Emt Mlrems 2.0

Front 1

Airway Management - Adult

Back 1

1. Establish patent BLS airway
manually open airway
head tilt/ chin lift
modified jaw thrust
2. Suction as needed
3. Oropharyngeal or nasopharyngeal airway as needed unless contraindicated
4. If ventilation status is inadequate, use positive pressure ventilation utilizing BVM with high concentration oxygen to
ventilate at a rate of 10-12 breaths per minute. Support spontaneous ventilations at an appropriate rate.

Front 2

Airway Management - Pediatric

Back 2

1. Establish a patent airway
manually open airway (head tilt chin lift or jaw thrust
2. Suction as needed
3. Oropharyngeal or nasopharyngeal airway as needed unless contraindicated.
4. If ventilation status is inadequate, use positive pressure ventilations utilizing BVM with high concentration oxygen to
ventilate at a rate of 12-20 breaths per minute. Support spontaneous ventilations as necessary.

Front 3

2.2 Airway Obstruction - Adult (Conscious Patient)

Back 3

Adequate air exchange (able to cough, speak, or breathe)
1. Reassure patient and place in position of comfort.
2. Encourage coughing. Clear oropharynx as needed.
3. Administer high flow oxygen.
Inadequate air exchange (cannot cough, speak, or breathe)
4. Administer continuous abdominal thrusts (Heimlich Maneuver; chest thrusts on pregnant patient) until adequate air
exchange is restored or the patient loses consciousness.

Front 4

2.2 Airway Obstruction - Adult (Unconscious Patient)

Back 4

5. Manually open airway, attempt to ventilate with 2 breaths. If unable to ventilate, reposition and reattempt to
ventilate.
6. Administer CPR.
7. Suction and finger sweep only if object visible.
8. Repeat this sequence from #5 as needed and begin timely transport.

Front 5

2.3 Airway Obstruction - Pediatric (Conscious)

Back 5

Airway should not be unnecessarily stimulated or examined in the situation of possible epiglottis or croup
Adequate air exchange (able to cough, speak, breathe, or cry)
1. Reassure patient and place in position of comfort.
2. Encourage coughing. Clear oropharynx as needed. DO NOT PERFORM BLIND FINGER SWEEPS.
3. Administer high flow oxygen.
Inadequate air exchange (cannot cough, speak, breathe, or cry)
4. Age <1 yr:
Administer 5 back slaps with head lower than body
Administer 5 chest thrusts
Repeat as necessary
Age >1 yr:
Administer continuous abdominal thrusts (Heimlich maneuver) until adequate air exchange is restored, or patient
loses consciousness.

Front 6

2.3 Airway Obstruction - Pediatric (Unconscious)

Back 6

5. Manually open airway, attempt to ventilate with 2 breaths. If unable to ventilate, reposition and reattempt to
ventilate.
6. Administer CPR.
7. Suction and finger sweep only if object visible.
8. Repeat this sequence from #5 as needed and begin timely transport.

Front 7

2.4 Altered Mental Status (Criteria)

Back 7

CRITERIA
• Decreased level of consciousness from all causes should be treated using protocol below.
• An ALS evaluation (including BG, SPO2, and ECG) should be performed on all patients whose mental status is
decreased and on all patients over the age of 35 who have had a syncopal episode.

Front 8

2.4 Altered Mental Status (Protocol)

Back 8

1. Routine medical care.
2. Assure airway patency and administer oxygen per protocol.
3. Assess signs, symptoms, hemodynamic status, medical history, possibility of poisoning, etc.
4. Consider need for spinal immobilization as appropriate.
5. Assess Blood Glucose (BLS if available) and refer to Diabetic Emergencies Protocol (2.14) if BG < 80 mg/dl.
6. All patients with an altered mental status should have timely transport to the hospital.
7. Consider other possible causes of decreased level of consciousness and refer to the appropriate protocol:
• head trauma - refer to Head Trauma Protocol (2.16)
• postictal - refer to Seizure Protocol (2.31)
• meningitis or other infectious processes – refer to agency infectious disease plan
• hypoxia – refer to Airway Management Protocols (2.0-2.3)
• stroke – refer to Stroke / CVA Protocol (2.32)
• overdose – refer to Poisoning / Overdose Protocol (2.25)

