(cardiac) Paramedic Protocols.pdf

The Charlotte Hungerford Hospital

Department of Emergency Medicine

Division of EMS

Sponsor Hospital Program

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Paramedic

Protocols

Revised 2005

Charlotte Hungerford Hospital Department of Emergency Medicine

PARAMEDIC PROTOCOL 2

IMPORTANT CAUTION

The information contained in these protocols is compiled from sources believed to be reliable and

significant efforts have been expended to make sure there are no inaccuracies. However, this

cannot be guaranteed. Despite our best efforts there may be typographical errors or omissions.

The Region V EMS Council or Medical Advisory Committee is not liable for any loss or damage

that may result from these errors.

ON-LINE MEDICAL DIRECTION

It is agreed upon in Region V that prehospital providers will contact the receiving hospital

regarding obtaining patient care orders.

COMMUNICATION FAILURE

In the event of complete communication failure, these protocols will act as the parameters for pre-

hospital patient care. If communication failure occurs the EMT-Paramedic (EMT-P) may follow

the guidelines to render appropriate and timely emergency care to the patient.

Upon arrival at the receiving hospital the EMT-P will immediately complete an incident report

relating to the communication failure describing the events including the patient’s condition and

treatment given. This incident report must be filed with the EMT-P’s sponsor hospital EMS

Medical Director and/or EMS Coordinator within 24 hours of the event. A copy of the patient’s

run form will also accompany the incident report.



Table of Contents

Subject Pages

Adult Cardiac 4-12

Adult Respiratory 13-19

Adult Medical 20-43

Adult Trauma 44-61

OB/GYN Emergencies 62-71

Pediatric Medical 72-90

Pediatric Trauma 91-101

Appendix A: Procedures 102-114

Rule of 9’s 115&116

Appendix B: Pharmacology 117-153

Appendix C: Spinal Assessment

and Immobilization Criteria

154




Paramedic Protocols

Cardiac Protocols



Description of Chest Pain

Cardiac disease can manifest itself in several ways. When assessing a patient suspected of suffering

cardiac disease, the paramedic should note each presenting complaint and obtain a history appropriate to

the presenting symptom. Common presenting symptoms of cardiac disease include:

• Chest pressure or discomfort

• Shoulder, neck or jaw pain

• Dyspnea

• Syncope

• Palpitations

Chest pain or discomfort is a common presenting symptom of cardiac disease. Chest pain is the most

common presenting symptom of myocardial infarction. When confronted by a patient with chest pain,

obtain the following essential elements of the history:

• Specific location of the chest pain (midsternal, etc.)

• Radiation of pain, if present (e.g., to the jaw, back, or shoulders)

• Duration of the pain

• Factors that precipitated the pain (exercise, stress, etc.)

• Type or quality of the pain (dull or sharp)

• Associated symptoms (nausea, dyspnea)

• Anything that worsens, intensifies or alleviates the pain (including medications, moving or

a deep breath)

• Previous episodes of a similar pain (e.g., angina)

It is important to remember that chest pain has many causes other than cardiac disease. The history,

therefore, is an important determining factor.

Shoulder, arm, neck, or jaw pain or discomfort may also be an indicator of cardiac disease. Any of these

may occur with or without associated chest pain, especially in older patients or patients with diabetes. If

the patient has any of these symptoms and you suspect heart disease, obtain information similar to that

described above for chest pain.



Ischemic Cardiac Chest Discomfort

1. Oxygen Therapy (90-100%)

2. Aspirin 325mg or Baby Aspirin 4 tabs PO (81mg each); unless patient is allergic, on

coumadin, or with a history of ulcerative disease

3. Cardiac Monitor and 12 lead EKG

4. Establish IV NS @ KVO

5. Consider and inquire about Viagra use within 6 hours: If used do not administer

Nitroglycerin products.

6. Nitroglycerin (NTG) 0.4mg (1/150 gr.) sublingual or NTG spray (1) metered dose if B/P >

100 systolic

7. May be repeated every 5 minutes to a total of 3 doses, until symptom free or SB/P <100

8. Morphine Sulfate 1 to 4mg IVP

Establish Medical Control Possible Physician Orders:

� Morphine Sulfate 1-4mg (up to 10mg) IVP, titrate to effect

� Nitropaste 1 inch topically

� Additional sublingual Nitroglycerine

� Hold if SB/P <100



Routine Cardiac Arrest Care

1. Assess patient’s (ABC’s)

2. Initiate CPR

3. Ventilate with Bag-Valve-Mask at 100%

4. Determine rhythm via quick look

5. Proceed to appropriate algorithm

6. Any changes in rhythm, follow appropriate protocol

NOTE: The following patient care guidelines are based upon the current American Heart

Association Guidelines for Advanced Cardiac Life Support 2000. Where there are notations that

refer to footnotes or additional information - please consult the AHA -ACLS 2000 Emergency

Cardiac Care Manual and note that specific algorithm.



Asystole Algorithm

ASYSTOLE

↓

Primary ABCD Survey

Focus: basic CPR and Defibrillation

•Check Responsiveness

•Activate emergency response system

•Call for defibrillator

A Airway: Open the airway

B Breathing: Provide positive pressure ventilation

C Circulation: Give chest compressions

C Confirm true asystole

D Defibrillation: Assess for VF/ pulseless VT; shock if indicated

Rapid scene survey: is there any evidence that personnel should not attempt resuscitation (eg,

DNR order, signs of death)?

↓

Secondary ABCD Survey

Focus: more advanced assessments and treatments

A Airway: Place airway device as soon as possible

B Breathing: Confirm airway device placement by exam plus confirmation device

B Breathing: Secure airway device; purpose made tube holders preferred

B Breathing: Confirm effective oxygenation and ventilation

C Circulation: Confirm true asystole

C Circulation: Identify rhythm → monitor

C Circulation: Give medication appropriate for rhythm and condition

D Differential Diagnosis: search for and treat identified reversible causes

↓

Transcutaneous pacing:

If considered perform immediately

↓

Epinephrine

1mg IV push, repeat every 3-5 minutes

↓

Atropine

1mg IV, repeat every 3-5 up to a total

of 0.04mg/kg

↓

Consider ceasing resuscitation efforts

(see appendix for “Termination of Resuscitation”).



Bradycardia Algorithm

· Assess ABCs · Assess vital signs

· Review history · Review history

· Administer oxygen · Perform physical examination

· Obtain IV access · 12-Lead if possible

· Monitor

Bradycardia, either absolute

(<60beats/min) or relative

Serious signs or symptoms?a,b

No Yes

Type II second-degree Intervention sequence

A-V heart block? · Atropine 0.5-1.0mgc,d

(I and IIa)

Or · Transcutaneous pacing (I)

Third-degree AV heart block?e · Dopamine 5-20µg/kg/min (IIb)

· Epinephrine 2-10µg/min (IIb)

No Yes

Observe Pacer in place / standby

Establish Medical Control

Possible Physicians Orders

Transcutaneous pacing

Note: If patient has chronic renal failure contact Medical Control for a possible order of

Calcium Chloride 1Gm IV and/or Sodium Bicarbonate 1meg/kg.

If patient is on beta-blockers or possible beta-blocker overdose contact Medical Control for a

possible order of Glucagon 2mg IV.



Pulseless Electrical Activity

Pulseless electrical activity (PEA)

includes the following:

· Electromechanical dissociation (EMD)

· Pseudo-EMD

· Idioventricular rhythms

· Ventricular escape rhythms

· Bradyasystolic rhythms

· Postdefibrillation idioventricular rhythms

• Continue CPR

• Intubate at once

• Obtain IV access

• Assess blood flow using end-tidal CO2 detector

Consider possible causes (possible therapies and treatments are given in parentheses)

·Hypovolemia (volume infusion) ·Drug overdoses, i.e.: tricyclics,

·Hypoxia (ventilation/O2) digoxin ß-blockers, etc.

·Cardiac tamponade (volume infusion) ·Hyperkalemiaa

·Tension pneumothorax (needle ·Acidosisb

decompression) ·Massive myocardial infarction

·Hypothermia

·Pulmonary embolism (O2, STAT transport)

• Epinephrine 1mg IVP,a,c

repeat 3-5 minutes

• If absolute bradycardia (<60 beats/min) or

relative bradycardia, give Atropine 1mg IVP

• Repeat Atropine 3-5 minutes to a total

doses of 0.03-0.04mg/kgd

Ventricular Fibrillation/Pulseless Ventricular Tachycardia Algorithm



Primary ABCD Survey

Focus: basic CPR and defibrillation

• Check responsiveness

• Activate emergency response system

• Call for defibrillator

A Airway: open the airway

B Breathing: provide positive-pressure ventilations

C Circulation: give chest compressions

D Defibrillation: assess for and shock VF/pulseless VT, up to 3 times

(200J, 300J, 360 J, or equivalent biphasic) if necessary.

↓ Rhythm after first 3 shocks?

↓

Persistent or recurrent VF/VT

↓ Secondary ABCD Survey • Epinephrine 1 mg IV push, repeat every 3 to 5

minutes

Focus: more advanced

assessments and treatments

or

• Vasopressin 40 U IV, single dose, 1 time only

A Airway: place airway ↓

device as soon as possible Resume attempts to defibrillate

B Breathing: confirm airway

device placement by exam 1 X 360 J (or equivalent biphasic) within 30 to 60

seconds

plus confirmation device.

B Breathing: secure airway

device; purpose-made tube

holders preferred.

B Breathing: confirm

effective oxygenation and

ventilation

Consider antiarrhythmics:

• Amiodarone (IIb for persistent or recurrent

VF/pulseless VT) *

• Lidocaine (Indeterminate for persistent or recurrent

VF/pulseless VT)

C Circulation: establish IV

Access • Magnesium (IIb if known hypomagnesemic

state)

C Circulation: identify

rhythm →→→→ monitor

C Circulation: administer

drugs appropriate for

rhythm and condition

D Differential Diagnosis:

• Procainamide (Indeterminate for persistent

VF/pulseless VT; IIb for recurrent VF/pulseless

VT

* The medical directors of Region 5 have elected

not to use Amiodarone in this protocol

Search for and treat

identified reversible causes

Resume attempts to defibrillate

Tachycardia



Evaluate patient

•Is patient stable or unstable?

•Are there serious signs or symptoms?

•Are signs and symptoms due to tachycardia?

Stable or Borderline Unstable*

Stable patient: no serious signs or symptoms

• Initial assessment identifies 1 of four types of

tachycardias

Unstable patient: serious signs or symptoms*

• Establish rapid heart rate as cause of signs

and symptoms

•Rate related signs and symptoms occur at

many rates, seldom <150 bpm

• Prepare for immediate cardioversion

100j, 200j, 300j, 360j for VT, PSVT, A-Fib, A-

Flutter

1. Atrial

Fibrillation

>150 BPM

12-Lead if Possible

Establish Medical

Control

Diltiazem (0.25mg/kg)

15-25mg slow IV push

4. Stable

monomorphic

and/or

polymorphic

VT

Lidocaine 1-1.5mg/kg

slow IVP may repeat in

5-10 min @ 0.5-0.75

Follow with drip

Establish Medical

Control

Procainamide

20mg/min IV

2. Narrow

Complex

Tachycardia

12-Lead if Possible

Vagal Stimulation

Adenosine 6mg rapid

IVP with 30cc rapid

flush; if no response

Adenosine 12mg x1

(12mg)

Contact Medical

Control

Diltiazem (0.25mg/kg)

15-25mg Slow IVP

3. Stable wide

complex

tachycardias:

unknown type

>140 bpm

Adenosine 6mg rapid

IV followed by 30cc

rapid flush

Lidocaine 1-1.5mg/kg

slow IVP may repeat in

5-10 min @ 0.5-0.75

mg/kg

Follow with IV Drip

Contact Medical

Control

* Unstable conditions must be related to the tachycardia. Signs and symptoms may include: chest pain,

shortness of breath, decreased level of consciousness, low B/P, shock, CHF, pulmonary congestion, and

AMI

• NOTE: Carotid sinus pressure is contraindicated in patients with carotid bruits or the elderly.




Paramedic Protocols

Respiratory Protocols



OXYGEN THERAPY

1. GENERAL ADULT PATIENTS:

NO PATIENT IN RESPIRATORY DISTRESS IS TO BE DENIED OXYGEN THERAPY

All Priority 1 and 2 patients should be administered oxygen in a concentration of 100% until

medical control can be contacted.

2. CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) PATIENTS:

Institution of oxygen therapy with COPD patients shall be as follows:

1. Priority 1 or 2 patients who do or do not demonstrate shock or shock-like symptoms should be

administered oxygen concentrations of 100% via appropriate facemask until medical control can be

contacted. *

2. Patients who can not tolerate a facemask may be given oxygen via nasal cannula at 4-6 liters/min.

3. Priority 3 patients who are not in respiratory distress, who are on home oxygen therapy, should

continue at the same concentration consistent with their home does.

* If a patient is not breathing adequately on his own, the treatment of choice is VENTILATION, not just

oxygen.

Note: Monitor closely the patient receiving high concentrations of oxygen for signs of decreased level of

consciousness and/or increased respiratory distress. Be prepared to provide ventilations if

indicated.



ACUTE PULMONARY EDEMA

1. Assess ABCs

2. Oxygen Therapy (90-100%)

3. IV Normal Saline at KVO

4. If Systolic Blood Pressure >120 mmHg Nitroglycerin 0.4mg (1/150 gr.) SL*

5. May repeat every 3-5 minutes prn

6. If SBP<120 Establish Medical Control

7. Lasix 40 mg IVP

If patient usually takes Lasix and they have NOT taken their daily dose,

the paramedic may administer 2x their usual daily does up to 200 mg slow IVP.

8. Establish Medical Control

Possible Physician Orders:

9. Nitropaste 1-2” topically

10. Repeat SL Nitroglycerin

11. Repeat Lasix

12. Morphine Sulfate 2-5 mg IVP

13. CPAP see protocol

* SL = this may be either metered dose spray or tablet that dissolve under the tongue.

Note: Morphine may cause respiratory depression. Be prepared to assist ventilations or intubate

as indicated.

CHF Vs Pneumonia: if the clinical impression is unclear and transport time is not prolonged, consider

using nitroglycerin and withhold furosemide (Lasix) or contact Medical Control.



Continuous Positive Airway Pressure (CPAP)

The application of continuous positive airway pressure by facemask.

Indications:

Hypoxemia secondary to Congestive Heart Failure and Acute Cardiogenic Pulmonary Edema. For relief

of Hypoxemia and Shortness of Breath (SOB)/Dyspnea secondary to Pneumonia, Chronic Obstructive

Pulmonary Disease (Asthma, Bronchitis, Emphysema). An adequately, spontaneous breathing patient.

Follow pathology specific guideline for medication treatment

Contraindications:

� Respiratory Arrest

� Agonal Respirations

� Unconscious

� Shock associated with cardiac insufficiency

� Pneumothorax

� Penetrating chest trauma

� Persistent nausea/vomiting

� Facial Anomalies / Stroke Obtundation / Facial Trauma

Signs and Symptoms:

1. Dyspnea and Tachypnea.

2. Chest Pain, Hypertension, Tachycardia.

3. Anxiety, Restlessness, Altered L.O.C.

4. Rales and Often Wheezes, Frothy Sputum (severe cases)

Procedure:

1. Assess Vital Signs

2. Attach heart monitor and pulse oximeter

3. If BP <100 systolic contact Medical Control prior to beginning CPAP

4. Verbally instruct patient.

i. Patient requires “verbal sedation” to be used effectively.

a. Example: Patient: “I can’t get air in!” Care Giver: “This will help you get air

in.” “This will help you breath easier as the pressure on the machine is

increased”.

ii. Start CPAP at ambient pressure (‘0’ cmH2O).

iii. Instruct patient to breath in through their nose slowly and exhale through their mouth

as long as possible (count slowly and aloud to four then instruct to inhale slowly).

iv. Explain to the patient that you will begin to slowly increase the pressure and to

continue exhaling out against the pressure as long as possible before inhaling.

v. Slowly titrate the pressure to:

a. CHF/ACPE 10cmH2O

b. All other SOB/Dyspnea 5 cmH2O

5. Treatment should be given continuously throughout transport to ED.

6. Vital Signs q5 minutes.



Continuous Positive Airway Pressure

7. In the event of life-threatening complications:

� Stop treatment

� Offer reassurance

� Institute BLS/ALS support

� Adverse reactions to therapy are to be documented using an Occurrence

Report. The Paramedic should immediately notify Medical Control and

ED staff upon arrival

8. Documentation in the runsheet narrative should include:

a. CPAP level

b. FiO2 100%

c. O2% Sat. q5 minutes

d. Vital Sign q5 minutes

e. Effects/Adverse reactions



COMPLETE AIRWAY OBSTRUCTION

Conscious

1. Assess to determine airway obstruction

2. Perform Heimlich Maneuver for conscious patient

3. Continue Heimlich Maneuver until airway is cleared or

4. patient is rendered unconscious

Unconscious

1. Assess to determine unresponsiveness.

2. Attempt to establish airway to determine airway obstruction.

3. Perform Heimlich Maneuver for unconscious patient.

4. If airway is still obstructed perform direct laryngoscopy.

5. Removal of any foreign body is attempted using Magill Forceps.

6. If airway is still obstructed, endotracheal intubation is attempted.

7. If airway is still obstructed consider Transtracheal Ventilation.


9. Possible physician order to push object into Right Main Stem Bronchi if obstruction is below

cricoid membrane.



RESPIRATORY DISTRESS

Wheezing

A patient who is experiencing moderate to severe respiratory distress with a respiratory rate > 24 with

wheezing presumed to be reactive airway disease.

Routine Paramedic Care - Initiate treatment based upon history and clinical presentation. If respirations

begin to decrease in rate or depth with a change in mental status, begin to assist ventilations immediately.

All that wheezes is not Asthma

- a wise man

Asthma

1. Routine Paramedic Care

2. Oxygen per protocol

3. Establish IV Normal Saline at KVO

4. Albuterol nebulizer Treatment 2.5 mg in 2.5 ml NS

5. Consider: In Severe cases Atrovent 2.5cc nebulizer treatment 6. NOTE: Do NOT use Atrovent in patients with known peanut allergy

7. Albuterol and Atrovent may be combined (Combivent)

8. May repeat updraft x 2


10. Possible Physician Orders:

11. Epinephrine (1:1000) 0.3 mg (0.01mg/kg) SQ, or 0.3mg of 1:10,000 Slow IV*

12. Repeat Nebulizer updraft(s)

13. Solu-Medrol 125 mg Slow IVP

COPD - Emphysema

1. Routine Paramedic Care


3. Establish IV Normal Saline at KVO

4. Albuterol nebulizer treatment 2.5 mg (0.5cc) with 2.5cc Atrovent 0.4%

5. Combivent as above is acceptable

6. May repeat updraft x 2


Possible Physician Orders

8. Epinephrine (1:1000) 0.3 mg (0.01 mg/kg) SQ*

9. Repeat nebulizer treatment

* Use with caution with preexisting dysrhythmias, hypertension, cardiac history, or history of ischemic cardiac chest

pain, and patients over the age of 50.




