indicated to a maximum of 60 ml/kg.

Front 19

SMOKE INHALATION

Back 19

BLS:
1. Initiate General Patient Care.
2. Administer 100% O2 via non-rebreather mask.
3. If present, treat burn injury as per Burn Protocol.
ILS:
4. If airway is not manageable by BLS methods, consider use of a Supraglottic Airway Device as indicated by patient condition.
5. Attempt Vascular Access.
6. If vital signs and patient’s condition indicate hypoperfusion, administer initial fluid challenge of 500 ml NS. If patient’s condition does not improve, administer additional challenges as needed, not to exceed 2,000 ml.

Front 20

STROKE BLS

Back 20

1. Initiate General Patient Care.
2. Position patient with head and chest elevated or position of comfort.
3. Administer oxygen to maintain normal oxygen saturation.
4. Suction as necessary and be prepared to assist ventilations.
5. Complete Cincinnati Stroke Scale (Appendix B).
6. Make telemetry contact with the receiving facility. Patients with a positive Cincinnati Stroke Scale shall be transported, based on the preference of the patient, to one of the following facilities:
7. If the patient does not have a preference, the patient shall be transported to the closest of the above facilities.
8. If, in the judgment of prehospital personnel, the transport time to one of the above facilities would be detrimental to a critically ill / unstable patient, the patient should be transported to the closest Emergency Department.
9. The patient may be transported to a non-designated facility:
a. At the request of the patient if deemed stable by the EMS provider; or 50 mile, doc called

Front 21

STROKE ILS

Back 21

ILS:
10. If airway is not manageable by BLS methods, consider use of a Supraglottic Airway Device as indicated by patient condition.
11. Attempt Vascular Access.
12. Obtain glucose reading: treat hypoglycemia per Altered Mental Status protocol.

Front 22

TRAUMA BLS

Back 22

BLS:
1. Initiate General Patient Care.
2. Control hemorrhage utilizing direct pressure or tourniquet, as indicated.
3. Immobilize suspected fractures and dislocations. In the case of severe deformity with distal cyanosis or pulselessness, apply gentle in-line traction before splinting. Document presence/absence of pulse before and after immobilization.
4. If a sucking chest wound is suspected, seal the wound with an occlusive dressing taped down on three sides. If the patient's breathing becomes worse, lift one corner of the dressing to release pressure, and then re-seal.
5. Impaled objects must be left in place, and should be stabilized by building up around object with multi-trauma dressings, etc., taking care that the penetrating object is not allowed to do further damage.

Front 23

Trauma

Back 23

ILS:
6. If airway is not manageable by BLS methods, consider use of the Supraglottic Airway Device as indicated by patient condition.
7. Attempt Vascular Access.
8. If vital signs and patient’s condition indicate hypoperfusion, administer initial fluid challenge of 500 ml NS. Administer additional challenges as needed, to maintain cerebral perfusion, not to exceed 2,000 ml.
Pediatric fluid bolus is 20 ml/kg. May repeat as clinically indicated to a maximum of 60 ml/kg.

Front 24

CHRONIC PUBLIC INEBRIATE

Back 24

A person who is suspected to be under the influence of alcohol and has no other emergent medical need may be transported to an approved alcohol and drug abuse facility rather than a hospital’s emergency department IF the patient meets ALL of the following criteria:
a.Patient is able to stand with minimal assistance of one or two people
b.Vitals as follows:
1)Blood Pressure: Systolic: 90–180
Diastolic: 60–100
2)Pulse rate of 60–120
3)Respiratory rate of 16–28
4)Glucose between 50-250
5)Glascow Coma Score >14
c.No acute medical complications
d.No signs of trauma
e.No suspected head injury
f.Approval of the physician or medical staff upon assessment of the patient after he/she arrives at the alternative facility.
2.If there is ANY doubt whether the person is in need of emergency medical care, they should be transported to the CLOSEST hospital’s emergency department.
All of the above parameters must be met and the patient must be clinically stable other than signs

Front 25

DO NOT RESUSCITATE ALERT

Back 25

A valid DNR Identification is a form, wallet card or medallion issued by the Southern Nevada Health District, Nevada State Health Division or an identification issued by another state indicating a person’s desire and qualification to have life resuscitating treatment withheld. A valid DNR Order is a written directive issued by a physician licensed in this state that life-resuscitating treatment is not to be administered to a qualified patient. The term also includes a valid do-not-resuscitate order issued under the laws of another state.
Note: Verbal instructions from friends or family members do NOT constitute a valid DNR.