Front 9

2.5 Anaphylaxis/ Allergic Reaction (Criteria)

Back 9

CRITERIA
• Respiratory distress (wheezing, stridor, or use of respiratory accessory muscles)
• Tongue, oropharynx, or uvular swelling
• Hives, itching, or flushing
• Signs of shock
• Auscultation of unusual/abnormal breath sounds (wheezing, stridor), or markedly decreased movement of air

Front 10

2.5 Anaphylaxis/ Allergic Reaction (Protocol)

Back 10

1. Routine medical care including oxygen saturation if available.
2. Assure airway patency and administer oxygen per protocol.
3. Assess signs, symptoms, and hemodynamic status.
4. If symptoms of shock, airway swelling or respiratory distress are present and:
• The patient has their own anaphylactic emergency kit, the provider may assist the patient in administering the
kit’s contents or
• If the BLS agency has completed registration as an EpiPen agency, the provider has been trained in its use
and an auto injector Epinephrine device (0.3 mg IM) is available, the provider may administer the device’s
contents.
If the patient has not had an epinephrine autoinjector previously prescribed, Medical Control
must be contacted before BLS may administer.
Use EpiPen Jr./Pediatric auto-injector (0.15 mg IM) for children under 30 kg (66 lbs).
Begin timely transport. If Epinephrine has been given, ALS must transport with the patient, but do not delay
transporting the patient while waiting for ALS.

Front 11

2.6 Apparent Life Threatening Event (ALTE) (Criteria)

Back 11

CRITERIA
• An episode in an infant or child less than 2 years old which is frightening to the observer and is
characterized by one or more of the following:
• Apnea (central or obstructive)
• Skin color change: cyanosis, erythema (redness), pallor, plethora (fluid overload)
• Marked change in muscle tone
• Choking or gagging not associated with feeding or a witnessed foreign body aspiration
• Seizure-like activity

Front 12

2.6 Apparent Life Threatening Event (ALTE) (Protocol)

Back 12

1. Routine medical care.
2. Assure airway patency and administer oxygen per protocol.
3. Timely transport to the emergency department. If the parent or guardian refuses medical care or transport, the
provider must contact Pediatric Medical Control. BLS cannot cancel ALS for ALTE.

Front 13

2.7 Avulsed Tooth Reimplantation (Criteria)

Back 13

CRITERIA
• Only reimplant permanent teeth
• Best chance for success is when reimplantation occurs less than 5 minutes from injury
• Do not reimplant if the alveolar bone / gingiva are missing or if the root is fractured
• Do not reimplant if the patient is immunosuppressed or reports having cardiac issues that require antibiotics
prior to procedures
• Do not reimplant if the patient requires spinal immobilization
• If not candidate for reimplantation, place tooth in interim storage media (low fat milk, patients’ saliva, or saline)
and keep cool. Avoid tap water storage but do not allow the permanent tooth to dry.

Front 14

2.7 Avulsed Tooth Reimplantation (Protocol)

Back 14

1. Routine medical care
2. Assure airway patency and administer oxygen per protocol
3. Assess signs, symptoms, hemodynamic status, and medical history
4. Consider need for spinal immobilization as appropriate (if spinal immobilization needed, do not reimplant)
5. Patients with an altered mental status should not be considered candidates for dental reimplantation
6. Hold the tooth by the crown
7. Quickly rinse the tooth with saline before reimplantation but do not brush off or clean tooth of tissue
8. Rinse and suction the clot from the socket
9. Reimplant tooth firmly into socket with digital pressure
10. Have the patient hold tooth in place using gauze and bite pressure
11. Report to hospital staff the efforts made to reimplant tooth

Front 15

2.8 Behavioral Emergencies (Criteria)

Back 15

CRITERIA
Any patient who demonstrates potentially violent behavior regardless of underlying diagnosis, who continues to
resist against appropriately applied restraints, and needs facilitation of physical restraint. In all cases, consider
staging until law enforcement is present.