Paramedic Protocols

Medical Protocols



ROUTINE ALS MEDICAL CARE

PURPOSE: All patients, after receiving their initial assessment and priority assignment, are to receive

routine medical care followed by the initiation of the appropriate protocol.

1. ABCs always first; Address life threats immediately per appropriate protocol

2. Maintain and protect airway, using adjuncts as necessary

3. Protect C-spine at all times if any possibility of injury


5. PATIENT ASSESSMENT

6. Develop a DIFFERENTIAL DIAGNOSIS. Avoid “tunnel vision” in your diagnostic impression !!

7. Place patient in position of comfort unless otherwise contraindicated

8. IV therapy as per protocol

9. Cardiac monitoring as appropriate for patient’s presentation

10. Initiate pulse oximetry monitoring

11. Treat the patient based upon appropriate patient care protocol based upon diagnostic impression

12. Obtain and record vital signs every:

a. 15 minutes for stable patient

b. 5 minutes for the unstable patient

c. After administration of medication or intervention

13. Destination hospital based upon patient condition, trauma regulation, request, or medical condition

14. Contact Medical Control as early as possible



PATIENT ASSESSMENT

PURPOSE: Each patient is to have an initial assessment as outlined in this section. Depending upon the

results of this patient assessment, the provider will advance to provide appropriate treatment.

Initial Patient Assessment

A. General Appearance

1. Age and sex

2. General state of health

3. Amount of distress (mild, moderate, severe)

B. Objective Signs

1. Level of consciousness: GCS/Trauma Score

2. Respiratory assessment

3. Skin: Temperature, color, moisture

4. Pupil status

5. Glasgow Coma Scale / Trauma Score if indicated

C. Vital Signs

1. Pulse: rate, quality, and rhythm

2. Respiratory rate, character of breath sounds

3. Blood pressure

4. Cardiac monitor finding where indicated

5. Pulse oximetry if available

D. History of Episode (obtained from patient, family, or observer)

1. Chief complaint

2. Time of incident or onset of symptoms

3. Prior treatment if related to present illness or injury

4. Mechanism of injury if trauma

E. Pertinent Medical History

1. Previous medical problems or conditions

2. Routine medications

3. Allergies

4. Last menstrual period? Pregnancy

F. Other Pertinent History

1. Social (substance abuse, smoker, violence, etc.)

2. Family (cardiac, diabetic, asthma)

3. Sexual (GxPx, LMP)

4. Systems review focused to presentation



Abdominal Pain

Assessment: Assessing a chief complaint of abdominal pain, can be one of the most difficult

tasks for the prehospital provider, due to the lack of CT scan or ultrasound for clinical diagnosis.

Abdominal complaints may be vague, nonspecific, and vary from patient to patient. Any patient

where hemorrhage is suspected should be treated for shock and transported immediately.

1. Routine BLS Care

2. Routine ALS Care


4. Establish IV of Normal Saline

Renal Colic (Kidney Stones)

Patient must have a history of Kidney Stones with similar symptoms

1. Morphine Sulfate: >50kg 2-5mg IV, IM, or SC (<50kg 0.1mg per kg diluted with 5cc normal

saline, administer over 3 minutes.)

2. Contact On-Line Medical Control

Possible Physician Orders:





ALLERGIC REACTION

DESCRIPTION

An allergic reaction is a hypersensitivity to a given antigen. It is usually not life threatening, merely

uncomfortable for the patient.

The patient is hemodynamically stable and complains of minor to moderate skin manifestation (erythema,

pruritus or urticaria) or mild inspiratory/expiratory wheezing.

ANAPHYLAXIS

DESCRIPTION

Anaphylaxis refers to the introduction of a foreign substance (antigen) into the body which, because of

patient sensitivity, produces a severe systemic reaction. This systemic reaction may include shock,

laryngospasm, angioedema, and/or respiratory distress. It can be fatal.

The patient may complain of respiratory symptoms, such as tightness in the chest, wheezing, or shortness

of breath. Other symptoms may include swelling, urticaria, nausea, vomiting, abdominal pain, or

diarrhea. These symptoms are due to the release of certain substances within the body, e.g., histamine,

SRSA (slow reactive substance of anaphylaxis) and bradykinin. Hypotension and bradycardia may also

result.

Anaphylaxis is a true emergency in that death may occur within minutes of the introduction of antigen.



ALLERGIC REACTION

Stable Hemodynamics (Blood pressure >90 mmHg systolic); with minor or moderate skin manifestations

and/or inspiratory/expiratory wheezing.

1. Oxygen as per protocol

2. Cardiac monitor

3. Establish IV with Normal Saline

4. Benadryl 1mg/kg IV or IM (max 50mg)

5. If wheezing is present:

6. Administer: Albuterol 0.5cc (2.5mg) via nebulizer


7. Possible Physician orders:

a. Epinephrine 1:1,000 0.3mg SQ

b. Solu-Medrol 125mg slow IVP

ANAPHYLACTIC SHOCK

Unstable Hemodynamics with hypotensive patient or impending upper airway obstruction; stridor; severe

wheezing and/or respiratory distress.

1. Airway management

2. Epinephrine 1:1,000 0.3mg SQ


4. Cardiac monitoring

5. IV Normal Saline titrated to a BP > 100 systolic

6. If patient remains unstable hemodynamically administer Epinephrine 1:10,000 0.3mg Slow IVP

or ET

7. Benadryl 1mg/kg Slow IVP (max. 50mg)

8. Albuterol 0.5cc via nebulizer for respiratory distress



a. Dopamine Drip

b. Repeat doses of Epinephrine

c. Epinephrine IV Drip (1mg mixed in 250cc of Normal Saline) run at 2-10

mcg/kg/min

d. Solu-Medrol 125mg slow IVP



ALTERED LEVEL OF CONSCIOUSNESS

DESCRIPTION

The arousability or wakefulness of a patient is described according to the patient’s response to various

types of verbal or painful stimuli. Various descriptions for these responses are used including, lethargic,

drowsy, stuporous, semicomatose, or comatose. Since interpretation of a single term can vary from one

person to another, it is always best to describe sensorium using the Glasgow Coma Scale or AVPU

system. A decreased level of consciousness at any of these levels is indication for following the

decreased level of consciousness protocol.

There are generally only two mechanisms capable of producing stupor or coma:

1. Structural lesions that depress consciousness by destroying or encroaching upon

the substance of the brain (trauma, tumor, hemorrhage).

2. Toxic-metabolic states involving either the presence of circulating toxins or

metabolites or the lack of metabolic substrates (oxygen, glucose, or thiamine);

these states produce diffuse depression of both cerebral hemispheres with or

without depression within the brainstem.

Protocol

1. Altered Mental Status: Unknown Etiology or Unresponsive

10. Routine ALS Care

11. Oxygen therapy

12. Assess level of consciousness according to Glasgow Coma Scale

13. IV Normal Saline @ KVO with blood draw and diagnostic blood glucose level

14. Thiamine 100mg IVP

15. Dextrose 50% 25 Gm IVP if blood glucose level is <70.

16. When IV access is unavailable administer Glucagon 1.0 mg IM

17. Narcan (Naloxone) 1-2 mg IntraNasal (IN) or

18. Narcan 0.4-2.0 mg IVP or IM / ET



a. Additional Dextrose and/or Narcan



2. Opiate Overdose Strongly Suspected

1. Routine ALS Care

2. Oxygen therapy

3. Assess level of consciousness and respiratory status (RR<12) initiate BVM support

4. IV Normal Saline @ KVO

5. Narcan 0.4-2.0 mg IVP or IM if no IV access

6. Rapid glucose determination with Dextrose or Glucagon for low glucose level

7. Reassess level of consciousness and respiratory status (RR<12) consider intubation



a. Repeat Narcan

b. Repeat Dextrose

NOTE: All empty medicine containers or other potentially relevant items to be transported to

receiving facility with patient whenever possible.



HEAT EXPOSURE (HYPERTHERMIA)

DESCRIPTION

The body’s normal core temperature is regulated by a number of factors that balance heat loss and heat

production. As the body’s temperature rises, vasodilation will lead to heat loss by radiation, convection,

and conduction. However, if the temperature outside the body exceeds the temperature of the skin, this

process is ineffective and evaporation by diaphoresis is necessary. The body’s physiological response to

excessive temperatures includes tachycardia as the heart attempts to increase cardiac output; diaphoresis

with subsequent loss of fluid (dehydration) and electrolytes; and signs of decreased cerebral perfusion,

e.g., headache, decreased responses to verbal and/or painful stimuli.

Heat Cramps: Pain in muscles due to loss of fluid and salt. Frequently affects lower

extremities and abdomen. Cool, moist skin, normal to slightly elevated

temperature; nausea.

Heat Exhaustion: The state of more severe fluid and salt loss leading to syncope,

headache, nausea, vomiting, diaphoresis, tachycardia, pallor and/or weak

pulse.

Heat Stroke: A very serious condition. The patient may present with hot and flushed

skin, strong bounding pulse and altered mental status. The situation may

progress to coma and/or seizures. CAUTION: Sweating may still be

present in 50% of heat stroke patients.

*Do not give patient oral fluids if patient is nauseated or confused.

*Place patient in cool environment and determine need for advanced life support.

*Determine patient’s past medical history and history related to present event.



HEAT RELATED EMERGENCIES

HEAT CRAMPS

1. Move patient to a cool environment


3. Establish IV Normal Saline

4. DO NOT MASSAGE CRAMPING MUSCLES

5. Monitor vital signs and record


HEAT EXHAUSTION

1. Move patient to a cool environment and elevate legs

2. Remove clothing as practical and fan moistened skin



5. Cardiac monitor





HEAT STROKE

1. Move patient to a cool environment

2. Remove as much clothing as possible

3. Cool the patient with a cool wet sheet

4. Apply cold packs under the arms, around the neck, and at the groin to cool large vessels



7. Cardiac monitor



Heat stroke is caused by a failure of the body’s normal temperature regulating mechanism. This results in

a cessation of sweating and subsequent surface evaporation. It generally results when the body

temperature reaches 105° F or more. A delay in cooling may result in brain damage or even death.

Vigorous efforts should be employed to decrease the temperature.



NEAR DROWNING

1. Routine ALS Care

2. While protecting the cervical spine, establish a patent airway appropriate to the clinical situation

3. If hypothermic, follow Hypothermic Protocol

4. Bronchodilator via nebulizer as required for bronchospasm

5. (follow Acute Respiratory Distress Protocol)

6. All near drowning victims must be transported to the hospital

Drowning: Death by water immersion.

Near Drowning: Refers to initial recovery after immersion.

“Dry” drowning: Little or no aspiration of water (10-20% of victims). Asphyxia by

laryngospasm.

“Wet” drowning: Aspiration of water accompanying drowning.



HYPOTHERMIA

DESCRIPTION

When the body’s core temperature decreases, the body will first respond by shivering. This is an attempt

by the body to generate heat from muscle activity. Vasoconstriction will shunt blood from the skin and an

increase in the patient’s metabolic rate will increase heat.

If these mechanisms cannot compensate for severe temperature drops and the body’s systems begin to fail,

i.e. respiratory function will deteriorate and lead to hypoxemia. The patient may also develop

dysrhythmias and cardiopulmonary arrest may occur.

Patients are particularly at risk for cardiac dysrhythmias during the warming phase of treatment.

GENERAL GUIDELINE FOR CARE:

Localized cold injury:

1. Follow BLS Guidelines.

2. Generalized Hypothermia:

3. Avoid rough handling or excessive movement

4. Remove patient from cold environment

5. Protect C-spine as necessary

6. Remove all wet clothing

7. Protect from further heat loss

8. Monitor cardiac rhythm

9. High flow oxygen




MODERATE HYPOTHERMIA

CLINICAL may include: Conscious, but often lethargic

Often shivering, skin pale and cold to touch

1. Follow General Hypothermic Care Guidelines

2. Hot packs wrapped in a towel may be applied to axillae, groin, abdomen

3. DO NOT DELAY TRANSPORT

4. Establish an IV Normal Saline (warmed) en route

5. Check blood glucose level with IV start



8. Dextrose 25 GMs IVP

9. Narcan 0.4-2.0mg IVP



SEVERE HYPOTHERMIA

CLINICAL may include: Unconscious or stuporous

Skin ice cold

Heart sounds inaudible; BP unobtainable

or severe hypotension; Pupils unreactive

Very slow or absent respirations

HANDLE VERY GENTLY: HEART MORE SUSCEPTIBLE TO FIBRILLATION

1. Maintain the airway

2. Administer humidified oxygen at 100%

3. Assist ventilations if respiratory rate is less than 5/minute,

4. but do not hyperventilate; keep rate of artificial

5. ventilations around 10/minute – consider intubation

6. Normal Saline IV bolus (200-500ml) warmed if possible

7. Cardiac monitor

8. If CPR is required refer to Hypothermic Arrest Protocol

9. Transport the patient supine in a 10° head-down tilt



12. Dextrose 25 GMs IVP

13. Narcan 0.4-2.0mg IVP

Avoid:

1. Hyperventilation because an extreme drop in CO2 may cause ventricular fibrillation.

2. Rubbing the skin.

3. Rewarming frostbitten extremities until after the core is rewarmed to prevent vascular

complications to the limb and the transportation of cold blood and detrimental by

-products to the core.

4. All unnecessary rough movements as they may precipitate arrhythmia.



HYPOTHERMIC ARREST

A. If spontaneous pulse and respirations are present or respirations are absent:

1. Remove all wet clothing unless frozen to the skin.

2. Cover patient with blanket(s)-DO NOT ATTEMPT ACTIVE EXTERNAL

REWARMING.

3. If respirations are absent intubate and ventilate at 10/minute.

B. If pulse is absent and EKG monitor shows ventricular fibrillation/tachycardia:

1. Defibrillate at 200 joules.

2. If no conversion, initiate CPR (deliver 40-50 compressions per minute).

3. Establish Medical Control for consideration of any further orders.

4. If no conversion, defibrillate at 300 joules.

5. If no conversion, defibrillate at 360 joules.

C. If pulse is absent:

1. Initiate CPR (deliver 40-50 compressions/minute).

2. Establish Medical Control for consideration of any further orders.

3. Transport.

Do not administer medications unless directed to do so by Medical Control Physician.

Once you have started CPR - DO NOT GIVE UP !

THE HYPOTHERMIC PATIENT IS NOT DEAD UNTIL HE IS WARM AND DEAD !

NOTE: Severely hypothermic patients may be without detectable pulse, blood pressure, or respirations.

This may be physiologic for a hypothermic patient. Successful resuscitation with CNS complications has

been accomplished in patients with a core temperature less than 70°F.



OVERDOSE/POISONINGS

SPECIAL INFORMATION

It is essential to obtain the following information on all drug overdoses and poisonings:

1. Name and ingredients of the substance(s) taken.

2. The amount taken.

3. Approximate time substance was taken.

4. Method of substance abuse: ingestion, injection, inhalation, or topical transmission.

5. Look for the container(s) of substance ingested and if appropriate transport with

patient.

6. Reason for the ingestion: e.g., suicide, accidental overdose, or mixture of

incompatible substances.

7. Vomiting prior to arrival.

At the earliest convenience contact Poison Control directly or through Medical Control

Altered Level of Consciousness

1. Routine ALS Care

2. Establish and maintain airway

3. Support ventilations as needed

4. Oxygen as per protocol

5. Cardiac Monitor - Treat symptomatic rhythm according to protocol

6. Establish IV of Normal Saline

7. Fluid bolus if hypotensive

If a Narcotic Overdose is suspected see altered mental state-opiate protocol

8. If patient remains unresponsive:

9. Rapid glucose determination

10. Administer Dextrose 50% 25 Gm IV for glucose <100



a. Management specific for agent exposure

b. Additional Dextrose

Conscious Patient with oral ingestion - Overdose/Poison



12. Routine ALS Care




a. Activated Charcoal 30-50 Gms PO

Important: NEVER INDUCE VOMITING

OVERDOSE/POISONING

Inhalation or Topical Exposure of a Poisonous Substance

1. Evaluate the scene for safety consideration as a Hazmat Incident

2. Notify CMED as indicated

3. Follow BLS Hazmat Guidelines as indicated

4. Routine ALS Care


Specific exposure information for further treatment orders and specific arrival instructions

(e.g., use a specific hospital entrance)



SEIZURES

DESCRIPTION

There are many causes of seizures including, but not limited to trauma, epilepsy, hypoxemia, meningitis,

stroke, hypoglycemia, drug overdose, drug withdrawal or eclampsia.

Routine ALS Care: Initiate treatment based upon history and clinical presentation. It is important to

make the distinction between focal motor, general motor seizures, and status epilepticus. Not all seizures

require emergent intervention.

Types of Seizures:

General or Grand Mal Motor seizures are tonic and clonic movements that are usually followed by a

postictal state.

The components of a grand mal seizure include aura, loss of consciousness, tonic phase (extreme

muscular rigidity), clonic phase (rigidity and relaxation in rapid succession), postictal state altered level of

consciousness).

Partial or Focal Motor seizures usually involve unilateral motor activity, but may not cause changes in

consciousness. Partial seizures may progress to generalized seizures.

Psychomotor seizures consist of personality alterations, staring, or peculiar motor activity with periods of

bizarre behavior.

Status Epilepticus is present when (a) 2 or more general motor seizures without a lucid interval is

witnessed by EMS personnel or (b) there exists continuous seizure activity lasting for greater than 10

minutes.



SEIZURES

1. Routine ALS Care

CONSIDER: Trauma, Hypoglycemia, Overdose - Go to appropriate protocol

2. High flow oxygen

3. Protect the patient from personal injury

4. Establish an IV of Normal Saline @ KVO

5. Obtain blood glucose level and record

6. IF BLOOD GLUCOSE LEVEL IS LOW THEN ADMINISTER THE FOLLOWING:

a. Dextrose 50% 25 Gm IVP

b. Glucagon 1mg IM if IV access unavailable



a. Valium 2-5mg (0.03mg/kg) IVP (over 30 seconds) (or)

b. Versed 2-4mg IVP or IM (or)

c. Ativan 1-2mg (0.02mg/kg) IVP



SHOCK

DESCRIPTION

Shock is best defined as inadequate tissue perfusion at the cellular level. Common manifestations are

decreased level of consciousness, peripheral vasoconstriction, decreased urine output, diaphoresis and

decreased blood pressure.

