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  • COOKE COUNTY EMERGENCY MEDICAL

    SERVICES Patient Treatment Protocols

    For use by Cooke County Emergency Medical Services

    These protocols are not valid unless signed by medical director in red ink on this page

    Douglas T. Lewis, M.D. Medical Director

    Effective Date: April, 2014

  • These protocols are unique to Cooke County EMS per Medical Director Page 1

    Table of Contents

    Geographical and Status Personnel ........................................................................................................... 5

    Protocol Definitions ................................................................................................................................... 6

    Trauma Section 5 37

    Introduction ................................................................................................................................................... 8

    Initial Scene Survey ...................................................................................................................................... 9

    Decision to Attempt Resuscitation .............................................................................................................. 10

    Initial Trauma Assessment and Treatment ......................................................................................... 11 14

    Traumatic Arrest ......................................................................................................................................... 15

    Traumatic Shock ......................................................................................................................................... 16

    Penetrating Injuries:

    Truncal Wounds .......................................................................................................................................... 17

    Neck wounds ............................................................................................................................................... 18

    Head/Face Wounds .................................................................................................................................... 19 Isolated Extremity Wounds ......................................................................................................................... 20

    Impaled Objects .......................................................................................................................................... 21

    Sucking Chest Wound ................................................................................................................................ 22

    Traumatic Brain Injury ......................................................................................................................... 23 24

    Eye Injuries:

    Corneal Burns and Abrasions ..................................................................................................................... 25

    Blunt or Penetrating Eye Injuries ................................................................................................................. 26

    Burn Injuries:

    Chemical Injuries to Eye .............................................................................................................................. 27

    Thermal Burns .................................................................................................................................... 28 29

    Chemical Burns .......................................................................................................................................... 30

    Electrical Burns / Electrocutions ................................................................................................................. 31

    Amputation ................................................................................................................................................. 32

    Pregnant Trauma Patient ............................................................................................................................ 33

    Pediatric Trauma ................................................................................................................................ 34 35

    Isolated Musculo-Skeletal Injury ................................................................................................................. 36

    Acute Blunt Spinal Cord Injury .................................................................................................................... 37

    Domestic Violence ...................................................................................................................................... 38

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    Medical Section 40 81

    Abdominal Pain .......................................................................................................................................... 40 Allergic Reaction Mild .............................................................................................................................. 41 Allergic Reaction Moderate ...................................................................................................................... 42 Allergic Reaction Severe - Anaphylaxis ...................................................................................................... 43 Cardiac Arrest ............................................................................................................................................. 44 Asystole ...................................................................................................................................................... 45 Pulseless Electrical Activity (PEA) .............................................................................................................. 46 VF / Pulseless VT ....................................................................................................................................... 47 Post Resuscitation ...................................................................................................................................... 48 Bradycardia ................................................................................................................................................ 49 PSVT: Stable .............................................................................................................................................. 50 PSVT: Unstable .......................................................................................................................................... 51 VT: Stable ................................................................................................................................................... 52 VT: Unstable ............................................................................................................................................... 53 Acute Coronary Syndrome (Chest Pain - Suspect MI) ........................................................................ 54 55 STEMI ................................................................................................................................................. 56 57 Induced Hypothermia .......................................................................................................................... 58 59 Cardiogenic Shock ...................................................................................................................................... 60 Hypotension / Shock unexplained ............................................................................................................ 61 Hypertensive Crisis ..................................................................................................................................... 62 Stroke ......................................................................................................................................................... 63 Asthma ....................................................................................................................................................... 64 CHF and Pulmonary Edema ....................................................................................................................... 65 COPD ......................................................................................................................................................... 66 Pneumonia / Bronchitis ............................................................................................................................... 67 Seizures ...................................................................................................................................................... 68 Dehydration ................................................................................................................................................ 69 Diabetic Emergencies ................................................................................................................................. 70 Altered Mental Status ................................................................................................................................. 71 Overdose / Poisoning ................................................................................................................................. 72 Behavioral/ Emotionally Disturbed .............................................................................................................. 73 Chemical Restraint ..................................................................................................................................... 74 Carbon Monoxide Poisoning ....................................................................................................................... 75 Heat Cramps / Exhaustion .......................................................................................................................... 76 Heat Stroke ................................................................................................................................................. 77 Hypothermia ............................................................................................................................................... 78 Radiation Exposure .................................................................................................................................... 79 Snakebite .................................................................................................................................................... 80 Sexual Assault ............................................................................................................................................ 81

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    OB / GYN Section 82 90

    Vaginal Bleeding ......................................................................................................................................... 83 Pre-Eclampsia / Eclampsia ......................................................................................................................... 84 Labor .......................................................................................................................................................... 85 Delivery ....................................................................................................................................................... 86 Breech Presentation ................................................................................................................................... 87 Cord Presentation ....................................................................................................................................... 88 Limb Presentation ....................................................................................................................................... 89