Front 16

2.8 Behavioral Emergencies (Protocol)

Back 16

CAUTION
Agitation may signal a physiologic deterioration of the patient and accompany hypoxia, hypoglycemia, cerebral
edema, or other medical problems. Treatment of medical disorders should always be done prior to any chemical
restraint.
1. Assess mental, emotional, and physical status thoroughly including all other potential causes of aggressive
behavior. Other causes should be treated first, which may be sufficient to resolve the aggressive behavior.
2. Attend to medical or trauma needs as per protocol.
No patient will be transported without law enforcement presence if his or her emotional or mental status poses a threat
to patient or crew safety.
Follow ‘Management of Violent and Potentially Violent Behavior’ procedures (Policy 9.3). If unable to manage with
physical restraints, consider chemical restraints below.

Front 17

2.9 Burns (Criteria)

Back 17

1. Remove patient from source of burn – heat source, chemicals, electricity source etc. Precautions should be taken
to prevent injury to the rescuers. Only trained personnel should perform high-risk rescue procedures as
appropriate. Decontamination measures should be taken as appropriate.
2. Assure airway patency and administer high flow oxygen.
3. Stop burning process by application of water, except in case of elemental metal burn. Dry chemicals should be
brushed away as much as possible before water is applied. In most cases 5-10 minutes is sufficient, although
longer periods may be needed for hot grease, asphalt or chemicals. Burns from sodium metal, potassium metal,
phosphorus, etc. should not be flushed with water, but instead should be covered with dry sterile dressings to
prevent both air and water from making contact with the area. Remove jewelry and clothing as appropriate.
4. Apply dry sterile dressings. Take other measures to keep the patient warm as needed.
5. Timely transport with early notification to emergency department if patient unstable, possibility of airway obstruction
exists, or extensive burns. Transport to burn center for:
• Burns compromising patient’s airway
• Burns of face, hands, feet, joints, perineum or genitalia
• Circumferential burns
• 20% total of 2nd / 3rd degree burns
• 5% 3rd degree burns
• Significant chemical burns

Front 18

2.10 Chest Pain / Threatened Myocardial Infarction (Criteria)

Back 18

CRITERIA
Patient with non-traumatic chest pain or other indications of possible Myocardial Infarction (shortness of breath,
nausea, diaphoresis, etc)
1. Routine medical care.
2. If systolic BP > 120 mmHg and HR > 50 and < 130 bpm, may assist patient with taking own nitroglycerin tablets.
If systolic BP remains > 120 mmHg, one tablet may be taken sublingually every 3-5 minutes up to total of 3 doses.

Front 19

2.10 Chest Pain / Threatened Myocardial Infarction (Protocol)

Back 19

CAUTION
Avoid Nitroglycerin in patients who have taken erectile dysfunction medication (Viagra™, Levitra™, or Cialis™) in
the past 72 hours
3. Aspirin 324 mg (if not already taken or contraindicated by allergy or active bleeding):
4 tablets 81 mg each should be chewed and swallowed for total dose of 324 mg.

Front 20

2.11 Chest Trauma (Protocol)

Back 20

1. Routine medical care.
2. Assure airway patency and administer high flow oxygen.
3. Stabilize but do not remove penetrating objects. Use occlusive dressing to seal sucking wounds on 3 sides only –
leave open on 4th side. Stabilize flail segments.
4. If signs/symptoms of tension pneumothorax present:
Remove occlusive dressing from sucking wound (if present).
5. Timely transport with early notification to hospital

Front 21

2.12 Conducted Energy Weapons (Criteria)

Back 21

CRITERIA
Conducted Energy Weapons (also referred to as Electronic Control Devices, Conducted Energy Devices, etc) are used
by law enforcement as an alternative to ballistic devices and other physical force in order to gain compliance with a noncooperative
person. These devices send an electrical charge of up to 50,000 volts per pulse with 12 to 20 pulses per
second up to five seconds per cycle. The electrical current is about 2.1-3.5 milliamps. The delivered energy is between
0.7 to 1.76 joules. The number of discharges and the duration of discharges can be controlled by the operator. The
discharge can either be through probes fired from the device with a range of up to 35 feet or with a contact discharge
where the device is held against the subject. Either method will work through clothing. Either method uses electricity to
cause the skeletal muscles between the probes to contract and release rapidly preventing voluntary control of the
affected muscles. The device may cause a brief altered mental status, but subjects regain normal mentation and
muscle control almost immediately, although some subjects may take up to a minute to recover.