Shock is frequently thought of as being divided into four types: (1) hypovolemic, (2) cardiogenic, (3)

vasogenic, and (4) anaphylactic. Hypovolemic shock means that there is insufficient blood or plasma in

the circulatory system to maintain adequate perfusion. Common causes are loss of blood (internal

bleeding, trauma, external bleeding) or loss of serum and plasma (burns, peritonitis). Cardiogenic shock

is due to the failure of the heart to pump effectively, as seen in serious myocardial infarctions. Vasogenic

shock means that the blood vessels are peripherally dilated and will not constrict appropriately to maintain

peripheral resistance and thereby maintain blood pressure. Common causes of vasogenic shock are sepsis

and so-called “neurogenic shock,” a type of vasodilation that occurs with spinal cord injury. Lastly,

anaphylaxis, an allergic reaction to an external antigen such as a bee sting or an ingested antigen such as a

drug (penicillin, etc.) can be viewed as a type of vasogenic shock. The reaction to the foreign antigen

releases histamine and other vasoactive chemicals in the body, which cause blood vessels to dilate and the

blood pressure to fall, resulting in shock.



HEMORRHAGIC/HYPOVOLEMIC/VASOGENIC SHOCK

1. Assess ABCs

2. Routine ALS Care

3. Control Obvious bleeding


5. Immediate and early transport of the patient

6. Establish large bore IV of Normal Saline

7. and titrate to a systolic BP > 100 mmHg

8. Establish second large bore IV line en route to the hospital

9. Continuously monitor and record vital signs

10. In trauma cases monitor Glasgow Coma Scale


CARDIOGENIC SHOCK

1. Assess ABCs

2. Routine ALS Care


4. Establish IV Normal Saline KVO

5. Treat any underlying arrhythmias as per protocol



a. Fluid Challenge of 300-500 ml

b. Dopamine 5 µg/kg/min up to 20 µg titrated to a systolic BP˜90 mmHg

Note: Lung sounds and respiratory status must be continuously monitored to avoid pulmonary

edema.



PAIN/ANXIETY RELIEF

The following medical control options may be utilized for the patient who has an isolated traumatic

extremity injury, painful paramedic initiated management (e.g. Transcutaneous Pacing), or psycho social

condition exhibiting extreme pain and/or anxiety, and who is hemodynamically stable.

This does not include the multiple trauma patient or a situation where multiple trauma may even

possibly apply.

1. Routine ALS Care

2. Morphine Sulfate 2 to 5mg IVP



a. Morphine Sulfate 2-5 mg IVP

b. Diazepam 2-5 mg IVP

c. Versed 2-4 mg IVP

d. Ativan 0.5-1.0 mg IVP

4. Repeat any of the above options as ordered

Paramedic Induced Pain / Painful Procedures

In the event of a painful procedure (i.e. Cardioversion and Transcutaneous Pacing) the paramedic may

administer:



OR

2. Diazepam 2-4mg IV

3. Versed 2mg IV

4. Ativan 0.5-1.0mg IV

Contact On-Line Medical Control


a. Repeat any of the above treatment options



DYSTONIC REACTION

DESCRIPTION

This is an idiosyncratic reaction to a neuroleptic and antiemetic medication. It frequently involves acute

onset of involuntary muscle spasm, which is painful and uncontrollable, possibly leading to respiratory

compromise. Spasms of the neck muscles and the face are common presentations. There is also

commonly difficulty with speech, swallowing, and breathing. Individuals may have ingested these

medications unknowingly, especially having purchased them “on the street” or given by family “as a

sleeping pill.” Clinically dystonia can give the appearance of anxiety reactions, tetanus, strychnine

toxicity, or atypical seizures.

Management

1. Routine ALS Care

2. Benadryl 25-50 mg IVP or IM





Paramedic Protocols

Adult

Trauma Protocols

>13 years Old



Specific Thoracic Injuries

Flail Chest: When several ribs or the sternum (or both) are fractured in more than one place a

segment of the chest wall will lose integrity. The flail chest segment may collapse during

inspiration and expand during expiration (paradoxical movement).

Pneumothorax: Presence of air in the pleural space, causing partial or complete lung collapse.

Hemothorax: Presence of blood in the pleural space.

Tension Pneumothorax: Results from air leaking into the pleural space (through an injury in the

lung or chest wall) that cannot escape.. This leads to shift of the mediastinum (tracheal shift may

be noticed) away from the injured side and an inhibition of the venous return to the right side of

the heart.

Sucking Chest Wound or Open Pneumothorax: Results from air being drawn into the pleural

space from an open chest wound by negative pressure during inhalation.

Myocardial Contusion: Bruising of the myocardium which may produce dysrhythmias.

Cardiac Tamponade: Accumulation of blood in the pericardial sac. It may be produced by blunt

or penetrating trauma. This accumulation may be sufficient enough to produce inadequate cardiac

filling, poor cardiac output, muffled heart sounds, decreased systolic blood pressure, distended

neck veins, and respiratory distress. Another result may be pulses paradoxus which is a drop in

the systolic blood pressure or more than 10-20 mmHg during inspiration.

Laceration or Rupture of the Aorta: The aorta is particularly susceptible to laceration or even

transection as a result of a deceleration impact or compression of the chest. The most common

location for rupture is the aortic isthmus, which is close to the ligamentum arteriosum and the

origin or the subclavian artery.



INJURED PATIENT TRIAGE PROTOCOL*

When transport to a Level I or II Trauma facility is indicated, but the ground transport time to that hospital is judged

to be greater than twenty (20) minutes, determination of destination hospital shall be in accordance with medical

control.

Measure vital signs and level of consciousness:

Glasgow Coma Scale 12 or less

Systolic blood pressure <90, or

Respiratory rate <10 or >29

If Yes If No

Take to Level I or II Assess anatomy of injury

Trauma Facility 1. Gunshot wound to chest, head, neck, abdomen or groin

2. Third degree burns >15% BSA or third degree burns of

face or airway involvement

3. Evidence of spinal cord injury

4. Amputation other than digits

5. Two or more obvious proximal long bone fractures

If Yes If No

Take to Level I or II Assess mechanism of injury and other factors

Trauma Facility 1. Mechanism of injury:

a. Falls >20 feet

b. Apparent high speed impact

c. Ejection of patient from vehicle

d. Death of same car occupant

e. Pedestrian hit by car >20MPH

f. Rollover

g. Significant vehicle deformity-especially steering wheel

2. Other factors:

a. Age<5 or >55

b. Known cardiac disease or respiratory distress

c. Penetrating injury to thorax, abdomen, neck or groin

other than gunshot wounds

If Yes If No

Call Medical Control for direction Evaluate as per usual protocols

Severely injured patients<13 years should be taken to a Level I or II facility with pediatric resources including

pediatric ICU.

All EMS providers transporting trauma patients to hospitals shall provide receiving hospital with a complete OEMS

approved patient care form prior to departing from the hospital.

WHEN IN DOUBT, CONSULT WITH MEDICAL CONTROL

*State of Connecticut Regulation of Department of Public Health and Addiction Services Concerning Statewide

Trauma System: Sections 19a-177-5.



INITIAL ASSESSMENT AND MANAGEMENT OF THE TRAUMA PATIENT

I. PRIMARY SURVEY

A. Airway and Cervical Spine Control

1. Maintain in-line cervical immobilization

2. Manual

a. Chin Lift

b. Jaw Thrust

3. Mechanical

a. Suction

b. Oropharyngeal Airway

c. Nasopharyngeal Airway

d. Pocket Mask

e. Orotracheal tube with in-line immobilization

f. Nasotracheal tube with in-line immobilization

g. Transtracheal Airway with in-line immobilization

Hypoxia is common in the trauma patient and correcting it is of the highest priority. A spinal injury may

be present and the airway should be managed as if C-spine instability exists. Concern about a spinal

injury must not delay institution of adequate ventilation and oxygenation. The neck should be

maintained in a neutral position. If an endotracheal tube is required, neutral stabilization of the spine

must be maintained throughout its insertion, so that the mandible and tongue are moved forward and the

head is not tilted backwards.

B. Breathing

1. Ventilation

a. Mouth to mask

b. Bag-valve-mask

2. Flail Chest

a. Airway management

3. Open Pneumothorax

a. Partially occlusive dressing (3-sided)

b. Assist ventilations as needed with supplemental O2

4. Tension Pneumothorax

a. Decompression

i. Large bore needle with plastic catheter (angiocath)

ii. Second intercostal space (ICS) in Midclavicular Line, superior

aspect of the Third Rib

iii. Fifth ICS in Midaxillary Line



TRAUMA PATIENT CON’T

C. Circulation and Bleeding Control

1. Evaluation

a. Pulse

i. Rate

ii. Strength

iii. Location

b. Skin

i. Color

ii. Moisture

iii. Temperature

2. Cardiac compressions as indicated

3. Hemorrhage control

a. Direct pressure on wound and/or pack wound with sterile gauze

b. Pressure points (usually not required)

c. Tourniquet (seldom, if ever, indicated)

d. Traction splint

e. PASG (for unstable pelvic fracture with hypotension in the adult >13 yrs.)

Pale skin color and pulse characteristics are accurate parameters used in assessing the status of tissue

perfusion. Blood pressure is obtained later in the patient’s assessment. Hemorrhage control in the

primary survey is used only for massive bleeding. Minor bleeding takes a lesser priority. For patients

with an unstable femur fracture, application of a traction splint is the most important field technique for

control of this type of hemorrhage. Patients with “open book” pelvic fracture will benefit from

stabilization and “direct pressure” from the PASG.

D. Disability

1. Glasgow Coma Scale

a. Eye Opening: 4 - spontaneous

3 - to voice

2 - to pain

1 - none

b. Verbal response 5 - oriented

4 - confused

3 - inappropriate words

2 - incomprehensible words

1 - none

c. Motor response 6 - obeys commands

5 - localizes pain

4 - withdrawal (pain)

3 - flexion (pain)

2 - extension (pain)

1 - none



TRAUMA PATIENT con’t

E. Exposure of the body for examination

It may be necessary to partially or completely expose the body to control hemorrhage

and perform lifesaving procedures. It is important to consider modesty and to respect

the individual’s needs. Nothing should be done to delay transport of the critically

injured patient.

II. RESUSCITATION

A. Supplemental oxygen should be delivered @100% for all multisystem trauma patients.

B. Volume replacement

1. Blood pressure should be monitored

a. systolic/diastolic

b. pulse pressure

2. Venous access

a. peripheral IV

i. Large bore catheters

ii. Two sites preferred

b. Fluid(s) Normal Saline

Excess time should not be spent in the field with multiple attempts to start an IV. Critically injured

patients should be placed as rapidly as possible in the ambulance and IVs started enroute to the hospital.

III. SECONDARY SURVEY

A systematic evaluation of the patient beginning at the head and proceeding to the neck, thorax, abdomen,

and extremities should be completed. Unnecessary delay in order to carry out diagnostic procedures that

do not produce information concerning direct treatment in the pre-hospital phase should not be attempted.

Rapidly identify those patients who, because of the critical nature of their situation, require rapid transport

to an appropriate facility. These patients should be stabilized and transported immediately.

A. Head

1. Airway

a. reevaluate

b. correct problems

2. Open Wounds

a. control hemorrhage with direct pressure

b. apply clean dressings to all wounds

3. Eyes

a. protect from further injury

b. irrigate to remove contaminants and debris (Morgan Lens if

appropriate)

c. do not remove foreign bodies




4. Nose and ears

a. pre-hospital evaluation for fluid (blood, CSF)

b. treatment usually not required

Most injuries to the face and head require hospital treatment - therefore delay in evaluation other than

hemorrhage control is usually not necessary. Lacerations of the scalp may have a fracture beneath;

therefore, unnecessary pressure is to be avoided. Use only enough pressure to control hemorrhage.

Transportation to the hospital should not be delayed other than to correct life threatening airway

problems.

B. Neck

1. Spinal immobilization; indications

a. any blunt injury above the clavicle

b. unconscious patient

c. multiple trauma

d. high speed crash

e. neck pain

f. complaints of extremity numbness/tingling

g. gunshot wound involving the torso

2. Wounds

a. leave foreign bodies in place, but stabilized

b. use direct pressure to control hemorrhage

Spinal immobilization should be accomplished without using the chin as a point of control. If the patient

vomits into a closed mouth, aspiration almost inevitably results. Studies have shown that the cervical

collar does not provide immobilization; therefore, a rigid cervical collar is used in conjunction with a long

or short backboard and other head immobilization devices. A patient should never be secured to a

backboard by the head alone. If such a patient became uncooperative, severe damage to the C-spine could

result.

Wounds of the neck should not be probed. Frequently a clot will have formed on the carotid artery or

jugular vein, which probing could dislodge, causing severe hemorrhage. Compression dressing should not

be tight enough to restrict blood flow to or from the brain and should not be circumferential.

C. Thorax

1. Ventilation

a. Assure adequacy of ventilation

b. Reevaluate injuries identified and managed in the primary

survey

2. Myocardial contusion

a. EKG monitoring

b. Treat dysrhythmias according to ACLS




3. Chest wall injuries

a. Simple isolated rib fractures, no pre-hospital management necessary

b. Flail chest

i. airway/ventilation management as necessary

c. Hemothorax

i. fluid replacement to treat shock

ii. ventilatory support as necessary

d. Open pneumothorax

i. three-sided dressing

e. Tension pneumothorax

i. needle decompression

f. Cardiac tamponade

i. fluid bolus

With the exception of myocardial contusion and pericardial tamponade, most of the chest conditions that

result from trauma are either managed when identified during the primary survey or at the hospital. Chest

injuries are the second leading cause of death and disability and these patients need to have a high

transport priority as part of their treatment plan.

D. Abdomen

1. Evisceration

a. Clean, moist dressing

2. Foreign body

a. Do not remove except by direct order of medical control

b. Stabilize foreign body to prevent further injury during transport

3. Intra-abdominal hemorrhage

a. Intravenous fluids

4. Pelvic fracture

a. Long backboard immobilization

b. Consider PASG stabilization

Prolonged evaluation of the abdomen for signs of an acute abdomen by checking for guarding, rebound

tenderness or bowel sounds requires extra delay and should be avoided. Most patients with intra-

abdominal injuries require hospitalization, evaluation, and treatment so delay to perform such diagnostic

techniques is not indicated.

E. Extremities

1. Examine for swelling and deformity

2. Check for neurovascular function

3. Apply direct pressure to control bleeding

4. Splint-reassess neurovascular status after splinting

5. Consider PASG for multiple lower extremity fractures




F. Neurologic - Head, spinal cord, and peripheral nerve trauma

1. Suspect associated C-spine injury and treat accordingly

2. If GCS <9 consider intubation and ventilation to protect/manage airway

3. Serial GCS determinations at least every 10 minutes

4. Pupillary evaluation

a. Reactivity

b. Equality

c. Size

5. Reassess motor and sensory function

6. IV fluids should be restricted unless shock is present

7. If shock is present, look for other causes of blood loss, as brain injury

alone is usually not the cause

IV. TRANSPORTATION

It is impossible to fully stabilize the unstable patient in the pre-hospital setting. There must be a

balance of lifesaving skills (such as endotracheal intubation) with minimizing scene time (<10

minutes) and rapid transport in order to reduce the time from injury to definitive surgical

treatment.

Early “trauma” notification to the receiving hospital is essential to ensure the immediate

availability of an appropriate in-hospital response.

See Appendix C

*Committee on Trauma; American College of Surgeons; Resources for Optimal Care of the

Injured Patient.



DESCRIPTION OF BURNS

For prognostic and management reasons burns are classified in several different ways.

1. Mechanism of burn: thermal, chemical, electrical or inhalation (e.g., smoke, carbon

monoxide, chemicals).

2. Depth of burn wound:

a. Superficial (1st degree) involvement of superficial layers of the skin, producing

redness and pain.

b. Partial thickness (2nd

degree) penetration to deeper layers of the skin producing pain,

blistering, and edema.

c. Full thickness (3rd

degree) involvement of all skin layers and can also involve

underlying muscle, bone, and/or other structures. Lack of pain is characteristic.

3. Extent (size) of burn wound; this is expressed as percent of total body surface area and

can be calculated using the Rule of Nines. Palm rule (patient’s palm=1% TBSA).

4. Location of burn wound: Burns of the face, neck, hands, feet, perineum, and

circumferential burns carry a higher risk of morbidity than burns of similar size in other

locations. Facial burns are often accompanied by upper airway edema; be prepared to

intubate this patient.

5. For every patient suspected of carbon monoxide or other inhalation injury (particularly

in closed space environmental fires, presence of singed nasal hairs or carbonaceous

sputum), begin oxygen at highest possible flow rate.

BURN PATIENTS ARE OFTEN VICTIMS OF MULTIPLE TRAUMA. TREATMENT OF ALL

MAJOR TRAUMATIC INJURIES TAKES PRECEDENCE OVER BURN WOUND MANAGEMENT.

AT ALL TIMES PROTECT YOURSELF FROM EXPOSURE.

Note: Rule of Nines graphic is located in the appendix.



THERMAL BURNS

Evaluate the causative agent before initiating treatment. Stop the burning process by removal of the

patient from the source of exposure or eliminate the source as per guidelines noted below. Evaluate the

degree and estimate the BSA (Body Surface Area) of the burn injury.

1. STOP THE BURNING PROCESS

2. Routine ALS care

3. Airway/oxygen per protocol

4. Check for the presence of signed facial or nasal hair; hoarseness, wheezing, cough, stridor and

document.

5. Assess percentage of Total Body Surface Area Burned.

6. Establish IV Normal Saline (in area not affected by burn) run at 200ml/Hr. Titrate to SBP

7. Remove loose clothing and jewelry/constriction hazards.

8. Apply clean dry towels or sheets to area. If the burns are less than 10% and are superficial or

partial thickness you can moisten the towels or sheets with sterile normal saline for comfort.

9. Cardiac monitor



a. Morphine Sulfate IVP

b. Versed 2-4mg IV

c. IV Fluid rate for resuscitation

d. Intubation

11. Transport to appropriate facility

DO NOT BREAK BLISTERS INTENTIONALLY. DO NOT APPLY CREAMS, OINTMENTS OR

ANTIBIOTICS TO BURN. DO NOT REMOVE ANY LOOSE TISSUE OR SKIN.



CHEMICAL BURNS

Consider any chemical burn situation as a Hazmat situation.

If potential Hazmat situation exists, notify receiving hospital ASAP

Personal Safety

1. Identify the situation if possible (including the type and amount of chemical)

2. Upon receiving the patient consideration that they may still be contaminated is key.

3. Airway/oxygen as per protocol

4. Remove affected clothing (if not already done)

5. Again, try and obtain name of the chemical or its I.D.

6. Flush with copious amounts of water or saline unless contraindicated. Irrigate burns to the eyes

with a minimum of 1 liter of normal saline. Alkaline burns should receive continuous irrigation

throughout transport. Consider the Morgan Lens for eye irrigation, (see below).