Front 26

DO NOT RESUSCITATE

Back 26

All patients with absent vital signs who do not have conclusive signs of death (refer to Prehospital Death Determination protocol) shall be treated with life- resuscitating measures unless EMS personnel are presented with a valid Do-Not Resuscitate (DNR) Identification or Order.
2. In preparation for, or during an inter-facility transfer, a valid DNR Order in the qualified patient’s medical record shall be honored in accordance with this protocol.
3. If the EMS provider is presented with a DNR Order or Identification, he shall attempt to verify the validity of the Order or Identification by confirming the patient’s name, age, and condition of identification.
4. The DNR Order or Identification shall be determined invalid if at any time the patient indicates that he/she wishes to receive life-resuscitating treatment. The EMS provider shall document the presence of the DNR Order or Identification and how the patient indicated that he/she wanted the Order or Identification to be revoked

Front 27

DO NOT RESUSCITATE

Back 27

5. Once the DNR Order or Identification is determined to be valid and has not been revoked by the patient, the emergency care provider shall provide ONLY supportive care and withhold life-resuscitating measures.
6. EMS personnel will document on the PCR the presence of the DNR Order or Identification. Documentation should include the patient’s name, physician’s name and identification number, which are found on the DNR Order or Identification.
7. An EMS provider who is unwilling or unable to comply with the DNR protocol shall take all reasonable measures to transfer a patient with a DNR Order or Identification to another provider or facility in which the DNR protocol may be followed.

Front 28

INTER-FACILITY TRANSFER OF
PATIENTS BY AMBULANCE

Back 28

1. Prior to the transfer, the transferring physician is responsible for notifying the receiving physician of the following:
a. Reason for transfer
b. Patient condition
c. Estimated time of arrival
2. The transferring physician must provide the ambulance attendants with the name of the receiving facility and receiving physician, copies of any available diagnostic tests, X-rays, medical records, and the EMTALA form prior to releasing the patient.
3. Ambulance attendants should only transfer a patient whose therapy required during the transfer lies within the ambulance attendant’s capabilities, unless capable personnel accompany the patient.
a. Ambulance attendants are authorized to administer or monitor all medications listed on the Official Drug Inventory as appropriate for their level of licensure and as per protocol.
b. ILS and ALS ambulance attendants are authorized to administer or monitor any crystalloid IV solution during transport.

Front 29

Inter facility Transports

Back 29

c. Arterial lines should be discontinued unless appropriate personnel from the initiating facility accompany the patient.
d. Heparin locks/implantable catheters with/without reservoirs may be closed off and left in place. If they are to be used during transport, then an IV drip should be established if tolerated by the patient.
e. IV pump systems should be discontinued unless capable personnel accompany the patient.
f. Orogastric or nasogastric tubes may be left in place and should either be closed off or left to suction per order of transferring physician.
g. Orthopedic devices may be left in place at the ambulance attendant’s discretion as to ability to properly transport the patient with existing device(s) in place.
h. Trained personnel authorized to operate the apparatus should accompany any patient requiring mechanical ventilation during transport. If the patient will require manual ventilatory assistance, then at least two persons shall be available to attend to the patient.

Front 30

PEDIATRIC PATIENT DESTINATION

Back 30

Pediatric patients(age <18 years of age)shall be transported in accordance with the following criteria:
1.Pediatric patients (including psychiatric patients) shall be transported, based on the preference of the parent or legal guardian, to one of the following facilities:
St. Rose Hospital – Siena Campus
Summerlin Hospital
Sunrise Hospital and Medical Center
University Medical Center
If the parent or legal guardian does not have a preference, the patient shall be transported to the closest of the above facilities.
3. If, in the judgment of prehospital personnel, the transport time to one of the above facilities would be detrimental to a critically ill / unstable pediatric patient, the patient should be transported to the closest Emergency Department.
4. The patient may be transported to a non-designated facility:
a. At the request of the parent or legal guardian and if the child is deemed stable by the EMS provider; or
b. The incident is greater than 50 miles from the