Front 22

2.12 Conducted Energy Weapons (Protocol)

Back 22

1. Assure patient is appropriately restrained and not a danger to care providers.
2. Assess patient for problems and treat as per appropriate protocol. The device does not cause an altered mental
status. Any altered level of consciousness must be assessed and treated in accordance with the Altered Mental
Status Protocol (2.4).
3. Assess patient for high-risk criteria. Most patients who have been exposed to a CED will be in police custody and
treatment decisions should be a cooperative venture. Presence of one or more of the following risk factors indicates
need for an ALS response and transport to an Emergency Department is encouraged:
• Known cardiac history including pacemaker/implantable defibrillator
• Known seizure disorder
• Pregnancy
• Altered mental status
• Extended physical struggle including multiple discharges or cycles
4. The barbs that contact the patient have an end that is similar to a fishhook and may imbed as much as 1.5 cm. To
remove the probe, stabilize the soft tissue around area with a gloved hand and remove the probe by pulling
outward. If there is resistance when removing the probe,

Front 23

2.13 Croup (Criteria)

Back 23

CRITERIA
• History consistent with upper respiratory infection
• Difficulty / inability to speak or presence of stridor

Front 24

2.13 Croup (Protocol)

Back 24

1. Routine medical care.
2. Assure airway patency and administer humidified high flow oxygen.
CAUTION
If possibility of epiglottitis, airway should not be stimulated or examined and Medical Control should be contacted
before other treatment is undertaken.
3. Timely transport.

Front 25

2.14 Diabetic Emergencies (Protocol)

Back 25

1. Routine medical care.
2. Assure airway patency and administer oxygen per protocol.
3. Assess signs, symptoms, medical history, and blood glucose (BG), if available.
4. If patient has BG < 80 mg/dL, appears hypoglycemic, or if you are unsure if patient is hypoglycemic:
If patient is able to speak coherently, offer any form of available sugar (non-diet soda, candy, orange juice, granular
sugar, or glucose gel).
5. All patients on oral hypoglycemic medications or long-acting insulin, who have been treated for potential
hypoglycemia, should be transported.
6. Treatment should not be withheld from patients with a stroke-like presentation, as this is likely due to hypoglycemia.

Front 26

2.15 Fluid Challenge / Replacement (Criteria/ Protocol)

Back 26

CRITERIA
• Medical hypovolemia due to dehydration:
• history consistent with decreased fluid intake and/or increased fluid loss
• decreased skin turgor or sunken eyeballs
• sinus tachycardia not clearly explained by other causes
• orthostatic changes: either patient becomes dizzy when standing, or pulse increases by >20 bpm
• Shock due to trauma or other causes (see appropriate protocol)

Front 27

2.16 Head Trauma (Protocol)

Back 27

1. Routine medical care.
2. Spinal immobilization. Patient’s head should not be lower than the body.
3. Assure airway patency and administer oxygen per protocol.
4. If BVM ventilation needed, ventilations should be slow and steady at a constant rate of 10 breaths per minute.
5. Timely transport with early notification to emergency department.

Front 28

2.17 Hyperthermia/ Heat Exhaustion / Heat Stroke (Criteria)

Back 28

CRITERIA
• Body temperature > 40.6 °C (105 ° F). Do not use tympanic thermometers.
• Infants and children, and frail, elderly, or chronically ill adults may show symptoms of hyperthermia at lower
temperatures than listed above. Patients on anticholinergic medications (Benadryl, Ditropan, Detrol,
haloperidol, amitriptyline, nortriptyline, etc) are prone to hyperthermia due to an inability to perspire.
• May be accompanied by CNS dysfunction (delirium, psychoses, coma, seizures), absence of sweating, pallor,
tachycardia, hypotension, cramping or tingling, nausea /vomiting, headache, dizziness.

Front 29

2.17 Hyperthermia/ Heat Exhaustion / Heat Stroke (Protocol)

Back 29

1. Routine medical care.
2. Assure airway patency and administer oxygen per protocol.
3. Assess signs, symptoms.
4. Remove patient from hot environment. Remove clothing.
5. Cool patient using whatever means immediately available:
• sprinkle or spray with fine water mist
• air conditioned ambulance, or fanning
CAUTION
Rapid cooling may cause shivering and vomiting
Wet sheets without air circulation will retain heat rather than dissipate it
Do not use alcohol to lower temperature
Do not delay transport to the hospital
6. Continue to monitor body temperature.