7. IV Normal Saline TKO

8. Cardiac monitor



a. Morphine Sulfate IVP

b. Versed 2-4mg IV

*Phosphorus burns should not be irrigated, brush chemical off thoroughly.

*Hydrofluoric Acid burns - be aware of cardiac implications due to induced hypocalcemia and the

need for immediate contact with Medical Control.



OPHTHALMIC CHEMICAL BURNS

1. Immediate and continuous flushing of the affected eye is performed using Normal Saline. If

contact lenses are known to be in the patient’s eyes, an attempt should be made to remove them

and continue flushing.

2. Unless contraindicated instill 1 or 2 drops of ophthalmic anesthesia

3. Continuously flush while in route to the hospital

4. Place the Morgan Lens in the affected eye(s) when possible

Note: Morgan Lens is not indicated in patients under six (6) years or age, or uncooperative

patients.

5. Advise patients not to touch/rub their eye(s) after instillation of anesthesia drops.

ELECTRICAL BURNS

1. Without placing self at risk, remove patient from the source of electricity or have the power cut

off.

2. Routine ALS Care

3. Suspect spinal injury secondary to tetanic muscle contraction

4. airway/oxygen as per protocol

5. IV Normal Saline

6. Cardiac Monitor

7. Treat any cardiac rhythm disturbances per protocol

8. Treat any trauma secondary to electrical insult as per protocol




SPINAL CORD INJURY

1. Routine ALS Care

2. Airway/oxygen as per protocol

3. Proper assessment, evaluation, and packaging of patient to include:

4. Movement/sensation of all four extremities before and after packaging patient

5. Rigid cervical/extrication collar

6. Long backboard/full body vac-u-splint or other immobilization device as the situation dictates

7. Continually reassess patient for any changes

8. IV Normal Saline TKO

9. If the patient is hypotensive administer 250ml fluid bolus




Emergency Incident Rehabilitation Recommended Practices & Protocol

Section 1: Recommended Practices for Fire/EMS Agencies

NOTE: These recommendations are based primarily on the DRAFT (November 2002) NFPA

1584 document entitled “Recommended practice on rehabilitation for members operating at

incident scene operations and training exercises, 2003 edition.”

Responsibilities:

1. Incident Commander: Implementation of formal emergency incident rehabilitation (EIR) is at

the discretion of the Incident Commander (IC). The IC should consider the circumstances of each

incident, and make adequate provisions early in the incident for the rest and rehabilitation of all

members operating at the scene. These provisions may include: physical and mental rest; fluid

and food replenishment; relief from extreme climatic conditions and other environmental

parameters of the incident; and medical evaluation, treatment, and monitoring.

2. Rehab Officer: An EMT-B, EMT-I, EMT-P, or Sponsor Hospital Physician or Medical Advisor

should be assigned to the rehab area, and if appropriate may be designated by the IC as the Rehab

Officer (RO). If available and practical, it is preferred that ALS-level personnel and equipment be

present, as indicated in NFPA 1500. Rehab sector medical personnel and other assets should be

dedicated to support of firefighters and other operational emergency responders, and should be

assigned no other responsibilities. The RO will typically report to the IC, although he/she may

report to the Logistics Officer at larger-scale incidents.

3. Rehab Team: The Rehab Team should include sufficient personnel to perform rehab sector

functions for the maximum number of personnel anticipated to be in the Rehab Area at any given

time. Generally, a ratio of one Rehab Team member for every ten personnel on scene is

recommended. The team should include sufficient EMS personnel to perform medical monitoring

tasks, but may include non-EMS personnel also. BLS is the minimum level of care needed at the

Rehab Area; ALS is considered preferable.

4. Supervisors / Company Officers: All supervisors and company officers should maintain their

awareness of the condition of each member operating within their span of control, and ensure that

adequate steps are taken to provide for each member’s safety and health. The ICS structure

should be utilized to request relief and/or reassignment of fatigued crews.

5. Personnel: Any member who believes that his or her level of fatigue or exposure to heat or cold

is approaching a level that could affect his or her performance or the operation in which he or she

is involved should advise his or her supervisor or company officer. Personnel should also remain

aware of the health and safety of other members of the crew.



Establishing the Rehabilitation Sector

1. The IC should establish a Rehab Sector or Group when conditions indicate that rest and

rehabilitation is needed for personnel operating at an incident scene or training exercise. This

determination should be made based upon the anticipated duration of the operation, level of

physical exertion, and environmental conditions, including temperature, humidity, and wind-chill.

Guidelines to consider include:

a. Heat stress index >90 degrees Farenheit (see table)

b. Wind chill index <10 degrees Farenheit (see table)

c. Personnel have completed (or will complete) exertional work with second 30 min SCBA

cylinder

d. Personnel have utilized (or will utilize) SCBA for >45 minutes of exertional work

2. It is recommended that an EMS vehicle not otherwise involved in emergency operations at the

scene be posted at the Rehab Area. If required, an additional ambulance should be requested to

the scene for this purpose. Except under extreme circumstances, this ambulance should not be

used for transport of civilian patients.

3. The location of the Rehab Area will be designated by the IC and/or the RO, and should:

a. Be far enough from the scene to allow personnel to safely remove (and leave outside the

area) SCBA and turnout gear, and remove personnel from the urgency of the scene, yet

close enough to allow prompt re-entry into the operation on completion of rehab.

b. Provide adequate protection from environmental conditions and exhaust fumes

c. Be easily accessible by EMS units

d. Be large enough to accommodate several crews

e. For extreme heat conditions, have shaded areas, misting systems and/or fans, and an area

to sit down

f. For extreme cold and/or wet conditions, have dry protected areas, heated areas, and dry

clothing

g. Be integrated with departmental system for personnel accountability, utilizing a single

entry and exit point when feasible.

Examples of sites that have been utilized include a nearby building, garage, or lobby; a school bus

or large van; or an open, shaded area. See attached example sketch of a typical rehab and

treatment area.

Rehab Operations

1. Resources: The RO should secure, through the IC or Logistics Officer, all necessary resources

to properly supply the sector. These may include oral fluids, foods, medical supplies, paperwork,

lighting, heaters, fans, a means of access to toilet facilities, and other assets as appropriate to the

incident.

2. Rotation of Personnel/Accountability: Companies and units will be assigned to the Rehab

Sector by the IC, or his/her designee e.g. Operations Officer. Whenever possible, the entire

company or unit should be assigned to the Rehab Sector as a group. The crew designation, names



of members, times of entry and exit, and appropriate medical information should be documented

by the Rehab Officer or designee on the EIR form (see attached) or similar document. Personnel

rotated to the Rehab Sector shall not leave until directed by the RO. If any member requires

transport to a medical facility, the IC shall be notified immediately.

3. Hydration: During exertional activity, in both hot and cold weather, personnel should consume

at least one quart per hour of water, activity beverage, or combination. Carbonated and

caffeinated beverages should be avoided. During a typical 20-minute rehab cycle, 12 to 32 oz of

fluids are recommended.

4. Nutrition: Food should be provided whenever operations exceed three hours. Fatty and salty

foods should be avoided.

Section 2: Protocol for EMS personnel operating in the rehab sector

Medical Evaluation

1. EMS personnel shall ask members arriving at the Rehab Area if they have any symptoms of

dehydration, heat/cold stress, physical exhaustion, cardiopulmonary abnormalities, or

emotional/mental stress. EMS personnel shall complete a medical evaluation, and appropriate

treatment and/or transport, for all members who report such symptoms.

2. A medical evaluation, with appropriate treatment and/or transport, shall also be completed for

any member meeting any of the following criteria:

a. The RO or Rehab Sector EMS staff observe evidence of one of the above conditions

displayed by a member

b. Another member, officer, or supervisor indicates he/she does not appear well.

c. The member had to leave an evolution for reasons of excessive fatigue or symptoms

3. Medical Treatment: Standard treatment and/or transport shall be provided in accordance with

regular CHH protocols.

4. When treating a member with signs or symptoms of dehydration or fatigue (such as vomiting

without evidence of toxic exposure or climate conditions producing multiple cases of mild heat

stress), with absence of chest pain, change in mental status, or other indicators of a medical

condition requiring emergent care, a paramedic or Sponsor Hospital Physician or Medical Advisor

working in the Rehab Sector may elect to perform a trial of intravenous rehydration if the

following resources are available:

a. 12-lead ECG, with appropriate interpretation training

b. Tympanic thermometer, with appropriate training

The member may be considered a candidate for non-transport if, following the intravenous

infusion of at least one liter of crystalloid, he/she has all of the following:

a. Complete resolution of symptoms

b. Vitals signs within the following ranges

1) Systolic blood pressure >90 and <200 mmHg



2) Pulse rate >50 and <100 beats per minute

3) Respirations >12 and <24 per minute

4) Temperature < 100.5 F

Even if the member is not transported to the hospital, he/she may not return to active duty for the

duration of that duty cycle or 24 hours, whichever is longer. If the member’s condition does not

improve, or worsens at any time during the trial of rehydration, the member shall be transported to

the hospital.




Paramedic Protocols

OB/Gyn Protocols



COMPLICATIONS OF PREGNANCY

ANTEPARTUM HEMORRHAGE

Placenta Previa - placenta overlying the cervix.

Abruptio Placenta - separation of the placenta from the uterine wall, often but not

necessarily associated with abdominal pain.

Uterine Rupture - sudden severe abdominal pain and shock.

DO NOT DELAY - TRANSPORT IMMEDIATELY TO THE HOSPITAL


2. Use a wedge to tilt patient to the left to move fetus off Inferior Vena Cave

3. IV Normal Saline wide open - titrate SBP >100

4. Keep patient warm

5. Elevate lower extremities


*Remember - Rapid Transport MUST be initiated anytime bright red vaginal bleeding is

present

Note: To quantitate bleeding use a pad count on any type of vaginal bleeding.



PREGNANCY INDUCED HYPERTENSION AND SEIZURES

(ECLAMPSIA / TOXEMIA)

Assess patient, careful consideration should be paid to the CNS and Cardiorespiratory function.

Verify by either history or observation the presence of tonic/clonic activity. Determine the

gestational age of the fetus (will be 2nd or 3rd

trimester and pregnancy should be apparent) and

previous history of pregnancy induced hypertension.

1. Routine ALS Care

2. If hypoglycemia or drug overdose induced status epilepticus is suspected, treat according

to appropriate protocol.



Magnesium Sulfate 4 Gms in 20 ml normal saline Slow IVP (over 5 minutes)

Follow with infusion of Magnesium Sulfate @ 1 - 2 Gms/Hour

Valium 5 - 10 mg Slow IVP (or)

Versed 2 - 4 mg IVP or IM

Ativan 0.5 – 1.0 mg IVP

Be alert for respiratory depression, if this occurs, stop medication, support respiration, and

contact medical control !

If seizures recur or do not subside, contact medical control for repeat of above.



OBSTETRIC EMERGENCIES

Although a number of medical emergencies may arise as a result of pregnancy, prehospital

intervention is often limited.

Emergencies which may arise include: Imminent Birth, Spontaneous Abortion, Vaginal Bleeding,

Breech Presentation Birth, Prolapsed Umbilical Cord, Limb Presentation Birth, Antepartum

Hemorrhage, Postpartum Hemorrhage, and Eclampsia.

Necessary Information to Determine Pre-delivery:

1. Due Date (EDC) or suspected length of pregnancy

2. Gravida=number of pregnancies; Para=number of live births

3. Expected multiple births

4. Membranes ruptured (time / color / odor)

5. Last Menstrual Period (LMP)

6. Prenatal Care

7. Signs of imminent delivery

a. Crowning

b. Urge to push (need to move bowels)

c. Time between contractions

8. Pertinent medical history

9. Current medications

10. Unusual complications (eclampsia)

Necessary Information to Determine Post-Delivery:

1. Time of delivery

2. Whether or not there was a cord around the neck

3. Note appearance of amniotic fluid (clear, green, brown, blood streaked)

4. Time placenta was delivered and condition

5. APGAR Score(s) One minute and Five minute

6. Any infant resuscitation and the infants response must be documented on the infant’s

PCR (Run Form)

Do not perform an internal or digital vaginal examination.



EMERGENCY CHILDBIRTH

1. Routine ALS Care


3. Establish IV Normal Saline at KVO rate

No Crowning or urge to push Crowning or urge to push

Transport and re-evaluate every 2-3 minutes Prepare for childbirth

Imminent Delivery

1. Control delivery with the palm of the hand so the infant does not “explode” out of the

birth canal. Support the infants head as it emerges and support perineum with gentle hand

pressure.

2. Support and encourage the mother to control the urge to push.

3. Tear the amniotic membrane, if it is still intact and visible outside the vagina.

4. Check for cord around the neck.

5. Gently suction mouth and nose (with bulb syringe) of infant as soon as head is

delivered.

a. Note the presence or absence of meconium staining. If meconium is present in the

airway suction extremely well. If necessary intubate and suction airway for thick

meconium. When possible use a meconium aspirator.

6. As shoulders emerge, guide head and neck slightly downward to deliver anterior shoulder,

then the posterior shoulder.

7. The rest of the infant should deliver with passive participation. Get a firm hold on the

baby.

8. Repeat gentle suctioning then proceed to postpartum care of infant and mother.

9. Dry and keep infant warm. If possible skin to skin contact with the mother while covering

the infant with a blanket provides a good warming source.

10. Establish date and time of birth and record, do APGAR at 1 and 5 minutes.



DELIVERY COMPLICATIONS

Nuchal Cord (cord around baby’s neck)

1. Slip two fingers around the cord and lift over baby’s head.

2. If unsuccessful: Double clamp cord, cut cord between clamps with sterile scissors (blunt side next

to baby, never use a scalpel) allow cord to release from baby’s neck.

3. Continue with normal delivery protocol.

Prolapsed Cord (cord presenting before the baby)

1. Elevate mother’s hips in knee-chest position or left side down in Trendelenberg position.

2. Protect cord from being compressed by placing a sterile gloved hand in vagina and pushing up

firmly on the presenting part of the fetus.

3. Palpate cord for pulsation

4. Keep exposed cord moist and warm.

5. Keep hand in position and transport immediately to approved OB facility.

6. Do not remove hand until relieved by OB personnel.

Breech Birth (legs or buttocks presenting first)

1. Never attempt to pull baby from the vagina by the legs or trunk.

2. After shoulders are delivered, gently elevate the trunk and legs to aid in delivery of head (if face

down)*

3. Head should deliver in 30 seconds* if not, reach 2 fingers into the vagina to locate the baby’s

mouth. Fingers in mouth will flex baby’s head and should assist in spontaneous delivery. If not:

Press vaginal wall away from the baby’s mouth to create an airway. If head does not deliver in 2

minutes, keep your hand in position and transport ASAP.

ESTABLISH MEDICAL CONTROL



DELIVERY COMPLICATIONS con’t

Extremity Presentation

1. Proceed immediately to the hospital


1. Do not attempt out of hospital delivery

2. Encourage mother to perform slow deep breathing

Post Partum Hemorrhage May be due to placental fragments not being delivered

1. Routine ALS Care

2. Massage the Fundus

3. Put the infant to breast

4. STAT Transport



a. Methergine 0.2mg IM

Postpartum Care of the Mother

1. Placenta should deliver within a few minutes to up to 30 minutes. DO NOT pull on cord to

facilitate placental delivery. If delivered bring the placenta to the hospital, do not delay on scene

waiting for the placenta to deliver.

2. If the perineum is torn and bleeding, apply direct pressure with trauma dressing to outside of

vagina only. DO NOT PACK VAGINA.

3. Observe for excessive bleeding. Titrate IV to maintain SBP >100 mm Hg.




POST PARTUM CARE OF THE INFANT

1. Note time and date of delivery.

2. Dry the infant immediately and keep warm.

3. Continue gentle bulb suctioning of the mouth and nose.

4. Stimulate baby by rubbing its back or flicking the soles of its feet, this should be enough to

stimulate the baby to begin crying and breathing.

5. *Spontaneous respirations should begin within 30 seconds after stimulation. If not, begin

artificial ventilations at 30 - 40 breaths/minute with infant B-V-M. Watch for chest rise. If no

pulse, or pulse< 80 bpm, begin CPR and follow appropriate Cardiac Algorithm (PALS).


6. If baby is cyanotic but breathing spontaneously, place an pediatric face mask approximately 4

inches from the baby’s face and run oxygen at 15 l/min. until color improves. Gentle suctioning

as needed.

Establish Medical Control (if not already done so)

7. Obtain 1 minute APGAR score

8. Clamp cord 6” to 8” from infants body. Cut cord with sterile scissors (blunt side next to infant)

between clamps. Clamping of cord is not critical, and does not need to be done immediately, but

keep the infant level with mom if cord is not clamped. This will prevent infant CHF (blood from

mom to baby) or infant anemia (blood from baby to mom).

9. If there is any bleeding from the cord clamp, reclamp again in close proximity to the “leaking”

clamp.

10. Allow mother to hold baby next to her if her condition does not contradict this. Wrap both baby

and mother together in blanket to diminish heat loss.

11. Obtain 5 minute APGAR score

*If meconium is present, perform deep aggressive tracheal suctioning until airway is clear before

stimulation of infant.



NEONATAL RESUSCITATION

1) Routine ALS Level Care.

2) Transport Immediately.

3) Position infant on his/her back with head down. Check for meconium. Suction mouth and

nose with bulb syringe. If thick meconium, aggressively suction until clear using ET tube

IMMEDIATELY FOLLOWING BIRTH. When possible use a meconium aspirator.

4) Dry infant and keep warm.

5) Stimulate infant by rubbing his/her back or flicking the soles of the feet.

6) If the infant shows decreased LOC, mottling or cyanosis, and/or presents with a heart rate

below 100 beats per minute:

a) Reassess effectiveness of:

b) Drying

c) Suctioning

d) Stimulation

e) Temperature

f) Airway and Ventilation

g) If the infant still shows little or no response:

h) If spontaneous respiration is <40 assist with B-V-M ventilations.

i) If pulse is <80 assist by performing chest compressions until responsive.

7) IV/IO access

8) 10-20 ml/kg Normal saline bolus

9) Epinephrine 0.01 mg/kg (1:10,000) IV/IO; 0.1 mg/kg (1:1,000) ET

10) Consider maternal condition including medications - Narcan 0.1 mg/kg IM/IV/IO/ET

11) Obtain blood glucose level


12) Possible Physician orders:

a) Repeat Epinephrine, Narcan

b) Dextrose 5% 5-10 ml/kg over 20 minutes



TRAUMA IN PREGNANCY

The most common cause of fetal death is maternal death.

1) Rapidly assess fetal viability - is uterus (fundus) above (viable) or below the umbilicus (non-viable

fetus).