Front 31

PREHOSPITAL DEATH DETERMINATION

Back 31

Patients who appear to have expired will not be resuscitated or transported by Clark County EMS personnel if any of the following obvious signs of death are present:
a)Body decomposition
b)Decapitation
c)Transection of thorax (hemicorpectomy)
d)Incineration
OR if ALL four(4)presumptive signs of death AND AT LEAST one(1)conclusive sign of death are identified.
2.If there is any question regarding patient viability, to include potential hypothermia, resuscitation will be initiated.
3.Once it has been determined that the patient has expired and resuscitation will not be attempted:
a)Immediately notify the appropriate authority;
b)DO NOT leave a body unattended. You may be excused once a responsible person (i.e. Coroner’s investigator, police, security, or family member) is present;
c)DO NOT remove any property from the body or the scene for any purpose;
d)NEVER transport / move a body without permission from the Coroner’s office except for assessment or its protection.

Front 32

The four (4) presumptive signs of death include:

Back 32

1) Unresponsiveness
2) Apnea
3) Pulselessness
4) Fixed dilated pupils

Front 33

Conclusive signs of death include:

Back 33

1) Dependent lividity of any degree
2) Rigor mortis
3) Massive trauma to the head, neck, or chest with visible organ destruction

Front 34

Can a body be covered

Back 34

If the body is in the public view and cannot be isolated, screened, or blocked from view, and is creating an unsafe situation with citizens/family, the body can be covered with a clean, STERILE BURN SHEET obtained from the EMS vehicle.

Front 35

QUALITY IMPROVEMENT REVIEW

Back 35

When EMS or hospital personnel wish to have an incident involving patient care reviewed within the Clark County Emergency Medical Services System, the following steps shall be taken:
1.The person requesting a review of an incident should contact the designated representative of the agency/hospital involved to initiate the process. If after gathering appropriate information and discussing the incident, both parties are satisfied a problem does not exist, nothing further needs to be done.
2 If either party would like to pursue an investigation of the incident, the “Southern Nevada Health District EMS Incident Report” should be completed and a copy should be forwarded to the OEMSTS.
3 Upon receipt of the “Southern Nevada Health District EMS Incident Report” OEMSTS staff will review the case, gather information from the agencies/hospitals involved and evaluate the need for further investigation. The agency/hospital may be asked to conduct an internal investigation, involving their medic

Front 36

TERMINATION OF RESUSCITATION Medical

Back 36

1. Resuscitation that is started in the field by Licensed EMS personnel CANNOT be
discontinued without a physician order. Licensed EMS personnel are not
obligated to continue resuscitation efforts that have been started by other
persons at the scene if the patient meets the criteria listed in the Prehospital
Death Determination protocol. This includes telephone CPR initiated by
Emergency Medical Dispatchers.
2. Resuscitation started in the field may be discontinued only by physician order
when the following conditions have been met:
a. For Medical Arrest:
1) The patient remains in persistent asystole or agonal rhythm and has
capnography (if available) <10 after twenty (20) minutes of appropriate
ALS resuscitation, to include:
1. CPR
2. Effective ventilation with 100% oxygenation
3. Administration of appropriate ACLS medications

Front 37

TERMINATION OF RESUSCITATION Trauma

Back 37

b. For Traumatic Arrest:
1) Open airway with basic life support measures
2) Provide effective ventilation with 100% oxygenation for two minutes
3) Perform bilateral needle thoracentesis if tension pneumothorax
suspected
c. The patient develops, or is found to have one of the following conclusive
signs of death at any point during the resuscitative effort:
1) Lividity of any degree
2) Rigor mortis of any degree
3. When resuscitation has been terminated in the field, all medical interventions
shall be left in place.
4. If possible, do not leave a body unattended. Once a responsible person (i.e.
coroner’s investigator, police, security, or family member) is present at the scene,
you may be excused.
5. NEVER transport/move a body without permission from the coroner’s office,
except for assessment or its protection.