Front 30

2.18 Hypotension / Shock (Criteria)

Back 30

CRITERIA
• Inadequate tissue perfusion as evidenced by one or more of the following:
• poor peripheral pulses, or capillary refill > 2 sec
• altered mental status
• cyanosis, pallor, diaphoresis, cool skin
• dizziness, light-headedness, nausea or vomiting
• tachycardia (in conjunction with one or more other symptoms and suggestive history)
SHOCK MAY BE PRESENT EVEN IN THE PRESENCE OF A NORMAL BLOOD PRESSURE, PARTICULARLY IN
CHILDREN AND YOUNG ADULTS

Front 31

2.18 Hypotension / Shock (Protocol)

Back 31

1. Routine medical care.
2. Assure airway patency and administer oxygen per protocol.
3. Assess signs, symptoms, and medical history.
4. Consider treatable causes:
• Anaphylaxis - see Anaphylaxis Protocol (2.5)
• Dysrhythmia - see appropriate Protocol (Section 3 or 4)
• Hypoglycemia - see Diabetic Emergency Protocol (2.14)
• Hypovolemia - see #5-6 below
• Hypoxia - see Airway Management Protocol (2.0, 2.1)
• Neurogenic or septic shock - see # 5-7 below
• Trauma - see appropriate Trauma Protocol (Chest – 2.11, Head – 2.16)
5. Timely transport in supine position, or shock position if appropriate. Keep the patient warm by passive measures
including warm ambulance compartment temperature, but avoid hyperthermia.

Front 32

2.19A Hypothermia (Criteria)

Back 32

CRITERIA
• Body temperature < 35 °C (95 ° F)
• Do not use tympanic thermometers.

Front 33

2.19A Hypothermia (Protocol)

Back 33

1. Routine medical care.
2. Move out of cold environment. Gently remove wet clothing, cover with blankets and otherwise protect from further
heat loss.
3. Assure airway patency and administer oxygen per protocol (with warm moist air if possible).
4. Maintain horizontal position.
5. Avoid rough handling during patient movement.
6. Timely transport (goal of <15 minute scene time).
7. Monitor temperature; assess cardiopulmonary status, and presence of other factors such as trauma, drug usage,
etc. Heart rates should be assessed for at least 1 full minute.
8. If temp is 30-35°C (86 - 95°F), gentle re-warming measures may be instituted (heated ambulance).
9. Assess BG (BLS if available). If hypoglycemic, see Diabetic Emergencies Protocol (2.14).

Front 34

2.19B Hypothermic Cadiac Arrest (Protocol)

Back 34

1. Institute CPR.
NOTE
Pharmacological and electrical interventions are often ineffective in severe hypothermia, and should be used only
with extreme caution.
2. Defibrillate once if shock advised.

Front 35

2.20 Nausea / Vomiting (Criteria)

Back 35

CRITERIA
Patient with uncontrolled nausea/vomiting and no evidence of head injury:

Front 36

2.20 Nausea / Vomiting (Protocol)

Back 36

1. Attempt to treat cause of the nausea

Front 37

2.21 Near-Drowning (Protocol)

Back 37

1. Routine medical care.
2. Assure airway patency, and administer oxygen per protocol.
3. If patient is pulseless and apneic, refer to Cardiac Arrest Protocols (3.0, 3.1, 4.0 and 4.1).
4. Initiate spinal immobilization precautions and trauma care as appropriate; see Spinal Immobilization Protocol (2.33).
5. Treat hypothermia (even in warm water drowning or warm environmental conditions) - see Hypothermia Protocol
(2.19A).
6. All patients should be transported for evaluation.
7. Unless contraindicated, transport patient in lateral recumbent position.
NOTE
Heimlich maneuver is contraindicated for the removal of water from the lungs.