2) Fetus may be in jeopardy while mother’s vital signs appear stable.

3) Treat mother aggressively for injuries based on mechanism of injury.

4) Follow Trauma Protocol with the following considerations.

5) Oxygen per protocol

6) Check externally for uterine contractions.

7) Check externally for vaginal bleeding and amniotic fluid leak (Broken water).

8) If patient becomes hypotensive while supine on blackboard elevate right side of backboard (to relieve

pressure on the inferior Vena Cava by uterus).

9) Early and rapid transport is essential




Paramedic Protocols

Pediatric Medical

Protocols



PEDIATRIC INITIAL ASSESSMENT

An organized pediatric assessment is imperative for the delivery of good medical care. The initial

assessment of a pediatric patient should include: Appearance, the work of breathing, and circulation to the

skin. Often times this can be done prior to actual “hands on” contact with the patient. Rapid assessment

is essential to determine the urgency for treatment and transport.

Points to consider with any ill child are: what are the symptoms, when did they begin, and how long have

they lasted.

Pediatric patients will compensate their “respiratory” or “shock” deficiencies. Once the pediatric

patient is unable to compensate, cardiopulmonary failure/arrest will follow.

He outcome of cardiac arrest in pediatric patients is poor, so prevention by early recognition and

treatment etiologies, whether respiratory or shock is essential. Rapid assessment of pediatric “ABC’s”

would be synonymous with the following:

1. Airway = Ventilation

Clear No airway assistance needed

Maintainable Head positioning

Suctioning

Supplemental oxygen

Unmaintainable B-V-M

Intubation only for patients who cannot be adequately

ventilated with B-V-M

2. Breathing = Oxygenation

Observe Facial expression, nasal flaring, neck muscle usage

Expose Chest to observe effort, rate, and effectiveness

Auscultate Effectiveness of ventilation

3. Circulation = Perfusion

Place patient in the supine position with feet at or equal to the level of the heart

and assess the following:

A. Pulses - Palpate femoral and pedal pulses and

note quality and rate

B. Capillary refill - Normal is less than 3 seconds

C. Note level of consciousness - Alert

Failure to recognize parents

Failure to respond to pain



PEDIATRIC ASSESSMENT con’t

A global deficit in oxygenation, ventilation or perfusion may result in bradycardia, a change to an

ineffective respiratory pattern, and/or change in neuro status. Remember - taking the work of

breathing away from a decompensated pediatric patient by assisting each breath with 100% oxygen

via a bag-valve-mask will result in turning that patient into a compensated patient for a while

longer.

Vital signs of a pediatric patient should be consistent with the ABC’s of initial assessment. The blood

pressure of a pediatric patient is a poor indicator for the perfusion status. The blood pressure will be well

maintained during the compensatory phase and will not decrease until the child is in the decompensated

phase. Therefore, a low blood pressure is a late sign of hypoprofusion.

Lower Limits of Normal Systolic Blood Pressure

Age Pressure

0 to 1 month > 60mm Hg

1 month to 1 year > 70mm Hg

> 1 year > 70 + (2x age in years) mm Hg

Normal Heart Rates for Age

Age Rate

0 to 1 month 120-160

1 month to 1 year 120-140

1 year to 3 years 100-140

3 to 5 years 100-120

5 to 10 years 80-100

>10 years 60-100

It is the standard of care that one should employ the use of a Pediatric Resuscitation Tape which

by measurement of the length of the child determine the child’s weight, appropriate emergency

equipment, and medication doses. This is more accurate, efficient, and safer than attempting to

estimate and calculate these values. Document use of the tape on the Patient Care Record (PCR).



PEDIATRIC PATIENT ASSESSMENT

Evaluate Airway

Not Patent Patent

Follow Pediatric Airway Algorithm Evaluate Breathing and Circulation (see page )

No Problem

Continue Transport

Reassess as necessary Problem with Either

BVM with 100% O2

Problem Corrected

Problem with Circulation

Establish IV/IO and administer 20ml/kg Normal Saline

Reassess

May repeat fluid infusion X 1




PEDIATRIC AIRWAY ALGORITHM

Assess Patient

Clear no assistance needed

Transport and reassess

Maintainable

Position Head

Suction

Supplemental O2

Unmaintainable

Factors Favoring B-V-M Factors Favoring Intubation

Unresponsive Inability to ventilate with BVM

Absent gag reflex Limited personnel available to assist

Combativeness during transport

Long extrication or transport times

Strong gag reflex

Presence of trismus (spasm of jaw muscle)

Short on-scene and transport times


Possible Physician Order:

Needle Cricothyroidotomy



GENERAL GUIDELINES for PEDIATRIC RESPIRATORY DISTRESS

Respiratory distress can be a life-threatening emergency. It may require immediate assessment

and management. Although the etiology of respiratory distress in the pediatric patient may vary,

the clinical manifestations are similar. The smaller tracheal diameter contributes to an easily

compromised airway. Respiratory distress may occur as a result of upper airway obstruction

(croup, foreign body, epiglottitis, congenital anomalies, edema, and allergic reactions) or from

lower respiratory airway obstruction (asthma, pneumonia).

Rapid assessment is essential. Do this by checking the patency of the airway: properly position

the airway, provide positive pressure ventilation using a B-V-M with 100% oxygen. Immediately

institute ventilatory support in severe respiratory distress or failure. Endotracheal intubation is

indicated only if there is an inability to secure a patent airway and ventilate the patient

adequately by B-V-M. Most children can be managed with B-V-M ventilation. Base the

decision to intubate on the response to limited ventilatory support and the distance from the

destination hospital.

Upper Airway Obstruction

Stridor and hoarseness are signs of upper airway distress. Croup and foreign body aspirations are

the most frequent causes. Rarely, epiglottitis may occur. Epiglottitis usually occurs in a two to

six year old child. The onset is usually abrupt and is associated with stridor, severe dysphagia,

high fever, and a toxic appearance. Epiglottitis also can occur in an infant or an adolescent.

Croup (laryngotracheal bronchitis) usually occurs in the infant or toddler. Its onset is more

gradual and is associated with low-grade fever, a barking cough, rapid respiratory rate, and

stridor. Foreign-body obstruction may present as stridor, dysphagia or respiratory arrest.

Lower Airway Obstruction

Wheezing is the hallmark of lower airway obstruction. Decreased, unequal or absent breath

sounds also can occur. The respiratory rate is generally rapid (although when expiration becomes

prolonged, the rate may fall, an ominous sign). Bronchiolitis, asthma, and foreign-body

obstruction should be considered.

Respiratory distress patients regardless of etiology, follow these general guidelines and see

other protocols as appropriate.



PEDIATRIC RESPIRATORY DISTRESS

1) Initial Assessment

2) Determine the appropriate weight of the patient

a) if more than 50 kg (110 pounds), treat as an adult.

b) (Use pediatric resuscitation tape if weight unavailable)

3) Ensure patency of airway

4) Assess respiratory rate and effort

5) If airway is obstructed follow Obstructed Airway Protocol 6) (see page 73)

7) Assess for sign of respiratory distress

a) Use of accessory muscles, stridor, retractions, nasal flaring or noisy respirations

8) Administer oxygen in the least irritating manner possible

9) Allow the child to assume the most comfortable position for themselves as practical and safe

during transport

10) See protocols for Croup/Epiglottitis or Asthma if indicated

11) If patient requires ventilatory assistance, remember:

a) DO NOT OVER EXTEND NECK

b) Ventilate with a B-V-M first

12) Follow airway algorithm (see page 68)

13) Early transporting of the pediatric patient is critical




PEDIATRIC ASTHMA

1) General Pediatric Respiratory Distress Guidelines

2) In all patients six (6) months of age or older with asthma or wheezing:

3) Albuterol nebulizer treatment: 2.5mg (0.5cc) in 1.5ml Normal saline at 6 L/min O2

a) May repeat X 1

If patient is under six (6) months of age:

Albuterol 1.25mg (0.25cc) in 2ml Normal saline at 6 L/min O2

May repeat X 1


4) Possible Physician Orders:

a) Establish IV Normal saline - administer Bolus

b) Repeat Nebulizer treatment

c) Epinephrine 0.01 ml/kg/dose Sub-Q (1:1,000)

Endotracheal Intubation should be avoided if possible

SUSPECTED CROUP or EPIGLOTTITIS

Obtain history and assess respiratory status to include:

• presence of stridor

• respiratory rate and effort

• drooling or mouth breathing

• degree of cyanosis

• increased skin temperature

DO NOT LOOK IN THE MOUTH !!!

IMPORTANT KEEP PATIENT CALM AND UPRIGHT

Allow child to achieve position of comfort



SUSPECTED CROUP or EPIGLOTTITIS Con’t

If respiratory status warrants, attempt to administer humidified 100% oxygen via mask held by

mother or significant other 4 inches in front of child’s face, but ONLY if well tolerated by child.

1) DO NOT ATTEMPT TO ESTABLISH AN IV

2) Transport ASAP



a) Nebulized Epinephrine (4.5ml of 1:1,000) if trying to achieve racemic epinephrine effect)

in 2.5-3ml NS for updraft

IF RESPIRATORY ARREST OCCURS FROM OBSTRUCTION

4) Rapid initial transport is imperative

5) Attempt ventilation with pediatric B-V-M

6) ?If ineffective, may use adult B-V-M?

7) If still ineffective, endotracheal intubation may be indicated

NOTE: In an unconscious patient, if there is strong suspicion for epiglottitis and if the patient is

unable to be ventilated with a B-V-M and if an enlarged epiglottis is visualized, ONE attempt at

intubation is allowed if the airway is able to be visualized.

Consider using a smaller size tube than you normally would.

8) If unsuccessful


9) Needle Cricothyrotomy if under 8 years of age



PEDIATRIC OBSTRUCTED AIRWAY

1) If patient can breath, cough, cry or speak (color pale or pale-pink):

2) Routine BLS medical care and general pediatric respiratory distress protocol.

3) Oxygen 100% by face mask held adjacent to face

4) Transport with parent, keeping child warm

5) If patient is conscious, but totally obstructed perform BLS airway clearing maneuvers

appropriate to age

6) If patient is unconscious or unable to ventilate and/or cyanotic with no air exchange:

7) Perform BLS airway clearing maneuvers appropriate to age

8) ALS Intervention - Open airway, attempt direct visualization with laryngoscope, and attempt

removal of foreign body using Magill forceps as needed

NOTE: In an unconscious patient, if there is a strong suspicion for epiglottitis and if the patient is

unable to be ventilated with a B-V-M and if an enlarged epiglottis is visualized, ONE attempt at

intubation is allowed if the airway is able to be visualized. Consider using a smaller size tube than

you normally would.

9) If unsuccessful, transport keeping the child warm, continuing BLS airway clearing maneuvers,

trying to ventilate with high pressure.

10) If unsuccessful with above airway maneuvers and child is over the age of 8 years consider

surgical cricothyroidotomy. If child is under the age of 8years, consider needle

cricothyroidotomy. Needle size is dependent upon the age/size of the child.


11) ?pushing the object into the right mainstem bronchi?



PEDIATRIC ALLERGIC REACTION

Stable Hemodynamics - no problem with ventilation, oxygenation or perfusion. Minor to

moderate skin manifestations and/or respiratory distress. No stridor.

1) Routine ALS Care

2) Oxygen per protocol

If mild to moderate respiratory distress:

3) Epinephrine 1:1,000 0.01 mg/kg to a total dose of 0.3 mg. Sub-Q

4) Albuterol nebulizer treatment

5) Establish IV Normal saline only if patient condition indicates.

6) Do not delay contacting Medical Control to establish IV

7) Benadryl 1 mg/kg IM or IV push (over one minute). Maximum dose 50 mg.



a) Epinephrine (1:1,000) 0.01 mg/kg Sub-Q



PEDIARTIC ANAPHYLAXIS

Unstable Hemodynamics - hypotensive patient according to normal values for age and weight;

pending upper airway obstruction with wheezing and/or stridor; or severe obstruction with

wheezing and/or stridor; or severe respiratory distress.

1) Routine ALS Care

2) Oxygen and airway management per airway protocol

3) In the event there is severe respiratory distress, B-V-M then intubation in the pre-hospital

setting is indicated.

4) Epinephrine (1:1,000) 0.01 mg/kg Sub-Q

5) Establish IV access

6) If bronchospasm, administer Albuterol nebulized treatment (0.5 ml in 1.5 ml NS)

7) Benadryl 1mg/kg IV push (over one minute) IM if no IV access. Maximum dose 50 mg.

8) If above treatment does not improve patient status:

9) Epinephrine (1:10,000) 0.01 mg/kg slow IV push

Establish medical Control


a) If no IV access IO for children <6 years old

b) Repeat Epinephrine Sub-Q or IV doses q 5 minutes

c) Epinephrine infusion 0.1 to 0.3 µg/kg/min increasing to 1.0 µg/kg/min as necessary

d) Solu-Medrol 2mg/kg infusion over 15 minutes

e) Fluid Bolus 20ml/kg of Normal saline

Reminder: Cardiac monitor is indicated for all patients receiving epinephrine.



PEDIATRIC ALTERED MENTAL STATUS/HYPOGLYCEMIA/COMA

1) Routine BLS / ALS Care

2) Consider etiology (trauma, hypoglycemia, overdose, seizure, hypoxemia, etc.)

3) Treat according to appropriate protocol

4) Support airway per protocol

5) Determine GCS

6) Establish IV access and check Blood Glucose Level

7) If:

� Glucose <60 or

� If glucose not available and patient is known diabetic or

� History consistent with hypoglycemia:

8) Administer Dextrose 25% 0.5 Gm/kg IV push

9) If IV access cannot be readily established administer Glucagon 0.02 mg/kg up to 1mg IM

10) If a narcotic overdose is suspected or unknown and respiratory insufficiency is present:

11) Administer Narcan 0.4 mg IV or IM. May repeat to a maximum dose of 2.0 mg.



a) If no IV access IO in child <6 years old

b) Repeat D25%

c) Repeat Narcan

13) Transport/destination decision



PEDIATRIC SEIZURES/STATUS EPILEPTICUS

Most seizures do not require emergent intervention.

1) Routine BLS/ALS Care

2) Initiate treatment based on history and clinical presentation. It is essential to make the

distinction between focal motor, general motor seizures, and status epilepticus.

3) Perform an initial assessment. Attempt to determine the etiology i.e. whether the patient has a

history of diabetes, seizure disorder, narcotic use, head trauma, poisoning or fever.

4) If post-traumatic Transport Now

a) Cervical and full spinal immobilization as appropriate while maintaining airway

5) Closely assess respiratory activity. Use blow-by oxygen.

6) Assist ventilations with B-V-M and 100% O2 as necessary.

7) Suction as necessary.

8) Consider IV access.

9) Consider hypoglycemia, check blood glucose level.

a) If glucose level <60 administer: Dextrose 25% 0.5 Gm/kg

10) Cardiac monitor

IF THE SEIZURE PERSISTS BEYOND 10 MINUTES (from onset) (Status epilepticus):

11) Administer:

a) Valium 0.25 mg/kg (up to 3 mg) IVP (or)

b) Ativan 0.1 mg/kg (up to 2mg) IVP

12) if unable to establish IV access administer:

a) Versed 0.1 mg/kg (up to 2 mg) IM

b) OR: Valium per rectum (see addendum)



a) Repeat administration of anti-seizure medications

b) Repeat Dextrose 25%

NOTE: If the seizure is controlled by one of the benzodiazepines, continuous assessment of

respiratory status is critical as respiratory arrest can occur with use of these medications.



PEDIATRIC CARDIAC RHYTHM DISTURBANCES

The EKG of all critically ill or injured children should be continuously monitored, although

primary cardiac events are unusual in the pediatric age group. Pediatric arrhythmias are more

frequently the consequences of hypoxemia, acidosis, and decreased cardiac output. There are

three groups of rhythms based on the rate of and the presence or absence of a pulse. These

classifications are bradycardias, tachycardias (narrow or wide complexes), and absent (PEA or

asystole).

Pediatric cardiac algorithms are based upon Pediatric Advanced Life Support from the

American Heart Association.



PEDIATRIC BRADYCARDIA

Most pediatric bradycardias are due to inadequate tissue oxygenation secondary to ventilation.

Supporting the airway may resolve the bradycardia.

Assess ABCs

Secure airway, ventilation, and administer 100% oxygen

Symptomatic / Severe Cardiorespiratory Compromise

Poor perfusion

Hypotension

Respiratory Difficulty

No Yes

Observe Begin chest compression if despite

Support ABCs oxygenation and ventilation heart rate

Transport <60 in an infant / child.

Establish IV/IO

Epinephrine IV/IO 0.01 mg/kg (1:10,000)

ET 0.1 mg/kg (1:1,000)

Repeat every 3-5 minutes

Atropine 0.02 mg/kg (minimum dose 0.1 mg

Maximum single dose:

0.5 mg - child

1.0 mg - adolescent

May repeat X 1


Possible Physician orders:

Pacing, other modalities

Note: Dosage differs with route of administration IV/IO vs. ET.



Pediatric Tachycardia

Rapid heart rate with adequate perfusion

Obtain 12-Lead EKG

if possible

Evaluate QRS duration

QRS duration QRS duration

normal for age =0.08 sec. Wide for age =0.08 sec.

Evaluate rhythm

Probable sinus tachycardia Probable SVT

Identify and treat possible Establish vascular access Establish vascular access

causes:

Fever, shock, hypoxia Adenosine 0.1-0.2 mg/kg

hypovolemia, drug ingestion follow with rapid NS flush Lidocaine 1 mg/kg IV

pneumothorax May repeat X 1 double dose May repeat X 2

Maximum dose 12 mg.


Termination

Yes No

If Lidocaine is successful Adenosine 0.1-0.2 mg/kg

start infusion at 20 to follow with rapid NS flush

50 µg/kg/min May repeat X 1 double dose

Establish Medical Control Maximum dose 12 mg.




PEDIATRIC TACHYCARDIA

Rapid heart rate with poor perfusion

Assess and maintain airway

Administer 100% oxygen

Ensure effective ventilation

Pulse present ?

No Yes

Begin CPR Evaluate QRS duration

See Asystole and pulseless

arrest decision tree

Is vascular access present

or rapidly available?