Front 38

TRAUMA FIELD TRIAGE CRITERIA
Step 1

Back 38

1. Step 1 – Measure vital signs and level of consciousness. If the patient’s:
(a) Glasgow Coma Scale is 13 or less;
(b) Systolic blood pressure is less than 90 mmHg; or
(c) Respiratory rate is less than 10 or greater than 29 breaths per minute (less than 20 in infant aged less than 1 year), or is in need of ventilatory support
the adult patient MUST be transported to a Level 1 or 2 center for the treatment of trauma in accordance with the catchment area designated. The pediatric patient MUST be transported to a pediatric center for the treatment of trauma.

Front 39

TRAUMA FIELD TRIAGE CRITERIA
Step 2

Back 39

Step 2 – Assess anatomy of injury. If the patient has:
(a) Penetrating injuries to head, neck, torso or extremities proximal to elbow or knee;
(b) Chest wall instability or deformity (e.g., flail chest);
(c) Two or more proximal long-bone fractures;
(d) Crushed, degloved, mangled, or pulseless extremity;
(e) Amputation proximal to wrist or ankle;
(f) Pelvic fractures;
(g) Open or depressed skull fractures; or
(h) Paralysis
the adult patient MUST be transported to a Level 1 or 2 center for the treatment of trauma in accordance with the catchment area designated. The pediatric patient MUST be transported to a pediatric center for the treatment of trauma

Front 40

TRAUMA FIELD TRIAGE CRITERIA
Step 3

Back 40

Step 3 – Assess mechanism of injury and evidence of high-energy impact, which may include:
(a) Falls
(1)Adults: greater than 20 feet (one story is equal to 10 feet)
(2)Children: greater than 10 feet or two times the height of the child
(b)High-risk auto crash
(1)Motor vehicle was traveling at a speed of at least 40 miles per hour immediately before the collision occurred;
(2)Intrusion, including roof: greater than 12 inches occupant site; greater than 18 inches any site;
(3)Ejection (partial or complete) from automobile;
(4)Motor vehicle rolled over with unrestrained occupant(s);
(5)Death in same passenger compartment
(c)Motorcycle crash greater than 20 mph
(d Auto vs. pedestrian/bicyclist thrown, run over, or with significant (greater than 20 mph) impact
the patient MUST be transported to a Level 1, 2, or 3 center for the treatment of trauma in accordance with the catchment area designated. For patients who are injured outside a a 50 mile radius from a trauma center, the

Front 41

TRAUMA FIELD TRIAGE CRITERIA
Step 4

Back 41

Step 4 – Assess special patient or system considerations, such as:
(a) Older adults
(1) Risk of injury/death increases after age 55 years
(2) SBP less than 110 mmHg might represent shock after age 65 years
(3) Low impact mechanisms (e.g., ground level falls) might result in severe injury
(b) Children
(1) Should be triaged preferentially to a trauma center
(c) Anticoagulants and bleeding disorders
(1) Patients with head injury are at high risk for rapid deterioration
(d) Burns
(1) Without other trauma mechanisms: transport in accordance with the Burns protocol
(2) With trauma mechanism: transport to UMC Trauma/Burn Center
(e) Pregnancy greater than 20 weeks
(f) EMS provider judgment

Front 42

SPINAL IMMOBILIZATION

Back 42

This procedure may be performed in any patient with a mechanism of injury that may cause spinal injury.
Assess patient for the presence of the following (ANY positives REQUIRE spinal immobilization):
a. Evidence of blunt trauma and meets Trauma Field Triage Criteria;
b. Numbness or weakness on neurological exam;
c. Any alteration in mental status;
d. Any evidence of drug and/or alcohol intoxication;
e. Any painful injury that might distract the patient from the pain of a C-spine injury;
f. Any point tenderness on palpation of the spine;
g. Any pain or numbness with cervical spine range of motion.
Contraindication(s): None
Considerations: If a through g, above, are ALL NEGATIVE, spinal immobilization is not required. The above steps in the evaluation to determine the necessity of spinal immobilization shall be done in the order listed.