Front 38

2.22 Neonatal Resuscitation (Criteria)

Back 38

CRITERIA
• The primary concerns of newborn resuscitation are adequate oxygenation, airway patency,
and warmth.
• Signs of inadequate oxygenation include:
• Quiet, not crying
• No response to tactile stimulation
• Diffuse, dark cyanosis over entire body (Initial cyanosis should "pink up" rapidly)
• Respiratory rate < 20 rpm
• Pulse rate < 100 bpm
• Flaccid, non-moving extremities
• Supplemental oxygenation (when needed) may be provided by holding mask near or on face:

Front 39

2.22 Neonatal Resuscitation (Protocol)

Back 39

1. Suction only if BVM is used.
2. Keep baby at level of vagina until umbilical cord is cut. Cord should be clamped and cut 30-45 seconds after birth.
3. Dry baby, warm with blankets, provide tactile stimulation. Environment should be warm.
4. If respirations < 30 rpm or heart rate < 100 bpm
Ventilate with 100% oxygen using neonatal or small child bag-valve mask at a rate of 40-60 breaths per minute.
5. If heart rate < 60 bpm
Begin chest compressions at rate of 120 per minute utilizing a compression/ventilation ratio of 3:1. Begin timely
transport.

Front 40

2.23 Obstetric Emergencies (Protocol)

Back 40

1. Routine medical care. Administer oxygen per protocol.
2. Assess signs, symptoms, and obstetric history.
3. If delivery imminent:
• Allow baby to deliver spontaneously.
• Support infant, but do not attempt to retard or hasten delivery.
• Begin timely transport with ALS transport/intercept if possible, but do not delay transport to wait for ALS.
• Contact Medical Control as necessary for instructions and destination.
• For routine deliveries, preference hospital affiliated with maternal Ob/Gyn physician
4. Check for nuchal cord.
5. Clamp cord in two places 8-12" from infant; cut cord between clamps.
6. Assess infant and proceed with neonatal resuscitation - see Neonatal Resuscitation Protocol (2.22)
7. Do not wait for delivery of placenta to begin transport. If the placenta delivers spontaneously, bring to hospital in
plastic bag. Do not pull on cord under any circumstances.
8. After delivery of placenta, massage uterus as needed for control of maternal hemorrhage.
9. If mother is hypotensive, refer to Hypotension/Shock Protocol (2.18) as needed.

Front 41

2.24 Pain Management (Protocol)

Back 41

1. Routine medical care. If pain is secondary to a burn, refer to Burn Protocol (2.9).
2. Assure airway patency. Administer oxygen per protocol.
3. Apply pain relief measures such as splinting, positioning, ice packs, etc. as appropriate.

Front 42

2.25 Poisoning/ Overdose (Criteria)

Back 42

CRITERIA
• Suspected or actual overdose of patient’s prescribed medications - accidental or intentional.
• Suspected or actual ingestion/injection of non-prescribed medications - accidental or intentional.
• Exposure to potentially toxic substance - ingestion, inhalation, dermal contact, etc.

Front 43

2.25 Poisoning / Overdose (Protocol)

Back 43

1. Routine medical care with transport in left lateral recumbent position if oral ingestion.
2. Assure airway patency and administer oxygen per protocol.
CAUTION
If carbon monoxide inhalation or inhalation injury, patient must be on 100% oxygen
3. Assess signs, symptoms, hemodynamic status, type, time and amount of poisoning. If possible, bring poison
container to hospital.
4. Poison control may be contacted for management advice, however all treatment orders must come from on-line
Medical Control.
5. If orally ingested poison less than one hour old in an alert patient who is able to protect their airway AND if
directed by Medical Control:
Sorbitol-free Activated Charcoal 50 g PO
Sorbitol-free Activated Charcoal 2 g/kg PO (Max 50 g)

Front 44

2.26 Pulmonary Edema / CHF (Criteria)

Back 44

CRITERIA
• Dyspnea/Tachypnea
• Rales/wheezing
• Pink, frothy sputum may be present or absent

Front 45

2.26 Pulmonary Edema / CHF (Protocol)

Back 45

1. Routine medical care.
2. Assess signs, symptoms and hemodynamic status.
3. Position patient with head elevated (High Fowlers).
4. Initiate oxygen therapy.
5. If inadequate respirations or decreased level of consciousness, consider use of BVM.
6. Begin timely transport.

Front 46

2.28 Re-Establishing Patient Medication IV (Criteria and Protocol)

Back 46

CRITERIA
• Adult or Pediatric patient with life-sustaining IV treatment which cannot be discontinued for a brief time without
major consequences (See list of allowed drugs below)
• IV/Central line infiltrated or pulled out with no other means of rapid IV access
1. Routine medical care as appropriate and transport to appropriate hospital. Bring bag of patient medication to hospital
if available and alert Medical Control that patient is en route.