Yes No

Treat rhythm as related to QRS Synchronized cardioversion

see PALS Fig 6 0.5-1.0 J/kg

Establish Medical Control May repeat as needed

Establish vascular access if possible




PEDIATRIC PULSELESS ARREST

Determine pulselessness and begin CPR

Confirm cardiac rhythm in more than one lead

Ventricular Fibrillation Pulseless electrical activity

Pulseless ventricular tachycardia Asystole EMD

Continue CPR Identify and treat causes

Secure airway Severe hypoxemia

Hyperventilate with 100% O2 Severe acidosis

IV/IO access Severe hypovolemia

but do not delay defibrillation Tension pneumothorax

Cardiac tamponade

Profound hypothermia

Defibrillate up to 3 times is needed

2 J/kg, 4 J/kg, 4 J/kg

Epinephrine, first dose Continue CPR

IV/IO: 0.01 mg/kg (1:10,000) Secure airway

ET: 0.1 mg/kg (1:1,000) Hyperventilate w/100% O2

IV/IO access

Defibrillate 4 J/kg 30-60 seconds

after each medication Epinephrine, first dose

IV/IO: 0.01 mg/kg (1:10,000)

Lidocaine 1 mg/kg IV/IO ET: 0.1 mg/kg (1:1,000)

Defibrillate 4 J/kg 30-60 seconds

after each medication Epinephrine, second and

subsequent doses:

Epinephrine, second and subsequent doses IV/IO/ET 0.1 mg/kg (1:1,000)

repeat q 3-5 minutes @ 0.1 mg/kg (1:1,000) repeat q 3-5 minutes

Lidocaine 1 mg/kg

Defibrillate 30-60 seconds after each medication

@4 J/kg





Regional Paramedic Protocols

Pediatric

Trauma Protocols

<13 Years



TRIAGE DECISION SCHEME When transport to a Level I or II Trauma facility is indicated, but the ground transport time to that hospital is judged

to be greater than twenty (20) minutes, determination of destination hospital shall be in accordance with medical

control.

Measure vital signs and level of consciousness:

Glasgow Coma Scale 12 or less

Systolic blood pressure <90, or

Respiratory rate <10 or >29

If Yes If No

Take to Level I or II Assess anatomy of injury

Trauma Facility 1. Gunshot wound to chest, head, neck, abdomen or groin

2. Third degree burns >15% BSA or third degree burns of

face or airway involvement

3. Evidence of spinal cord injury

4. Amputation other than digits

5. Two or more obvious proximal long bone fractures

If Yes If No

Take to Level I or II Assess mechanism of injury and other factors

Trauma Facility 1. Mechanism of injury:

a. Falls >20 feet

b. Apparent high speed impact

c. Ejection of patient from vehicle

d. Death of same car occupant

e. Pedestrian hit by car >20MPH

f. Rollover

g. Significant vehicle deformity-especially steering wheel

2. Other factors:

a. Age<5

b. Known cardiac disease or respiratory distress

c. Penetrating injury to thorax, abdomen, neck or groin

other than gunshot wounds

If Yes If No

Call Medical Control for direction Evaluate as per usual protocols

Severely injured patients<13 years should be taken to a Level I or II facility with pediatric resources including

pediatric ICU.

All EMS providers transporting trauma patients to hospitals shall provide receiving hospital with a complete OEMS

approved patient care form prior to departing from the hospital.

WHEN IN DOUBT, CONSULT WITH MEDICAL CONTROL

*State of Connecticut Regulation of Department of Public Health and Addiction Services Concerning Statewide

Trauma System: Sections 19a-177-5.

PEDIATRIC TRAUMA PATIENT



I. PRIMARY SURVEY

A. Airway and Cervical Spine Control

1. Maintain in-line cervical immobilization, children <8yrs of age have larger occiputs and

require elevation of the upper torso to achieve appropriate in-line cervical spine

immobilization.

2. Manual

a. Chin Lift

b. Jaw Thrust

3. Mechanical

a. Suction

b. Oropharyngeal Airway

c. Nasopharyngeal Airway

d. Pocket Mask

e. Orotracheal tube with in-line immobilization

f. Nasotracheal tube with in-line immobilization

g. Transtracheal Airway with in-line immobilization

Hypoxia is common in the trauma patient and correcting it is of the highest priority. A spinal injury may

be present and the airway should be managed as if C-spine instability exists. Concern about a spinal

injury must not delay institution of adequate ventilation and oxygenation. The neck should be

maintained in a neutral position. If an endotracheal tube is required, neutral stabilization of the spine

must be maintained throughout its insertion, so that the mandible and tongue are moved forward and the

head is not tilted backwards.

B. Breathing

Note degree of respiratory distress: increased respiratory rate, skin color change,

accessory muscle usage or noisy respirations.

Refer to Pediatric airway algorithm for management. Refer to Pediatric Medical protocols for

“Norms” in pediatric vital signs.

1. Ventilation

a. Mouth to mask

b. Bag-valve-mask

Age specific rates: <3yrs 30

3-6yrs 25

>6yrs 20

2. Flail Chest

a. Airway management




3. Open Pneumothorax

a. Partially occlusive dressing (3-sided)

b. Assist ventilations as needed with supplemental O2

4. Tension Pneumothorax

a. Decompression

i. Large bore needle with plastic catheter (angiocath)

ii. Second intercostal space (ICS) in Midclavicular Line, superior

aspect of the Third Rib

iii. Fifth ICS in Midaxillary Line

C. Circulation and Bleeding Control

1. Evaluation

a. Pulse

i. Rate

ii. Strength

iii. Location

b. Skin

i. Color

ii. Moisture

iii. Temperature

2. Cardiac compressions as indicated

3. Hemorrhage control

a. Direct pressure on wound and/or pack wound with sterile gauze

b. Pressure points (usually not required)

c. Tourniquet (seldom, if ever, indicated)

d. Traction splint

Pale skin color and pulse characteristics are accurate parameters used in assessing the status of

tissue perfusion. Blood pressure is obtained later in the patient’s assessment. Hemorrhage

control in the primary survey is used only for massive bleeding. Minor bleeding takes a lesser

priority. For patients with an unstable femur fracture, application of a traction splint is the most

important field technique for control of this type of hemorrhage. Patients with “open book”

pelvic fracture will benefit from stabilization and “direct pressure” from the PASG, in the

pediatric patient correct sizing is critical.




D. Disability

Glasgow Coma Scale

CHILD INFANT

Eye Opening 4 - opens spontaneously 4 - opens spontaneously

3 - opens to speech 3 - opens to speech

2 - opens to pain 2 - opens to pain

1 - none 1 - none

Verbal Response 5 - oriented 5 - coos and babbles

4 - confused 4 - irritable cry

3 - inappropriate words 3 - cries in pain

2 - incomprehensible words 2 - moans in pain

1 - none 1 - none

Motor response 6 - obeys commands 6 - spontaneous movement

5 - localizes pain 5 - withdraws to touch

4 - withdrawal to pain 4 - withdraws to pain

3 - flexion (pain) 3 - flexion (pain)

2 - extension (pain) 2 - extension (pain)

1 - none 1 - none

Changes in neurologic status can be of significance to the trauma surgeon or to the neurosurgeon.

Significant alteration can change the outcome for the patient

E. Exposure of the body for examination

It may be necessary to partially or completely expose the body to control hemorrhage

and perform lifesaving procedures. It is important to consider modesty and to respect

the individual’s needs. Nothing should be done to delay transport of the critically

injured patient.

II. RESUSCITATION

A. Supplemental oxygen should be delivered @100% for all multisystem trauma patients.

B. Volume replacement

Excess time should not be spent in the field attempting to establish and IV. Critically injured

patients should have rapid transportation to the trauma center and IV started enroute. Fluid

resuscitation is only indicated for patients with signs and symptoms of shock.




1. Blood pressure should be monitored

a. systolic/diastolic

b. pulse pressure

2. Venous access

a. peripheral IV (IO indicated in child<6yrs with symptomatic shock)

i. Large bore catheters

ii. Two sites preferred

b. Fluid(s) Normal Saline or Lactated Ringers; 20 ml/kg bolus

Repeat bolus per Medical Control

c. Buretrol/volutrol should be used for children <25kg.

III. SECONDARY SURVEY

A systematic evaluation of the patient beginning at the head and proceeding to the neck, thorax,

abdomen, and extremities should be completed. Unnecessary delay in order to carry out

diagnostic procedures that do not produce information concerning direct treatment in the pre-

hospital phase should not be attempted. Rapidly identify those patients who, because of the

critical nature of their situation, require rapid transport to an appropriate facility. These patients

should be stabilized and transported immediately.

A. Head

1. Airway

a. reevaluate

b. correct problems

2. Open Wounds

a. control hemorrhage with direct pressure

b. apply clean dressings to all wounds

3. Eyes

a. protect from further injury

b. irrigate to remove contaminants and debris (Morgan Lens if

appropriate)

c. do not remove foreign bodies

4. Nose and ears

a. pre-hospital evaluation for fluid (blood, CSF)

b. treatment usually not required




Most injuries to the face and head require hospital treatment - therefore delay in evaluation other

than hemorrhage control is usually not necessary. Lacerations of the scalp may have a fracture

beneath; therefore, unnecessary pressure is to be avoided. Use only enough pressure to control

hemorrhage. Transportation to the hospital should not be delayed other than to correct life

threatening airway problems.

B. Neck

1. Spinal immobilization; indications

a. any blunt injury above the clavicle

b. unconscious patient

c. multiple trauma

d. high speed crash

e. neck pain

f. complaints of extremity numbness/tingling

g. gunshot wound involving the torso

NOTE: For small children, an appropriate size collar may not be available. In the event that

collars available are too large, maintain cervical spine immobilization with an appropriate

pediatric immobilization board with head immobilizers or an appropriately padded KED may be

employed according to PEPP Guidelines.

2. Wounds

a. leave foreign bodies in place, but stabilized

b. use direct pressure to control hemorrhage

C. Thorax

1. Ventilation

a. Assure adequacy of ventilation

b. Reevaluate injuries identified and managed in the primary

survey

2. Myocardial contusion

a. EKG monitoring

b. Treat dysrhythmias according to PALS

3. Chest wall injuries

a. Simple isolated rib fractures, no pre-hospital management necessary

b. Flail chest

i. airway/ventilation management as necessary

c. Hemothorax

i. fluid replacement to treat shock

ii. ventilatory support as necessary




d. Open pneumothorax

i. three-sided dressing

e. Tension pneumothorax

i. needle decompression

f. Cardiac tamponade

i. fluid bolus

D. Abdomen

1. Evisceration

a. Clean, moist dressing

2. Foreign body

a. Do not remove except by direct order of medical control

b. Stabilize foreign body to prevent further injury during transport

3. Intra-abdominal hemorrhage

a. Intravenous fluids

4. Pelvic fracture

a. Long backboard immobilization

b. Consider PASG stabilization

E. Extremities

1. Examine for swelling and deformity

2. Check for neurovascular function

3. Apply direct pressure to control bleeding

4. Splint-reassess neurovascular status after splinting

5. Consider PASG for multiple lower extremity fractures

F. Neurologic - Head, spinal cord, and peripheral nerve trauma

1. Suspect associated C-spine injury and treat accordingly

2. All unconscious patients should be considered to have an inadequate respiratory

status and should have aggressive airway management with C-spine control.

3. If GCS <9 consider ventilation with B-V-M. Intubation (refer to airway algorithm)

4. Serial GCS determinations at least every 10 minutes

5. Pupillary evaluation

a. Reactivity

b. Equality

c. Size

6. Reassess motor and sensory function

7. IV fluids should be restricted unless shock is present

8. If shock is present, look for other causes of blood loss, as brain injury

alone is usually not the cause.




IV. TRANSPORTATION

It is impossible to fully stabilize the unstable patient in the pre-hospital setting. There must be a

balance of lifesaving skills (such as endotracheal intubation) with minimizing scene time (<10

minutes) and rapid transport in order to reduce the time from injury to definitive surgical

treatment.

Early “trauma” notification to the receiving hospital is essential to ensure the immediate

availability of an appropriate in-hospital response.

Committee on Trauma; American College of Surgeons; Resources for Optimal Care of the

Injured Patient.



PEDIATRIC BURN PATIENT

The approach to the pediatric burn patient should be similar in your approach to any burn patient,

assuring your safety, the patient’s safety, stopping the burning process, and airway management

all remain paramount.

These protocols will deal with specific fluid resuscitation measures and special considerations.

Please refer to the appendix for the “Rule of Nines.” Please refer to the Adult Trauma - Burn

section of these protocols for your “systems” approach to patient care.

Fluid Resuscitation

1) IV Normal Saline

2) IO is indicated in the patient <6yrs who needs fluid replacement and an IV cannot be

established.

3) As with adults, IV or IO sites should not be through a burn site unless no other site exists.

4) Administer 20 ml/kg bolus



a) Repeat bolus of fluid

b) Morphine 0.05-0.1 mg/kg for pain management

c) Versed 0.05 mg/kg for anxiety

Special Considerations:

The anatomical map of the pediatric patient changes with age, if in doubt as to the Body Surface

Area involved in the burn see the “Rule of Nines.”

Be suspicious for burn patterns that may indicate child abuse, i.e. “stocking” or “glove” pattern

burns.

Ophthalmic Chemical Burns

The Morgan Lens may be utilized in children >6yrs who are cooperative. Care must be take to

prevent any child who has had topical ophthalmic anesthesia from rubbing their eye - additional

injury may occur since the pain receptors have been blocked.



PEDIATRIC SPINAL CORD INJURY

1) Routine ALS Care

2) Focus on patient packaging with proper spinal immobilization

3) May be necessary to aggressively manage airway and ventilatory support

4) IV Normal saline

5) Reassess neurological status to all extremities

6) monitor vital signs

7) If the patient is hypotensive and tachycardic administer fluid bolus 20 ml/kg



a) Additional boluses IV fluids at 20 ml/kg

If evidence suspicious for spinal cord trauma: do not delay transport



Appendix A

Procedures



Conscious Sedation

Conscious sedation should be considered for those patients who require advanced airway management

and prior attempts at oral / nasal tracheal intubation has failed due to intact gag reflex, combative

behavior, and/or involuntary muscle contraction.

1) Routine BLS Care

2) Utilize BVM to ensure ability to provide ventilation

3) Routine ALS Care

4) Be sure to treat underlying pathology

Repeat attempt at intubation

5) If the patient cannot be intubated using usual methods contact On-Line Medical Direction for the

following sedation guidelines. Using the term “Medication Facilitated Intubation” will cover all

medications

6) Ativan 1mg SIVP or Valium 3-5mg SIVP

7) Etomidate (Amidate) 0.3mg/kg SIVP

8) If no response or inadequate sedation occurs:

9) Ativan 2-4mg SIVP or Valium 3-5mg SIVP

10) There is no second dose for Etomidate

11) Perform Endotracheal Intubation

12) Place a Bite block/Oral Pharngeal Airway to protect Endotracheal Tube

13) Confirm Tube Placement and Secure

Unable to Intubate

14) Resume BVM Ventilations

15) If unable to effectively ventilate with BVM, place CombiTube as per protocol

16) Unable to intubate cannot ventilate perform alternative airway per protocol

� Criccothyrodomy



Sedation to Manage Patient Airway Post-Intubation

Patient is intubated and being managed according to the proper protocol and begins to “fight the

tube.” In order to protect the patient’s airway and to manage the patient in a safe and effective

manner the follow protocol should be utilized.

1) Patient is intubated and has positive confirmation of tube placement.

2) Patient begins to “buck” or “fight the tube.”

3) If SBP > 100 may

a) Administer Versed 2-5mg slow IV to sedate patient or

b) Ativan 2-4 mg slow IV

4) Reconfirm tube placement in the usual manner.

5) Establish Medical Control

6) Possible Physician Orders:

a) Morphine 4mg IV

b) Additional Medication to sedate patient



Nasal-Tracheal Intubation

1. NASOTRACHEAL INTUBATION

Nasotracheal intubation requires both skill and patience to perform correctly. It is

frequently more time-consuming than orotracheal intubation. Nasal intubation can have

serious complications including epistaxis, sinusitis, and increased intracranial pressure. It

should be reserved for the critically ill patient who has failed to respond to conventional

airway and pharmacological interventions such as 100% oxygen by bag-valve-mask

ventilation, nitroglycerin, and furosemide.

Indications

1. Breathing patients requiring intubation where direct visualization of the posterior pharynx

is difficult or impossible, e.g., the inability to open the patient’s jaw or blood or emesis in

the airway obscuring direct visualization of the vocal cords, OR

2. Breathing patients with severe respiratory distress indicated by decreasing level of

consciousness, cyanosis, ineffective or decompensating respiratory effort.

Contraindications

1. Apnea

2. Suspected epiglottitis characterized by a sore throat, fever, and drooling

3. Pediatric patients weighing less than 30 kg (8 years old). This group of patients is best

managed with orotracheal intubation or bag-valve-mask ventilation.

4. Suspected mid-facial fractures or suspected basilar skull fractures indicated by head or

facial trauma with nasal hemorrhage, periorbital ecchymosis or swelling, hemorrhage from

ear canals, or maxillary bone deformity and instability.

5. Head injury

6. History of bleeding disorders or current anticoagulation therapy with agent such as

warfarin (Coumadin®).

7. Penetrating neck trauma or suspected laryngeal injury due to blunt trauma

Complications

1. Unrecognized esophageal intubation with subsequent hypoxic brain injury

2. Nasal bleeding

3. Turbinate avulsion



4. Nasopharyngeal or retropharyngeal laceration

5. Injury to vocal cords, epiglottis, or other airway structures

6. Vomiting and subsequent aspiration

7. Sinusitis, otitis media, bacteremia

Protocol

1. Begin preoxygenation with 100% O2 prior to the procedure. If the patient is conscious,

explain what is about to happen. Ensure that the scene is calm enough to hear the air

exchange when advancing the tube.

2. Instill Neosynephrine, two or three drops or sprays into both external nares. Early

installation allows adequate time to effect vasoconstriction of the nasal mucosa.

3. Prepare suction. In addition to vomiting, bleeding in the posterior pharynx may occur due

to insertion of the endotracheal tube.

4. Choose an endotracheal tube. The primary criteria for tube size is the nasal canal diameter.

Often a 7.0 mm tube is the best size for adults. Rarely a tube less than 6.5 mm will be

necessary. ET tubes with attached pull-rings (Endotrol) are preferable for the procedure.

5. Lubricate the endotracheal tube with 2% lidocaine gel or 2% lidocaine viscous.

6. Position the patient with head in midline, sniffing position. Use neutral neck position with

a cervical immobilization collar in place if cervical spine injury is suspected. The patient

may be in a sitting or upright position; patients in severe respiratory distress should be

intubated in the upright position.

7. With gentle steady pressure, advance the tube perpendicular to the facial plane through the

nare to the posterior pharynx. The beveled edge of the tube is placed against the nasal

septum to reduce the risk of bleeding. Advancing the tube tip along the nasal floor avoids

the turbinates and reduces the incidence of epistaxis. Never force the tube. If resistance is

felt, the tube could be dissecting under the nasal or pharyngeal mucosa. Withdraw the tube

part way, redirect, and advance again with gentle steady pressure.