Front 43

SUPRAGLOTTIC AIRWAY DEVICE

Back 43

ILS:
Indication(s):
This procedure may be performed in any patient in which attempts at basic airway and ventilatory support are unsuccessful AND who has at least one of the following: Hypoxia Respiratory Arrest/Failure Obtundation Failed endotracheal intubation
Contraindication(s):
Absolute Contraindications: Gag reflex History of esophageal trauma, or known esophageal disease Recent ingestion of a caustic substance Tracheostomy or laryngectomy Suspected foreign body obstruction
Relative Contraindications: Suspected narcotic overdose / hypoglycemia prior to administration of Naloxone (Narcan) / Glucose 50%.
Consideration(s): Position the patient's head in a neutral or slightly flexed position if no suspected spinal injury (if a spine injury is suspected, maintain a neutral, in-line head position). Never force the device; if it does not advance, simply readjust the insertion.

Front 44

VASCULAR ACCESS

Back 44

Indication(s) Peripheral Vascular Access:
This procedure may be performed on any patient whenever there is a potential need for: Intravenous drug administration Need to administer IV fluids for volume expansion.
Contraindication(s): None
Consideration(s): Saline locks may be used when appropriate and flushed with a 3 cc bolus of NS, as needed. Extension tubing should be utilized on ALL IV lines.

Front 45

ACETYLSALICYLIC ACID (Aspirin)

Back 45

FORM: 81 mg chewable tablet
CLASS: Nonsteroidal anti-inflammatory (NSAID)
ACTION: Platelet inhibition
PROTOCOL(S): Acute Coronary Syndrome (Suspected)
ROUTE: Adults: PO (chew and swallow)
Pediatrics: Not recommended for use
SIDE EFFECTS: None
CONTRAINDICATIONS: Allergy to Aspirin

Front 46

ACTIVATED CHARCOAL

Back 46

FORM: 25 grams in 4 ounces
CLASS: Adsorbent
ACTION: Inhibits gastrointestinal absorption of toxic substances
PROTOCOL(S): Overdose / Poisoning
ROUTE: Adults: PO (swallow with water)
Pediatrics: PO (swallow with water)
SIDE EFFECTS: May cause nausea and vomiting
CONTRAINDICATIONS: Altered mental status; ingestion of acids, alkalis or petroleum distillates; inability to swallow; previous administration of an emetic

Front 47

ALBUTEROL (Proventil)

Back 47

FORM: 2.5 mg/3 ml unit dose
CLASS: Sympathomimetic
ACTION: Bronchodilator
PROTOCOL(S): Allergy / Anaphylaxis
Cardiac Dysrhythmia: Asystole / PEA
Cardiac Dysrhythmia: Ventricular Fibrillation or Pulseless Ventricular Tachycardia
Hyperkalemia (Adult)
Pulmonary Edema / CHF (Adult)
Respiratory Distress with Bronchospasm
ROUTE: Adult: Inhalation by oxygen nebulization
Pediatric: Inhalation by oxygen nebulization
SIDE EFFECTS: Tachycardia, palpitations, anxiousness, and headache
CONTRAINDICATIONS: Hypersensitivity to this drug

Front 48

BRONCHODILATOR METERED DOSE INHALER

Back 48

FORM: Dependent upon medication (e.g. Proventil, Alupent, Ventolin)
CLASS: Sympathomimetic
ACTION: Bronchodilator
PROTOCOL(S): Allergy / Anaphylaxis
Respiratory Distress with Bronchospasm
ROUTE: Adult: Inhalation
Pediatric: Inhalation
SIDE EFFECTS: Tachycardia, palpitations, anxiousness, and headache
CONTRAINDICATIONS: Hypersensitivity to this drug

Front 49

DIPHENHYDRAMINE HYDROCHLORIDE (Benadryl)

Back 49

FORM: 50 mg/ml
CLASS: Antihistamine
ACTION: Blocks histamine receptors; Has some sedative effects; Anticholinergic
PROTOCOL(S): Allergy / Anaphylaxis
Overdose / Poisoning
ROUTE: Adult: IV or deep IM
Pediatric: IV or deep IM
SIDE EFFECTS: Sedation, palpitations, decreased blood pressure, headache, dries (thickens) bronchial secretions, blurred vision
CONTRAINDICATIONS: Hypersensitivity to the drug