    Pediatric Section 90 115

    Post Delivery .............................................................................................................................................. 91 Neonatal Resuscitation ............................................................................................................................... 92 Meconium Staining ..................................................................................................................................... 93 Asystole ...................................................................................................................................................... 94 PEA ............................................................................................................................................................ 95 VF / Pulseless VT ....................................................................................................................................... 96 Post Resuscitation ...................................................................................................................................... 97

    Unstable Narrow Complex Tachycardia ..................................................................................................... 98

    Bradycardia ................................................................................................................................................ 99

    Abdominal Pain ........................................................................................................................................ 100

    Allergic Reaction Mild ............................................................................................................................ 101 Allergic Reaction Moderate ...................................................................................................................... 102 Allergic Reaction Severe- Anaphylaxis ...................................................................................................... 103 Altered Mental Status ............................................................................................................................... 104 Hypoglycemia ........................................................................................................................................... 105 Hyperthermia ............................................................................................................................................ 106 Hypothermia ............................................................................................................................................. 107 Near Drowning .......................................................................................................................................... 108 Overdose / Poisoning ................................................................................................................................ 109 Asthma ..................................................................................................................................................... 110 Bronchiolitis .............................................................................................................................................. 111 Croup ........................................................................................................................................................ 112 Epiglottitis ................................................................................................................................................. 113 Obstructed Airway / Foreign Body ............................................................................................................ 114 Seizures .................................................................................................................................................... 115

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    Appendix: Procedure Protocols 114 153

    Pain Management ..................................................................................................................................... 117 Medication Assisted Intubation (MAI) ....................................................................................................... 118 Rapid Sequence Induction for Intubation (RSI) ............................................................................... 119 120 Continued Sedation / Paralysis ................................................................................................................. 121 Airway Management for the Burn Victim ................................................................................................... 122 Air Evacuation Protocol ............................................................................................................................ 123 Pacing Protocol ........................................................................................................................................ 124 DNR Protocol .................................................................................................................................. 125 126 Transtracheal Jet Ventilation .................................................................................................................... 127 Surgical Cricothyroidotomy ....................................................................................................................... 128 Nasotracheal Intubation ............................................................................................................................ 129 Orotracheal Intubation .............................................................................................................................. 130 King Airway ............................................................................................................................................... 131 Needle Chest Decompression .................................................................................................................. 132 Mucosal Atomization device (MAD) .......................................................................................................... 133 Portable Ventilator .................................................................................................................................... 134 Tidal Volumes (Pedi & Adult) ..................................................................................................................... 135

    Blood Administration ................................................................................................................................. 136

    Continuous Positive Pressure ................................................................................................................... 137

    EZ IO Intraosseous Infusion .................................................................................................................. 138

    Rule of Nines Adult Burn Chart ................................................................................................................ 139

    Rule of Nines Child Burn Chart ................................................................................................................ 140

    Lund & Browder Burn Chart ...................................................................................................................... 141

    Classification of Burn Severity Reference ................................................................................................. 142

    Pediatric Drug Chart ................................................................................................................................. 143

    Drug Calculations ...................................................................................................................................... 144

    Dopamine Drip Chart ................................................................................................................................ 145

    Levophed Drip Chart ................................................................................................................................. 146

    Nitroglycerin Drip Dosage Chart ............................................................................................................... 147

    Dobutamine Drip Chart ............................................................................................................................. 148

    Nasogastric Tube ..................................................................................................................................... 149

    12 Lead Placement Reference .............................................................................................................. 150

    Termination of Pre-hospital Resuscitation ................................................................................................. 151

    Spinal Immobilization Clearance .............................................................................................................. 152

    Orthostatic BP Measurement .................................................................................................................... 153

    Start Triage Guide System .................................................................................................................... 154

    Rapid NIHSS form .................................................................................................................................... 155

    Drug Guide Section 155 200

    Pregnancy Category for Drugs ................................................................................................................. 156 Drugs A Z .................................................................................................................................... 157 205

  • These protocols are unique to Cooke County EMS per Medical Director Page 5

    Geographical and Status of Personnel

    Geographical Responsibility and Status of Personnel

    Cooke County Emergency Medical Services covers 874 Sq. Miles of Cooke County. We are a rural EMS provider with

    pockets of dense population. This protocol is to clarify when an EMT, EMT-P, Licensed Paramedic or Critical Care

    Paramedic may perform his or hers protocols and in what areas they may utilize these protocols.

    It is intended that these protocols are for on duty personnel. It is understood that there are times the off duty personnel

    respond to major incidents, and in this case, the off duty personnel may utilize their skills. It is further understood that off

    duty personnel may come across incidents that may require for them to utilize their skills. Within the operating area of

    Cooke County, the personnel may utilize their skills, but all must be documented on the Patient Care Report.

    Off Duty personnel that are traveling outside of Cooke County, that come across an incident, may utilize all their skills

    within the guidelines of these protocols. An incident report must be completed and turned into the Administrator, and a copy

    must go to the Medical Director for review.

    On Duty personnel that are out of Cooke County EMS operating area and come across and incident, may utilize their

    skills to the certified level. All appropriate patient care documentation must be completed.