8. Keeping the curve of the tube exactly midline, continue advancing slowly while listening

to air movement and watching for condensation in the tube. When the tube tip is nearest

the trachea, air movement will feel the strongest and sound the loudest. It may be helpful

to obstruct the mouth and the opposite nare.

9. A slight resistance may be felt just prior to entering the trachea. At the onset of the next

inspiration, advance the tube into the trachea with a quick, controlled movement. Usually

the first sign of correct passage is a violent cough. Advance the tube approximately one

inch further and then inflate the cuff.



10. If the patient develops laryngospasm or if the tube enters the esophagus, withdraw the tube

slightly. Reposition the tube tip above the level of the cords and wait until the patient

repeats inhalation. Re-attempt tube advancement. Application of cricoid pressure may

assist successful passage of the tube into the trachea.

11. If positive pressure ventilation with the bag-valve device produces sounds of air leakage

around the cuff, check the cuff inflation and the tube placement.

12. Ventilate and auscultate for bilateral breath sounds in the axillae and for the absence of

ventilatory sounds in the epigastrium.

13. Confirm proper placement with the use of a mechanical device such as Capnograghy,

Esophageal Bulb.

14. Tape or securely tie the tube with umbilical tape or other suitable material.

Notes

15. The attempt to nasotracheally intubate the patient should not exceed three minutes from

the time the ET tube is first introduced into the patient’s nare.

16. Whenever possible, pulse oximetry should be used during the procedure to monitor the

patient’s oxygenation status.

17. Some patients are best served by application of 100% oxygen by non-rebreather face mask

followed by urgent transport to a center capable of rapid sequence intubation. In general

most breathing head injury patients fall into this category because the adverse response to

the pain of nasotracheal intubation is likely more harmful than the short delay to definitive

placement of an endotracheal tube.

18. Documentation in the patient’s record should include at least the following:

a. Precautions taken (i.e. in-line stabilization)

b. Size of tube

c. Number of attempts where an attempt is defined as insertion of a endotracheal tube

into one of the nares

d. Depth of insertion (i.e "X" number of centimeters at the nares)

e. Complications

f. Method of confirmation of correct placement (e.g. esophageal intubation detector,

clinical exam).

19. When in doubt, take it out; and assure oxygenation by another attempt or method



TUBE CONFIRMATION ADJUNCTS

Statement: There are a number of different types and brands of end-tidal CO2 detectors, it will

not be dictated by the Region which type or which brand to use. However, it is the policy in the

Region that each patient who is intubated will have an end-tidal CO2 and/or Esophageal

Intubation Detector (EID) used to confirm placement and to monitor placement.

Indications:

All intubated patients weighing > 15 kg.

Procedure:

1. Following oral or nasal intubation, confirmation via positive and equal breath sounds and the

absence of epigastric sounds an end-tidal CO2 and/or EID will be placed.

2. Usual ventilation of the patient will take place with 100% oxygen.

3. Depending upon the type/brand of end-tidal CO2 detector used the paramedic will

confirm tube placement by noting color change or CO2 numbers.

4. If the EID (Esophageal Intubation Detector) is used, a rapid reinflation will occur

with correct placement of the ETT.*

5. If confirmation that the tube is correctly placed is noted, ETT will be secured in place

in the usual manner and monitored en route to the hospital.

6. If the end-tidal CO2 detector or EID indicates incorrect ETT, immediate visualization

of tube placement should be done. If ETT is incorrectly placed, immediately remove

ETT, hyperoxygenate patient and reattempt intubation.

7. If visualization shows the ETT properly placed, secure tube in the usual manner and

continue to ventilate and monitor patient en route to the hospital. Report finding to

physician caring for patient.

Note: Proper documentation on the patient’s PCR should indicate use of end-tidal CO2

and/or use of EID and findings.

*It is possible to have a positive placement finding with the EID. If the tube tip is

at the level right above the vocal cords, but not through the cords rapid inflation

of the bulb may occur.

Once a patient has stopped cellular respiration (death) color change is not always

possible even with a properly placed ETT.

It is possible for an end-tidal CO2 detector to have a positive color change with an

esophageal intubation. This may occur for a limited time (usually on 4 or 5

ventilations) correct color change can be assured after this.



INTRAOSSEOUS INFUSION

Indications:

1. Age 6 and under.

2. Unstable pediatric patient where IV access is unobtainable within 90 seconds, and:

i. Full arrest

ii Imminent arrest secondary to dysrhythmia or hypovolemic shock of any

etiology.

iii Status epilepticus not broken by medication given IM or rectal route.

3. Medications needed cannot be administered via an existing ET tube or other

medications or fluids are required.

Contraindications:

1. Fracture below the level of the insertion site.

2. Areas of cellulitis, burns or infections should be avoided.

Procedure:

1. Prep the skin with betadine or alcohol.

2. Identify the flat antero-medial surface of the tibia.

3. Move 1-3 cm below the tibial tuberosity.

4. Place the IO needle perpendicular to the skin and insert with a rotary twisting motion.

5. When decreased resistance (the “pop”) is noted, remove the stylet from the needle and

infuse 20 ml of Normal Saline push to clear the needle.

6. Observe the surrounding tissue for extravasation of fluid.

7. Connect the IV tubing and fluid to the intraosseous needle.

8. You may make two (2) attempts in the cardiac arrest setting.

Complications:

1. Infection

2. Compartment syndrome.

3. Subcutaneous extravasation.

4. Clotting of marrow in needle.

5. Localized cellulitis increases with length of time the needle is in place.



NEEDLE CRICOTHYROTOMY

Indication:

The inability to secure the patient’s airway by other invasive procedures, (endotracheal

intubation).

Cautions:

1. Needle cricothyrotomy is an invasive procedure and requires proper training and certification

through one of the Regional Sponsor Hospitals.

2. Carbon dioxide (CO2) build-up occurs rapidly. The procedure can be used only for a

short period of time (30 minutes maximum) at which time a definitive airway must be

established such as a Pertrach device.

3. The patient must have a patent airway or a means established to allow outflow of air

from the lungs.

Contraindications:

1. The ability to establish an easier and less invasive airway rapidly.

2. Acute laryngeal disorders such as laryngeal fractures that cause landmark distortion or

obliteration of landmarks.

3. Bleeding disorders.

4. Injury or obstruction below the level of the cricothyroid membrane.

Complications:

Pneumothorax

Subcutaneous emphysema

Catheter dislodgment

Hemorrhage

Esophageal or mediastinal injury

Hypercarbia

Equipment:

• 14 gauge over-the-needle catheter

• 10 cc syringe

• 3 cc syringe

• 15 mm adapter from a 7.0 ET tube

• Bag-valve-mask

• Oxygen

• Providone iodine swabs

• Adhesive tape



NEEDLE CRICOTHYROTOMY CON’t

Equipment:

• Trauma shears

• Suction equipment

• Gloves

• Goggles

Procedure:

• Observe basic precautions

• Prepare equipment: remove plunger from barrel of 3cc syringe. Attach 15mm

adapter from the 7.0 ET tube.

• Palpate the thyroid cartilage, cricothyroid membrane, and suprasternal notch.

• Prep the skin with two providone iodine or alcohol swabs.

• You may attach the 10 cc syringe to the over-the-needle catheter, or you may elect to

use the catheter-needle assembly by itself. Puncture the skin over the cricothyroid

membrane.

• Advance the needle at a 45-degree angle caudally (toward the feet).

• Carefully push the needle until it pops into the trachea (aspirating on the syringe as

you advance the needle if you are using a syringe).

• Free movement of air confirms you are in the trachea.

• Advance the plastic catheter over the needle, holding the needle stationary, until the

catheter hub comes to rest against the skin.

• Holding the catheter securely, remove the needle.

• Reconfirm the position of the catheter. Securely tape the catheter.

• Attach the 3 cc syringe with the 7.0ET adapter to the catheter hub. Attach the B-V-M

to the adapter and forcefully ventilate the patient. Forcefully squeeze the B-V-M over

one second to inflate and then remove the B-V-M to allow for exhalation (for 4

seconds).

• Constantly monitor the patient’s breath sounds, ventilation status, and color.

Adequate exhalation never forcefully occurs with this technique. The patient may

develop hypercarbia (increased CO2) and increased air pressure in the lungs possibly

causing alveoli to rupture.



NEEDLE THORACOSTOMY

Indication:

Tension pneumothorax associated with either traumatic or spontaneous lung collapse and

manifested by hypotension, severe respiratory distress, absent breath sounds with hyperresonance

on the affected side. There may be possible tracheal shift to the unaffected side.

Contraindications:

There are no contraindications for field use.

Procedure:

1. The patient is supine with head and chest to 30 degrees (semi-sitting position).

2. Explain procedure and rationale if patient is conscious. Bare the chest.

3. Select site for procedure—usually the anterior second or third intercostal space in the

midclavicular line. The anterior axillary line in the 5th

or 6th

intercostal space is

another good site, and may be technically easier and safer than the midclavicular

approach.

4. Prepare the skin with Betadine.

5. Select needle or over-the-catheter needle size 14 gauge or larger.

6. Holding the needle/catheter perpendicular to the chest wall, insert it straight into the

thorax, going just above a rib when one is encountered. Insert until air is heard

escaping. Advance catheter and remove needle. This converts a tension

pneumothorax to a simple pneumothorax. A chest tube thoracostomy will need to be

placed in the ED.

7. Cover puncture site, stabilize catheter to transport. Although not mandatory, when

possible, attach tube to flutter valve or flap valve.

“Pearls”

• Do not select a site near previous puncture site or scars.

• Use the largest needle or catheter possible since “plugging” with tissue may occur.

• Intercostal nerve or artery damage, be sure to go above not below it.

• Injury to the diaphragm - site is too low or the patient is not positioned correctly.

• Subcutaneous placement - insertion not perpendicular to chest wall (remember it is

curved not flat).

• Infections - late complication - prevent this by prepping the skin well.



ESOPHAGEAL-TRACHEAL COMBITUBE

Indication:

Apneic patient without a gag reflex in whom endotracheal intubation is unable to be established.

Contraindications:

1. Patient under the age of 16 years.

2. Patient under 5’0’’ or over 6’6” in height. (for patients under 5’0” there is a SA tube)

3. Ingestion of a caustic substance. “SA” for short adult

4. Severe oral facial trauma.

5. Esophageal disease.

6. Patient with a stoma.

Procedure:

1. Use basic precautions including gloves and goggles.

2. Hyperoxygenate patient before attempting placement.

3. Test equipment while patient is being oxygenated.

4. If basic airway is in place remove it; Keep head in neutral or slightly flexed position.

5. With one hand, grab tongue/mandible and lift towards ceiling.

6. With the other hand place the Combitube so that it follows the natural curve of the

pharynx.

7. Insert to the tip of the mouth and advance gently until the printed ring is aligned with

the teeth.

8. Do Not Force. If the Combitube does not advance easily withdraw and reinsert.

9. Inflate the blue tube balloon with 100 cc of air. Inflate the white tube balloon with

15cc of air.

#1 Blue - will inflate the posterior pharyngeal balloon.

#2 White - will inflate the distal balloon.

10. Begin ventilation through the longer blue connecting tube. If auscultation of breath

sounds is positive and auscultation of gastric insufflation is negative, continue

ventilations.

11. IF NECESSARY, if auscultation of breath sounds is negative, and gastric insufflation

is positive, immediately begin ventilation through the shorter connecting clear tube.

Confirm tracheal ventilation by ausculation of breath sounds and absence of gastric

insufflation.

12. Removal of Combitube: a. Reassure patient

b. Have suction ready and roll patient on their side.

c. Remove 100cc of air from #1 (Blue line).

d. Remove 15cc of air from #2 (White line).

e. Gently withdraw Combitube, suction patient as necessary.



MORGAN LENS

Indication:

For use in patients age 6 years and older who have sustained an exposure injury to the eye(s), (i.e.

dry or liquid chemical).

Equipment:

1. Gloves

2. 1000ml IV bag Normal Saline

3. IV tubing (macro drip)

4. Morgan Lens

5. Tetracaine or other ophthalmic anesthetic

6. Towels or chux

Procedure:

• Explain procedure to patient and give rationale.

• Use BSI (Body Substance Isolation)

• Unless contraindicated*, instill one or two drops of Tetracaine.

• Instruct patient not to touch/rub eye(s).

• Spike IV bag and attach/flush tubing, connect Morgan Lens, maintain sterile

environment of Morgan Lens.

• Have the patient look down, insert the Morgan Lens under the upper lid, then have the

patient look up, retract lower lid and allow lens to drop into place.

• Begin flow rate at wide open and maintain this rate per patient tolerance. Have plenty

of towels or chux to absorb flow.

*Contraindication: allergic reaction to local anesthetics, i.e. Novacaine, Lidocaine



RULE of NINES ADULT



RULE of NINES PEDIATRIC

Area Age 0 1 5 10 15

A= ½ of Head 9 ½ 8 ½ 6 ½ 5 ½ 4 ½

B= ½ of Thigh 2 ¾ 3 ¼ 4 ½ 4 ¼ 4 ½

C= ½ of Leg 2 ½ 2 ½ 3 3 3 ¼

Lund and Browder method of calculating pediatric BSA for burns.



Pediatric Rectal Valium Administration

1. Assure routine paramedic care

2. CONTACT ON-LINE MEDICAL CONTROL for the following

A. Administration of Diazepam for the clinical indication

B. Administration of the medication via the rectal route

It should be understood that permission for administering diazepam does not constitute

medical direction for administering per rectum.

Administering medication per rectum requires specific medical control.

Procedure:

1. Draw up contents of the vial into 2 tuberculin syringes. Each TB syringe will contain

5mgs in 1cc.

2. REMOVE THE NEEDLE FROM THE SYRINGE AND LUBRICATE THE TIP.

3. Gently insert the syringe into the patient’s rectum. This may facilitated by using a

finger.

4. Administer Diazepam. The dose should be 0.5mg/kg (0.1cc/kg) with a maximum dose

of 10mgs. No repeat doses may be administered.

5. Remove the syringe and squeeze the patient’s buttocks together for 5 minutes to

ensure medication does not leak out.

6. Monitor the patient’s respiratory status and vital signs, watching carefully for any

signs of respiratory depression or hypotension.



Appendix B

PHARMACOLOGY



Normal Saline (0.9% NaCl)

Class: Isotonic electrolyte

Action: Fluid and sodium replacement

Indications: IV access in emergency situations

Fluid replacement in hypovolemic states

Used as a dilutent for IVPB medications

Contraindications: None for field use

Precaution: Fluid overload

Side Effect: Rare

Dose: Dependent upon patient condition and situation, TKO, fluid bolus,

“wide open”

Route: IV infusion

Pediatric Dose: TKO or 20ml/kg bolus



Oxygen

Class: Gas

Action: Odorless, tasteless, colorless gas that that is necessary for life. Brought

into the body via the respiratory system and delivered to each cell via the

hemoglobin found in RBCs.

Indications: Any hypoxic patient or patient who may have increased oxygen demands

for any reason.

Contraindications: None for field use

Precautions: Patients with a history of COPD, however O2 should never

be withheld from any hypoxic patient.

Side effects: None with field use

Dose: Patient dependent 1 liter/minute to 100%

Route: Inhaled, or delivered via supplemental respiratory drive.



Adenocard (Adenosine)

Class: Endogenous nucleoside

Action: Stimulates adenosine receptors; decreases conduction through the AV

node

Indication: PSVT

Contraindication: Patients taking Persantin or Tegretol.

Precaution: Short half-life must administer rapid normal saline bolus immediately after

administration of drug. Use IV port closest to IV site.

Side effect: Arrhythmias, chest pain, dyspnea, bronchospasm (rare)

Dose: Adult - 6mg IV over 1-2 seconds; may repeat 12mg twice at 2 minute

intervals. Pedi - 0.1mg/kg, may repeat twice at 0.2mg/kg

Route: IV push



Atrovent (ipratropium bromide)

Class: Anticholinergic Bronchodilator

Action: Relaxes bronchial smooth muscle

Effect: Bronchodilation

Indication: For use in severe COPD and Asthma cases after Albuterol

Dose: 2.5ml nebulizer

Route: Nebulized updraft

Side effects: Tachycardia, palpitations, headache (most common)

Special Information: If patient has a know sensitivity to peanuts, soybeans do not give

them Atrovent. - Anaphylactic reaction.



Aspirin (acetylsalicylic acid)

Class: Antiplatelet

Action: Inhibitor of platelet aggregation

Effects: Decrease clotting time

Indication: Chest pain of cardiac origin

Dose: 325mg tab or 4-baby aspirin (81mg per tab)

Route: PO

Side Effects: None with field use

Contraindication: Sensitivity to ASA. Ulcerative disease and patients already on coumadin.

Note: GI upset is not a true allergy.



Versed (Midazolam HCL)

Class: Benzodiazepine (Short Acting)

Indications: Seizures, Sedation for Intubation and Pain Control (cardioversion and TCP)

Contraindications: Sensitivity to Versed or Benzodiazepines, Acute narrow angle glaucoma

Action: CNS Depressant

Effect: Sedation and Seizure Control

Onset: 1-3 minutes

Duration: 2-6 hours

Adverse Effects: Decreased Tidal Volume, Decreased Respiratory Rate, Respiratory Arrest,

Hypotension, Bradycardia, Pain During Injection, Site Tenderness, Hiccups, Nausea and

Vomiting, Oversedation, Potentiates Narcotics and dosages of both must be reduced.

Dosage Schedule: ADULT:

Seizures: 2-4mg IVP/IM may repeat as per MD Order.

Sedation for Pain and Anxiety: 2-4mg IVP/IM may repeat as per MD

Order.

Sedation to Aid or Post Intubation: 2mg IVP may repeat per MD Order.

NOTE: You will induce apnea prior to creating a “flaccid” patient.

PEDIATRIC:

Seizures: 0.1mg/kg (up to 2mg) slow IV/IM slow IV is given over 2

minutes. May be diluted normal saline or D5W for administration control.

NEONATES (0-6mo):

Seizures: 0.05 mg/kg Slow IV/IM slow IV is given over 2 minutes. May be

diluted normal saline or D5W for administration control.



Methergine (methylergonovine maleate)

Class: Oxytocics

Action: Increases motor activity of the uterus

Effect: Causes the uterus to contract

Indication: Postpartum hemorrhage caused by uterine atony

Dose: 0.2mg

Route: IM

Side effects: Rare in the field; dizziness, headache, hypertension

Special information: On set of action 2-5 minutes after IM injection

If discolored - do not use



ALBUTEROL (Ventolin, Proventil)

Class: ß2 Agonist

Synthetic sympathomimetic

Bronchodilator

Action: Stimulates ß2 receptors in the smooth muscle of the bronchial tree.

Indication: Relief of bronchospasm.

Contraindication: None for field use.

Precaution: Patient with tachycardia.

Side effect: Tachycardia

Dose: 2.5mg (0.5ml of the 0.5% solution) diluted to 3ml NS for nebulized updraft.