Front 50

EPINEPHRINE

Back 50

FORM: 1.0 mg/1.0 ml (1:1,000); 1.0 mg/10 ml (1:10,000)
CLASS: Sympathomimetic
ACTION: Bronchodilation; Positive chronotrope; Positive inotrope
PROTOCOL(S): Allergy / Anaphylaxis
Cardiac Dysrhythmia: Asystole / PEA
Cardiac Dysrhythmia: Bradycardia
Cardiac Dysrhythmia: Ventricular Fibrillation or Pulseless Ventricular Tachycardia
Respiratory Distress with Bronchospasm
ROUTE: Adult: IV, IM or ETT
Pediatric: IV, IM, Nebulized or ETT, not to exceed adult dose
SIDE EFFECTS: Palpitation due to tachycardia or ectopic beats, may produce arrhythmia if cardiac disease present, elevation of blood pressure, headache, anxiousness
RELATIVE CONTRAINDICATIONS: Underlying cardiovascular disease / angina, hypertension, pregnancy, patient over 40 years of age, hyperthyroidism

Front 51

EPINEPHRINE AUTO-INJECTOR

Back 51

FORM: 0.3 mg (0.3 ml) 1:1,000 Adult OR 0.15 mg (0.3 ml) 1:2,000 Pediatric
CLASS: Sympathomimetic
ACTION: Bronchodilation; Positive chronotrope; Positive inotrope
PROTOCOL(S): Allergy / Anaphylaxis
ROUTE: Adult: IM ONLY
Pediatric: IM ONLY
SIDE EFFECTS: Palpitations due to tachycardia or ectopic beats, may produce arrhythmia if cardiac disease present, elevation of blood pressure, headache, anxiousness
RELATIVE CONTRAINDICATIONS: Underlying cardiovascular disease / angina, hypertension, pregnancy, patient over 40 years of age, hyperthyroidism

Front 52

GLUCAGON

Back 52

FORM: 1.0 mg/ml
CLASS: Insulin antagonist
ACTION: Reverses the effects of hypoglycemia
PROTOCOL(S): Altered Mental Status
Cardiac Dysrhythmia: Asystole / PEA
Cardiac Dysrhythmia: Ventricular Fibrillation or Pulseless Ventricular Tachycardia
Endotracheal Intubation
Overdose / Poisoning
ROUTE: Adult: IM or IV
Pediatric: IM
SIDE EFFECTS: May cause nausea and vomiting
CONTRAINDICATIONS: None

Front 53

GLUCOSE

Back 53

FORM: 25 gm/50 ml (50%); 25 gm in oral suspension
CLASS: Carbohydrate
ACTION: Quick infusion of sugar into blood for metabolism
PROTOCOL(S): Altered Mental Status
Cardiac Dysrhythmia: Asystole / PEA
Cardiac Dysrhythmia: Ventricular Fibrillation or Pulseless Ventricular Tachycardia
Chronic Public Inebriate
Hyperkalemia (Adult)
Overdose / Poisoning
Supraglottic Airway Device
ROUTE: Adult: Slow IVP or PO
Pediatric: Slow lVP or PO
SIDE EFFECTS: None
CONTRAINDICATIONS: None

Front 54

NALOXONE HYDROCHLORIDE (Narcan)

Back 54

FORM: 2.0 mg/2 ml
CLASS: Narcotic antagonist
ACTION: Reverses effects of narcotics
PROTOCOL(S): Altered Mental Status
Overdose / Poisoning
ROUTE: Adult: IV, IM or IN
Pediatric: IV, IM, IN
SIDE EFFECTS: Rapid administration causes projectile vomiting
CONTRAINDICATIONS: Patients with a history of hypersensitivity to this drug; intubated patients; the newly born during initial resuscitation

Front 55

NITROGLYCERIN

Back 55

FORM: Sublingual spray or tablet
CLASS: Vasodilator
ACTION: Dilates systemic arteries and veins; Reduces both preload and afterload
PROTOCOL(S): Acute Coronary Syndrome (Suspected)
Pulmonary Edema / CHF (Adult)
ROUTE: Adult: Sublingual
Pediatric: Not recommended for use
SIDE EFFECTS: Hypotension
CONTRAINDICATIONS: Hypotension (do not administer if systolic pressure below 100 mmHg unless ordered by a physician). Use of Viagra (Sildenafil) or similar medication within the past 24 hours or 48 hours for tadalafil (Cialis). Patients with demonstrated hypersensitivity to nitrates or nitrites

Front 56

GENERAL PATIENT CARE RESPONSE

Back 56

Review the dispatch information and select appropriate response.