Front 47

2.29 Respiratory Distress / Bronchospasm (Criteria)

Back 47

CRITERIA
• Oxygen saturation < 92%
• Cyanosis
• Respiratory rate < 8 rpm or > twice normal for age
• Use of accessory muscles for respiration
• Auscultation of adventitious breath sounds (wheezing, stridor), or markedly decreased air movement

Front 48

2.29 Respiratory Distress / Bronchospasm (Protocol)

Back 48

1. Routine medical care including ensuring airway patency and administering high flow oxygen.
2. Assess signs, symptoms and hemodynamic status including vital signs, ability to speak in sentences, presence of
accessory muscle use or wheezing.
3. If patient has own inhaler / nebulizer, may assist patient to use the device.
4. If patient is between 1 and 65 years of age and
• has physician diagnosed asthma with previously prescribed use of Albuterol, and
• agency approved for Albuterol use with a provider trained in Albuterol administration:
Albuterol 5 mg by nebulizer, if available, may repeat x1 if ALS still en route or not available
Albuterol 2.5 mg by nebulizer, if available, may repeat x1 if ALS still en route or not available
CAUTION
Medical Control should be contacted first (BLS Only) if patient has cardiac history (CHF, angina,
arrhythmias, previous AMI, etc)
5. Timely transport with ALS if available. (ALS can not release to BLS for transport after medication administration.)

Front 49

2.30 Sedation (Criteria and Protocol)

Back 49

CRITERIA
Any adult or pediatric patient who requires a painful therapeutic procedure or whose condition is interfering with
their clinical management including:
• Synchronized cardioversion
• Transcutaneous pacing
• Post-intubation sedation
CONTRAINDICATIONS
• Known history of hypersensitivity or other adverse reactions to the required medications
• Clinical condition or vital signs contraindicate the use of sedative medications
NOTE
For extremely agitated or combative patients, refer to Behavioral Emergencies Protocol (2.8)
All Sedation and Analgesia medications should be used with caution if MAP < 65 mmHg

Front 50

2.31 Seizures (Protocol)

Back 50

1. Routine medical care.
2. Assure airway patency and administer oxygen per protocol.
3. Assess signs, symptoms, and medical history.
4. Consider possible causes:
• Existing seizure disorder
• Toxic ingestion - see Poisoning / Overdose Protocol (2.25)
• Head Injury - see Head Trauma Protocol (2.16)
• Hypoglycemia - see Diabetic Emergencies Protocol (2.14)
• Eclampsia (if maternity patient beyond 20 weeks or up to 6 weeks after delivery)
5. If seizing, begin timely transport.
6. Assess BG (BLS, if available; mandatory for ALS) - If hypoglycemic, see Diabetic Emergencies Protocol (2.14).

Front 51

2.32 Stroke (Protocol)

Back 51

1. Routine medical care with evaluation of the Cincinnati Stroke Scale, which includes:
• Facial droop during smile
Normal = equal smile
Abnormal = one side moves less
• Arm drift (arms held straight for 10 seconds with eyes closed)
Normal = no movement or equal movement
Abnormal = 1 arm drifts or cannot lift arm against gravity
• Speech (“You can’t teach an old dog new tricks”)
Normal = correct words/ no slurring
Abnormal = slurred words / wrong words / no speech
Determine the time at which the patient’s symptoms began (abnormal speech, extremity weakness, numbness,
paralysis, facial droop, etc.)
2. Assure airway patency and administer oxygen per protocol.
3. Consider other causes for altered mental status – refer to Altered Mental Status Protocol (2.4).
4. Assess blood glucose (BLS if available). If hypoglycemic, refer to Diabetic Emergencies Protocol (2.14).
Do not withhold treatment for hypoglycemic patients who present with stroke-like symptoms
5. Timely transport. If patient fulfills following criteria, contact Medical Control of a Stroke Center* and advise of a
“Stroke Alert” by providing appropriate clinical information to the Medical Control Physician:
• One or more abnormal findings on Cincinnati Stroke Scale (see above) AND
• Symptoms for <5 hours AND
• Blood Glucose >80 mg/dl