May repeat in 10-20 minutes.

Route: Inhaled as a mist via nebulizer.

Pediatric Dose: 1.25mg (0.3 ml of 0.5% solution) to 2.5mg diluted to 3ml NS for nebulized

updraft. May repeat in 10-20 minutes.



Ativan (lorazepam)

Class: Benzodiazepine

Action: Decreases cerebral irritability; sedation

Effect: Stops grand mal seizures; produces sedation

Common Indication: Status epilepticus, sedation for painful procedures

Dose: 1-2mg may repeat per MD orders

Route: IV push or IM

Side Effects: CNS and respiratory depressant



ATROPINE (Atropine Sulfate)

Class: Antimuscarinic

Parasympathetic blocker

Anticholinergic

Action: Blocks acetylcholine (ACh) at muscarinic sites

Indication: Symptomatic bradyarrhythmias

Cholinergic poisonings

Asystole

Refractory bronchospasm

Contraindication: none in emergency situations

Side effects: Tachyarrhythmias

Excerbation of Glaucoma

Precipitation of myocardial ischemia

Dose: Bradyarrhythmias - 0.5mg -1.0mg MR q 3-5 minutes

Asystole - 1mg MR q 3-5 minutes (total max. dose 3mg)

Organophosphate poisonings - 1mg - 2mg MR prn

Route: IV push

Pedi dose: 0.02mg/kg IV



Benadryl (diphenhydramine)

Class: Antihistamine

H1 blocker

Action: Blocks histamine receptor sites

Indication: Systemic anaphylaxis

Drug induced extrapyramidal reactions

Contraindication: None with emergency use

Precaution: Asthma

Side effect: Sedation

Hypotension

Dose: 25 -50mg

Route: IV push, may also be given IM

Pedi Dose: 1mg/kg



Calcium

Class: Electrolyte

Action: Facilitates the actin myosin interaction in the heart muscle.

Indication: Hypocalcemia

Hyperkalemia

Calcium channel blocker intoxication

Contraindication: Not to be mixed with any other medication - precipitates easily.

Precaution: Patients receiving calcium need cardiac monitoring

Side effect: Cardiac arrhythmias

Precipitation of digitalis toxicity

Dose: Usual dose is 5-10ml of 10% Calcium Chloride in 10ml.

Route: IV push

Pedi Dose: 0.2ml/kg of 10% concentration



Activated Charcoal

Class: Absorbent

Action: Absorbs many drugs and poisons in the GI tract

Indication: Toxic ingestions - not caustics or pure petroleums

Contraindication: None for emergency use

Dose: 50-100 grams

Route: PO - usually in liquid form to drink

Pedi dose: 1-2 grams/kg



Dextrose (D50)

Class: Carbohydrate

Action: Raises the blood sugar

Indication: Diabetic patients with low blood sugar level

Altered mental states

Seizure

Contraindication: none for field emergency use

Precaution: Tissue necrosis if infiltration occurs

Side effects: As above-infiltration

Intracerebral hemorrhages in neonates with undiluted D50

Dose: 25 Gms Slow IV push, may repeat

Route: IV slow, confirm IV placement prior to and during administration.

Pedi Dose: 1ml/kg of D50 slow IV push. Dilute 1 to 4 in those less than 1 week old

and 1 to 2 in those 1 week to 1 year.



Dopamine (intropin)

Class: Naturally occurring catecholamine, adrenergic agents

Action: Stimulates α, β1 and dopaminergic receptors

Effects: 0.5 to 2 µg/kg/min - Renal and mesenteric vasodilation.

2 to 10 µg/kg/min - Renal and mesenteric vasodilation persists and

increased force of contraction (FOC).

10 to 20 µg/kg/min - Peripheral vasoconstriction and increased FOC (HR

may increase).

20 µg/kg/min or greater - marked peripheral vasoconstriction (HR may

increase).

Indication: Shock - Cardiogenic

- Septic

- Anaphylactic

Contraindication: Pre-existing tachydysrhythmias or ventricular dysrhythmias.

Precaution: Infuse in large vein only

Use lowest possible dose to achieve desired hemodynamic effects, because

of potential for side effects.

Do not D/C abruptly, effects of dopamine may last up to 10 minutes after

drip is stopped.

Do not mix with NaHCO3 as alkaline solutions will inactivate dopamine.

Side effect: Tachydysrhythmias

Ventricular ectopic complexes

Undesirable degree of vasoconstriction

Hypertension relate to high doses

Nausea and vomiting

Anginal pain

Dose: 2.0 - 20. µg/kg/min titrated to desired effect

Route: IV drip

Pedi dose: same as adult dose - titrate to effect



Epinephrine 1:10,000

Class: Natural catecholamine, adrenergic

Action: Stimulates both alpha (a) and beta (ß1 and ß2) receptors.

Indication: Cardiac arrest

Severe anaphylaxis with shock

Contraindication: Use in pregnant women should be conservative

Pre-existing tachydysrhythmias

Side effects: Tachydysrhythmias

Hypertension

May induce early labor in pregnancy

Headache, nervousness, decreased level of consciousness

Dose: 0.5 to 1.0 mg (usual)

Route: IV, IO

ET if given this route the dose should be doubled

Pedi Dose: 0.01 mg/kg



Epinephrine 1:1,000

Class: Same as Epi 1:10,000

Action: Same as Epi 1:10,000

Indication: Severe allergic reaction

Angioneurotic edema

Bronchial edema

Contraindication: Use with caution in the presence of:

pre-existing tachydysrhythmias

hypertension

significant cardiac history

pregnancy

Side effect: Same as Epi 1:10,000

Dose: 0.3 mg

Route: Sub-Q

Pedi dose: 0.01 mg/kg to a max. 0.3 mg

see PALS guidelines



Etomidate

Trade Name: Amidate

Classification: Non-Narcotic, Non-Barbituate sedative hypnotic agent.

Mechanism: Etomidate produces deep hypnosis and sedation with an onset of 10-15 seconds and duration

of 5-15 minutes. It may lower intra-ocular and intra-cerebral pressure, and decrease cerebral oxygen

demand.

Dosage: 0.3mg/kg SIVP over 30-60 seconds.

Route: IV Only. Preferred site is ante-cubital as it may irritate the vasculature.

Indications: Conscious Sedation to facilitate intubation

Contraindications: Known Hypersensitivity. Under ten years of age.

Precautions: Hypoventilation and possible apnea in overdosage.

Myoclonus, or diffuse muscle contraction, which can be painful once the patient awakens. This

can be limited with the use of Ativan or Valium as premedication.

Side Effects: Pain at injection site, Hypotension, apnea, tachycardia, nausea/vomiting.

Note: Etomidate does not cause analgesia, therefore, reflex sympathetic hypertension and tachycardia

may be anticipated.



Lasix (furosemide)

Class: Loop diuretic

Action: Blocks active reabsorption of chloride in the kidney, results in diuresis

Mild venodilation results in decreased preload

Indication: Pulmonary edema

Contraindication: Allergy to sulfa drugs

Children under 12 yrs

Pregnancy

Precaution: Lasix bolus should be given over 1 minute

Lung sounds should be noted before and after administration of Lasix

Patients already taking diuretics may require a high dosage

Side effect: Dehydration

Decreased circulating plasma volume

Decreased cardiac output

Loss of electrolytes K+ and Mg++

Transient hypotension

Dose: 0.5 - 1.0 mg/kg (usual dose 40 mg)

Route: IV push - slow



Glucagon

Class: Pancreatic hormone

Action: Increases blood glucose by converting liver glycogen to glucose

Indication: Hypoglycemic patient who does not have IV access

Beta-blocker or calcium channel blocker overdose

Food bolus impaction in the esophagus

Contraindication: Known hypersensivity

Pheochromocytoma / insulinoma

Precaution: Mix with own dilutent - do not mix with saline

Side effect: Nausea / vomiting

Hyperglycemia

Dose: 1mg (1unit)

Route: IM

Pedi dose: 0.5 - 1mg



Lidocaine (Xylocaine)

Class: Antiarrhythmic

Action: Decreases ventricular irritability

Elevates fibrillation threshold

Indication: Intractable ventricular fibrillation

Ventricular ectopy consisting of wide complex tachycardia including VT

After successful defibrillation to prevent the reoccurrence of VF

Contraindication: AV blocks

Sensitivity to medication

Idioventricular rhythms

Sinus bradycardias, SA arrest or block

Ventricular conduction defects

Not used to treat occasional PVCs

Precaution: Reduce dose in patients with CHF, renal or hepatic diseases

Side effect: Early: Anxiety, apprehension, decreases LOC, tinnitus, visual

disturbances, euphoria, combativeness, nausea, twitching,

numbness, difficulty breathing or swallowing, decreased heart rate.

Late: Seizure, hypotension, coma, widening QRS complex, prolongation

of the P-R interval, hearing loss, hallucinations.

Dose: 1.0 -1.5 mg/kg, may repeat 3-5 minutes

IV - Drip usual dosage rate 2-4 mg/min

Route: IV, IO

ET - double usual IV dose.

Pedi dose: 1.0mg/kg total pedi dose-3mg/kg



Magnesium Sulfate

Class: Electrolyte

Action: Facilitates the proper function of many enzyme systems in the body

Facilitates the Na-K magnesium dependent ATPase pump

Blocks calcium non-selectively

Indication: Torsades de pointes

Refractory or recurrent VF or pulseless VT

Refractory seizures

Digitalis-induced cardiac arrhythmias

Pre-eclampsia

Documented hypomagnesemia

Contraindication: none for field emergency use

Precaution: Use with caution or not at all in the presence of renal insufficiency or high

degree AV block.

Side effect: Hypotension - mild but common

Heart block - uncommon

Muscular paralysis, CNS and respiratory depression - toxic effects

Dose: Torsades, refractory seizures, Digitalis, hypomagnesemia

- 2 grams over 1-2 minutes

Pre-eclampsia

- 4 grams over IV drip over ½ hour

- if actively seizing as above

VF/VT

- 2 grams IV bolus

Route: IV drip or IV push



Morphine Sulfate

Class: Narcotic analgesic

Action: Decreases pain perception and anxiety

Indication: AMI

Pulmonary Edema

Burns

Injuries not involving mental status changes

Contraindication: Head injury

Undiagnosed abdominal pain/injury

Multiple trauma

COPD/compromised respirations

Hypotension

Allergic to Morphine, Codeine, Percodan

Side effect: Respiratory depression or arrest

Decreased LOC

Hypotension

Increased vagal tone (slowed heart rate)

Nausea/vomiting

Pin-point pupils

Increased cerebral blood flow

Urticaria

Dose: 2 to 15mg - dependent on patient situation.


IO push - slow

IM

Pedi dose: 0.1mg/kg (usual dose)



Narcan (naloxone)

Class: Narcotic antagonist

Action: Reverses the effects of narcotics by competing for opiate receptor sites.

Will reverse respiratory depression cause by narcotics

Indications: Suspected overdose with depression of sensorium and/or respiration

Diagnostic tool in coma of unknown origin

Contraindication: none for emergency field use

Side effect: Narcotic withdrawal

Dose: 0.4mg to 2.0mg IV - titrate to respiratory effort

Alternative route is Intranasal (IN)

Route: IV push

IM

Pedi dose: 0.01mg/kg



Intra-Nasal Medication Delivery

Utilizing the Mucosal Atomization Device (MAD)

1) Draw Nalaxone into 3cc syringe.

a) Nalaxone concentration will be 1mg per 1cc.

b) Purge all air from syringe.

2) Remove and discard of needle in appropriate sharp proof container.

3) Attach Mucosal Atomization Device.

4) Place tip of MAD into nostril and deliver 1mg per nostril.

5) MAD can be reused on a single patient, and discarded after use.

6) Note medication delivery time.

7) If no response, proceed with intravenous access and intravenous medications.

8) Absorption may be inhibited by:

a) Epistaxis

b) Nasal Septum Deviation

c) Nasal Trauma.

If these conditions are suspected, do not utilize the MAD, proceed with IV access and IV

medication administration.



Neo-Synephrine (phenylephrine)

Class: Topical vasoconstrictor

Action: Stimulates alpha (a) receptors in blood vessels of the nasal mucosa

causing vasoconstriction. Decreases risk and amount of nasal bleeding.

Indication: Facilitation of nasotracheal intubation


Precaution: Administer prior to setting up equipment to allow medication a chance to

take effect.

Side effect: Hypertension

Palpitations

Dose: 2-4 sprays each nostril

Route: Nasal spray



Nitroglycerine

Class: Vascular smooth muscle relaxant

Action: Systemic vasodilator which decreases myocardial workload and oxygen

consumption.

Indication: Angina Pectoris

Pulmonary edema

Contraindication: Hypotension

Children under 12 yrs

Side effect: Hypotension

Headache and facial flushing

Dizziness, decreased LOC

Dose: 0.4mg may repeat q 3-5 minutes, titrate to pain, effect and blood pressure

Route: Sublingual - spray or tablet



Procainamide (pronestyl)

Class: Antiarrhythmic

Action: Suppress ventricular activity. May be effective when lidocaine is not.

Indication: Ventricular dysrhymias not controlled by lidocaine.

- recurrent VT

- refractory PSVT

- refractory VF/Pulseless VT

Contraindication: Complete heart block

PVCs in conjunction with bradycardia

Precaution: Hypotension following rapid injection

Widening of the QRS complex and lengthening of the PR or the QT

interval may induce AV conduction disturbances.

Use with caution in patients with AMI

IVP should not exceed 20mg/min. Not to exceed 1 gram total dose.

Side effect: Hypotension

Heart blocks, asystole, VF

Anxiety

Nausea/vomiting

Seizures

Dose: 20mg/min until one of the following is observed:

- arrhythmia is suppressed

- hypotension ensues

- QRS complex is widened by 50% of its original width

- a total of 1 gram has been given

Route: IV push

IV infusion (usual dose is 1-4 mg/min IV drip)

Pedi dose: Not for use in the pediatric patient



Sodium Bicarbonate (NaHCO3)

Class: Alkalotic agent

Action: Neutralizes acid in the blood. May help pH return to normal limits.

Indication: Combat metabolic acidosis

Tricyclic medication overdose after hyperventilation

Contraindication: Respiratory acidosis

Not to be used routinely in cardiac arrest

Side effect: Metabolic alkalosis

Lowers K+ which may increase cardiac irritability

Worsens respiratory acidosis if ventilation is inadequate

Dose: 1.0 Meq/kg, may repeat if indicated at ½ initial dose

Route: IV push



Solu-Medrol (methylprednisolone)

Class: Steroid

Glucocorticoid

Anti-inflammatory

Action: Thought to stabilize cellular and intracellular membranes

Indication: Reactive airway disease

Anaphylactic reaction

Spinal cord injury


Dose: Reactive airway disease - 40 to 125mg

Spinal cord injury - 30mg/kg IV drip over 15-20 minutes


IV drip (infusion)

Pedi dose: Reactive airway disease - 2 to 4mg/kg



Tetracaine Ophthalmic Solution

Class: Topical anesthetic for the eye only

Action: Produces anesthesia in the eye approximately 30 seconds after application

Indication: For pain control in burns to the eye

Contraindication: Known allergic reaction to Tetracaine or Novacaine type

medications.

Dose: 1 or 2 drops to the affected eye

Route: Topically to the eye

Pedi dose: 1 or 2 drops to the affected eye



Thiamine (Vitamin B1)

Class: Vitamin

Action: Essential for normal metabolism of carbohydrates (glucose)

Indication: Suspected malnourished or alcoholic patients receiving dextrose


Dose: 100mg

Route: IV push over one minute

May be given IM



Valium (diazepam)

Class: Benzodiazepine

Action: Decreases cerebral irritability

Calms CNS

Indication: Major motor seizures

Acute anxiety states

Pre-cardioversion


Dose: 2 to 20mg to control seizure activity

2 to 5mg for anxiety or pre-cardioversion


Pedi dose: 0.5mg/min to control seizure. Total dose 0.5mg/kg



Cardizem (Diltiazem)

Class: Calcium channel blocker

Action: Partial blockade of AV node conduction

Indication: Atrial fibrillation, atrial flutter, narrow complex tachycardia

Contraindication: Hypotension

Hypersensivity to drug

Wide complex tachycardia

Known history of Wolf Parkinson White (WPW)

2° or 3° AV block

Relative contraindication: Already on Digoxin and Beta Blocker

Side effect: May induce VF if given to patient with wide complex tachycardia that is due to

WPW.

May cause hypotension

Dose: 0.25mg/kg average dose 25mg per adult male

Route: IV push (bolus) given over 2 minutes; reconstitute according to manufacturer’s

recommendation.

Pedi dose: 0.25mg/kg

Important points: If patient is hypotensive secondary to drug administration:

- If bradycardia give Atropine

- If not in failure give fluids

- If CHF ensues or worsens administer Dopamine infusion



Hurricaine spray (benzocaine)

Class: Topical anesthetic

Action: Blocks conduction of impulses at the sensory nerve endings.

Indication: Nasal intubations or oral intubations where patient may still have gag reflex. To

improve patient comfort and tolerance of intubation.

Contraindication: Known sensitivity to benzocaine products.

Children under 1 year of age.

Precaution: Children under 6 years of age.

Side effect: Rash

Dose: 2-3 short sprays to the posterior pharynx, allow approximately 20-30 for effect to

occur.

Route: PO



REGION V M.A.C.

Spinal Assessment and Immobilization Criteria

Immobilize for ANY “Yes” Answer(s)

1. High Risk mechanism of Injury Yes No a. Patient Ejected from Vehicle? � �

b. Death in Same Passenger Compartment? � �

c. Fall Greater than 15 Feet or 3 Times Patient Height? � �

d. Vehicle Rollover (Patient’s Vehicle)? � �

e. High Speed1 Collision? � �

f. Vehicle Vs. pedestrian or Vehicle Vs. Bicycle Collision? � �

g. Motorcycle Collision/Accident? � �

h. Unresponsive or Altered Mental Status Following Fall/Collision? � �

i. Penetrating Injury to Head, Chest or Abdomen? � �

2. Unreliable Patient History/Exam Yes No a. Confused or Disoriented? � �

b. Intoxicated2? � �

c. Psychological/Psychiatric Indications? � �

d. Head Injury? � �

e. Loss of Consciousness? � �

f. Distracting injury(ies)? � �

g. Unable to Communicate Adequately? � �

Yes No

3. Neck or Back pain/Tenderness? (Palpate Entire Spine) � �

4. Abnormal Sensory/Motor Exam Yes No a. Inability to Move? � �

b. Asymmetrical Movement of Any Extremity? � �

c. Unable to Communicate Adequately? � �

d. Complaining of Burning, Tingling, or Numbness in Extremity? � �

Documents

(cardiac) Paramedic Protocols.pdf