Front 57

SCENE ARRIVAL AND SIZE-UP

Back 57

1. Consider Body Substance Isolation (BSI).
2. Consider Personal Protective Equipment (PPE).
3. Evaluate the scene safety.
4. Determine the number of patients.
5. Consider the need for additional resources.

Front 58

PATIENT APPROACH

Back 58

Determine the Mechanism of Injury (MOI) / Nature of Illness (NOI).

Front 59

INITIAL ASSESSMENT

Back 59

1. Check for responsiveness and breathing. If unresponsive and apneic or abnormal or gasping breathing, check for a pulse for no more than 10 seconds. If no pulse, begin appropriate arrest procedures. Otherwise, follow the following ABCDE assessment.

Front 60

Airway

Back 60

a. Open and establish airway.
1) Head tilt – chin lift if no suspicion of cervical spine injury
2) Jaw thrust if evidence of potential cervical spine injury
b. Suction as necessary
c. If necessary, insert airway adjunct
1) Oral airway if gag reflex is absent
2) Nasal airway if gag reflex is present
d. Cervical Spine Immobilization
GENERAL PATIENT CARE
ALERT
Correct life-threatening problems as identified.
For all emergency scenes where patient needs exceed available EMS resources, initial assessment and treatment shall be in accordance with an approved triage methodology.
If patient presents with a traumatic mechanism of injury refer to Spinal Immobilization protocol.
If the ability to adequately ventilate the patient cannot be established, the patient MUST be transported to the nearest emergency department

Front 61

Breathing

Back 61

Breathing
a. Determine if breathing is adequate.
1) If patient’s ventilations are not adequate, provide assistance with
100% oxygen using Bag-Valve-Mask (BVM).
2) Administer oxygen as appropriate.
a) Utilize pulse oximetry, if available. Oxygen treatment should be titrated to maintain a SPO2 > 94%.
b) Patients with a history of prescribed home oxygen for chronic conditions should receive their prescribed home dosage of oxygen or an amount sufficient to provide for a SPO2 > 90%.

Front 62

Circulation

Back 62

a. Assess pulse.
1) Infants and children less than 12 years of age:
a) If patient is symptomatic with poor perfusion (unresponsive or only responds to painful stimuli) and pulse is less than 60 bpm or absent begin CPR.
b) If pulse is greater than 60 bpm, continue assessment.
2) If pulse is absent, begin CPR and attach AED.
For children and infants age 1 to 8, an AED with a dose-attenuator is desirable, but if not available, a standard AED is to be used. For infants under 1 year, a manual defibrillator is preferred but if not available, an AED with a dose-attenuator is desirable. If neither is available, a standard AED is to be used.

Front 63

Disability

Back 63

a. Assess mental status using AVPU Scale
1) Alert
2) Responds to Verbal stimuli
3) Responds to Painful stimuli
4) Unresponsive
b. Perform Mini-Neurologic Assessment (Pulse / Motor / Sensory).
Exposure
To assess patient’s injuries, remove clothing as necessary, considering condition and environment.

Front 64

HISTORY AND PHYSICAL EXAMINATION
For UNSTABLE / UNRESPONSIVE trauma patients:

Back 64

a. Conduct Rapid Trauma Assessment, assessing for DCAP-BTLS:
1) Head
a) Crepitation
2) Neck
a) JVD
b) Tracheal Deviation
3) Chest
a) Crepitation
b) Respiration
c) Paradoxical Motion
d) Breath Sounds
4) Abdomen
a) Rigidity
b) Distention
5) Pelvis / GU
a) Pain on Motion
b) Blood, Urine, Feces
6) Extremities
a) Pulse / Motor / Sensory
7) Posterior
b. Obtain Baseline Vital Signs
c. Obtain SAMPLE History