Front 52

2.33 Suspected Spinal Injuries (Criteria and Protocol)

Back 52

1. Patients with mechanism capable of producing spinal injuries meeting any of the following criteria must immediately
receive spinal immobilization:
Age
Patients < 8 or > 65 years old
Medical History
Patient’s with Down Syndrome History of spinal tumors
History of degenerative bone disorders History of spina bifida
Mechanism of Injury
Death of passenger in same compartment Motorcycle crash
Falls greater than standing height Vehicle versus bicycle >5 mph
Vehicle-pedestrian collision Axial load (diving injury, spearing tackle)
Patient ejection Vehicle rollover
Collision >20 mph with 12 inches deformity to vehicle
Physical Findings
HR < 50 or > 120 bpm SBP < 90 mmHg
RR < 10 or > 28 bpm GCS < 15
Burns >15% BSA or facial/airway burns Two or more proximal long bone fractures
Trauma of two or more body systems Flail Chest
Amputation (except digits)
2. Patients not meeting any of the above criteria should be assessed for the following. If any are present, the patient
must receive spinal immobilization.
• Altered Mental Status for any reason, including possible intoxication from alcohol or drugs (signs of poor
judgment, GCS <15 or AVPU other than A).
• Complaint of neck and/or spine pain or tenderness.
• Weakness, tingling, or numbness of the trunk or extremities at any time since the injury.
• Deformity of the spine not present prior to this incident.
• Distracting injury or circumstances (i.e. anything producing an unreliable physical exam or history).
3. Provide routine care per relevant protocol.
NOTE
Once spinal immobilization has been initiated (i.e. extrication collar placed on patient) spinal immobilization
MUST be completed and may not be removed in the prehospital setting.

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2.37 VENTRICULAR ASSIST DEVICES (Criteria)

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CRITERIA
Any request for service that requires evaluation and transport of a patient with a Left Ventricular Assist Device
(VAD)

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2.37 VENTRICULAR ASSIST DEVICES (Protocol)

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1. Assess airway and breathing. Treat airway obstruction or respiratory distress per protocol. Treat medical or
traumatic condition per protocol.
2. Assess pump function and circulation:
• Listen to motor of pump over heart and observe green light on system control device.
• Assess perfusion based on mental status, capillary refill, and skin color. The absence of a palpable pulse is
normal for patients with a functioning VAD. They may not have a blood pressure.
• DO NOT PERFORM CPR.
3. Perform secondary assessment, treat per protocol.
4. Notify URMC Heart Failure Coordinator ASAP, regardless of the patient’s complaint.
Call 1-800-892-4964 and declare a “VAD EMERGENCY”
5. Bring patient’s power unit and batteries to the Emergency Department. Unless otherwise directed by Medical
Control, transport patient to URMC-Strong Memorial Hospital.
6. Trained support member must remain with patient.
7. Do not delay transport to hospital.

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2.38 Crush Injuries (Criteria)

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CRITERIA
• Crushed extremities distal to the axilla and iliac crest.
• Entrapped body parts may not have suffered crush injuries
• Prolonged and continuous heavy pressure to any portion of the body

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2.38 Crush Injuries (Protocol)

Back 56

1. Routine Care (1.0)
2. Ensure patent airway and support oxygen/ventilation per protocol 2.0 or 2.1
3. Spinal Immobilization as indicated per protocol 2.33
4. Consider Pelvic splinting
5. Conserve Body Heat
6. Consider placement, but not tightening of tourniquet on extremity
a. Be prepared for significant bleeding
b. Tighten if directed by Medical Control or Paramedic
7. Hypotension and shock treatment per protocol 2.18

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2.39 Cyanide (Criteria)

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CRITERIA
• Known or suspected exposure to cyanogenic compound due to combustion or chemical process.
• Signs and symptoms including any of the following:
a. Tachypnea
b. Tachycardia
c. Central and peripheral cyanosis
d. Throbbing headache
e. Hypotension
f. Syncope
g. Weakness
h. Agitation
i. Seizures
j. Cardiac arrest

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2.39 Cyanide (Protocol)

Back 58

1. Routine Standing Orders.
2. Rapid transport once necessary decontamination completed. Transport patients who have ingested cyanide salts in
vehicles with windows open and/or good ventilation.
3. Mild exposures with conscious and alert patients should be given oxygen and observed for signs and symptoms.
No antidotes should be administered for mild exposure.