Front 65

HISTORY AND PHYSICAL EXAMINATION
For STABLE / RESPONSIVE trauma patients:

Back 65

a. Determine chief complaint
b. Perform focused examination of the injured site and areas compatible with given MOI
c. Obtain Baseline Vital Signs
d. Obtain SAMPLE History

Front 66

HISTORY AND PHYSICAL EXAMINATION
For UNSTABLE / UNRESPONSIVE medical patients:

Back 66

a. Perform Rapid Physical Examination
1) Head and Neck
a) JVD
b) Medical Alert Device
2) Chest
a) Breath Sounds
3) Abdomen
a) Rigidity
b) Distention
4) Pelvis / GU
a) Blood, Urine, Feces
5) Extremities
a) Motor / Sensory / Pulse
b) Medical Alert Device
6) Posterior
b. Obtain Baseline Vital Signs
c. If possible, obtain history of episode from family or bystanders (OPQRST).
d. If possible, obtain SAMPLE History from family or bystanders

Front 67

HISTORY AND PHYSICAL EXAMINATION
For STABLE / RESPONSIVE medical patients:

Back 67

a. Obtain history of episode (OPQRST).
b. Obtain Baseline Vital Signs
c. Obtain SAMPLE History
d. Perform a Focused Physical Exam, checking areas suggested by NOI.

Front 68

Perform Detailed and Ongoing Assessments as dictated by patient condition.

Back 68

a. Reassess unstable patients frequently (recommended every 5 minutes).
b. Reassess stable patients at a minimum of every 15 minutes.

Front 69

COMMUNICATIONS

Back 69

Telemetry contact shall be established:
a. For all Code 3 transports.
b. For any medical emergency in which the EMS provider’s judgment suggests consultation with a telemetry physician is necessary.
c. For all trauma patients going to a Trauma Center.
d. When telemetry contact is required per protocol

Front 70

For patients who met Trauma Field Triage Criteria, telemetry reports shall include:

Back 70

a. Patient age
b. Gender
c. Mechanism of injury
d. Ambulatory at scene
e. Suspected injuries
f. Vital signs
g. Airway status
h. Neurologic status
i. ETA
j. An incident identifier if multiple patients are involved (e.g. fire department command code “Main Street Command”)

Front 71

For all other patients, telemetry reports shall include, at a minimum:

Back 71

a. Attendant / vehicle identification
b. Nature of call: INFORMATION ONLY or REQUEST FOR PHYSICIAN ORDERS
c. Patient information: i.e. number, age, sex
d. Patient condition: i.e. stable, full arrest
e. History
1) Basic problem or chief complaint
2) Pertinent associated symptoms
3) Time since onset
4) Past history, if pertinent
f. Objective findings
1) General status of patient
2) Level of responsiveness
3) Vital signs
4) Pertinent localized findings
5) Working impression of patients' problem
g. Treatment
1) In progress
2) Requests for drugs or procedures
h. Estimated Time of Arrival, including any special circumstances that may cause a delay in transport

Front 72

Notification of transport shall be provided to the receiving hospital for ALL other calls.

Back 72

Notification can be completed via:
1) Radio
2) Telephone
3) EMSystem
b. Notification reports shall include:
1) Patient age
2) Chief complaint
3) Type of bed required (monitored / unmonitored)
4) Unit #
5) ETA

Front 73

Altered Mental Status ILS

Back 73

ILS:
5. Determine blood glucose using Chemstrip / Glucometer. If BS<80 mg/dl in the adult patient, administer:
a. Glucose 50% (D50) 25 gm IV. If no response, repeat one additional 25 gm amp in 5 minutes to a total dose of 50 gm; OR
b. Glucagon 1.0 mg IM for patients in whom IV access cannot be achieved within ten minutes or three IV attempts.
If BS<60 mg/dl in the pediatric patient or <40 in the newborn patient, administer Glucose 0.5 gm/kg IV/IO.
<15 kg Glucose 12.5% (D12.5) 4 ml/kg
>15 kg Glucose 50% (D50) 1 ml/kg
Pediatric Glucagon dose is 0.5 mg IM
6. If airway is not manageable by BLS methods, consider use of the Supraglottic Airway Device as indicated by patient condition.