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    Protocol Definitions

    Definitions

    1. Vital signs

    For the purposes of these protocols, vital signs will be defined as follows:

    a. Pulse b. Respirations c. Blood Pressure d. Pulse Oximetry e. Temperature f. Blood Glucose (as Indicated) g. End Tidal Co2 numbers and Charted waveforms on the following types of patients:

    1) All intubated patients

    2. Multi-Casualty Incident: Any incident that overwhelms local response capabilities

    3. Verified intubation tube placement

    A successful endotracheal intubation will be verified and documented by at least 4 of the following criteria:

    a. Direct Visualization of tube passing through the cords b. Auscultation of six lung fields with positive air return c. Auscultation of an absence of air in the epigastrium d. Fogging of the tube e. Positive initial ETCO2 return f. Continuous ETCO2 return g. Charting of ETCO2 waveform h. Proper use of Bougie Stylet device

    4. Pediatric Limits

    a. Any patient < 18 years of age and < 40 kg or b. Any patient < 12 years of age.

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    Trauma

    Protocols

  • These protocols are unique to Cooke County EMS per Medical Director Page 8

    Trauma Introduction

    The initial assessment and treatment of a trauma patient must be performed in a rapid, systematic, and thorough fashion. Evaluation of the patient according to established priorities will help one to identify serious life-threatening situations quickly, so that intervention can take place, possibly preventing further deterioration in the patients status. The systematic evaluation of the trauma patient should be performed on all injured patients, even those with minor trauma. The most important priorities in the evaluation and treatment of the trauma patient are found in the primary survey of the patient. Frequently, patient assessment must occur simultaneously with patient treatment during this phase of the patients evaluation. At times, invasive procedures (e.g., intubation with in-line cervical stabilization) or initiation of rapid transport may be required before the complete, overall patient assessment is achieved.

    The primary survey in a trauma patient includes assessment and treatment of the following:

    1. Airway Evaluation, establishment, and maintenance of an airway using C-spine precautions; determination of the patients level of consciousness in order to provide additional information concerning the patients airway status.

    2. Breathing Determination of whether or not a trauma patient is adequately breathing and oxygenating. Serious chest injuries may rapidly progress to cardio-respiratory arrest, and certain chest injuries

    that may require immediate intervention (sucking chest wounds, tension pneumothorax).

    3. Circulation Determination if a pulse is present, controlling external bleeding, and identification of injuries that may use significant blood loss. Initiation of rapid transport and intravenous fluids play a role in the treatment of the patient at this stage.

    4. Disability Performance of a rapid neurological evaluation to establish a patients level of consciousness, and pupillary size and reaction.

    5. Exposure The clothing is removed to identify all injured areas with special care to avoid hypothermia.

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  • These protocols are unique to Cooke County EMS per Medical Director Page 9

    Trauma - Initial Scene Survey This guideline should be used in the initial assessment of the scene where a trauma patient is located.

    1. Survey the scene for possible hazards and resurvey periodically. 3. Secure the scene. 4. Protect yourself first, then victims from hazards. 5. Identify mechanism of injury. 6. Identify all potential patients. Notify Medical Control of victim count. 7. Prioritize patients, if more than one, using the same ABC system. 8. If MCI, triage using START. 9. Notify Medical Control of victim count.

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  • These protocols are unique to Cooke County EMS per Medical Director Page 10

    Trauma Decision to Attempt Resuscitation

    The following are guidelines regarding the decision to attempt resuscitation in the field. Good judgment and common sense shall be used in the application of these guidelines. 1. In all situations where there is any possibility that life exists, every effort should be made to resuscitate the patient and transport to the hospital. 2. The paramedic should be aware of the following facts:

    a. Those persons in VF, PEA, and Asystole can potentially be resuscitated. b. That time down is an inaccurate parameter of resuscitation, as the patient could have been in bradycardia or

    simply unconscious for all of that time, yet still perfusing blood to the brain. Additionally, information received from bystanders in regard to time is often inaccurate.

    c. That pupil size and response to light can be inaccurate as medications taken orally or intraocular can affect them. Additionally, children and hypothermic patients may have fixed and dilated pupils from anoxia and yet be resuscitated without neurological deficit.

    3. Resuscitation need not be attempted in the field in cases of:

    a. Decapitation b. Decomposition c. Rigor mortis d. Dependent lividity e. Visual massive trauma to the brain or heart conclusively incompatible with life

    f. Blunt mechanism of injury in cardiac arrest 4. Mass Casualty Incidents - In these situations, the acceptable triage protocol will apply.

    5. Living Wills - The paramedics actions should not be changed by a Living Will described or produced by the family or bystanders. 6. NO TRANSPORT Decisions to not transport must be approved through MEDICAL CONTROL.

    Note: Since it is usually not possible to predict no recoverability of a brain acutely insulted by cardiac arrest and attempts to do so increase anoxia time with the likelihood of further permanent brain damage, the responsible paramedic is usually obligated to start CPR. Paramedics should keep in mind that they may be held liable if they elect not to do so, on an arbitrary basis.

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  • These protocols are unique to Cooke County EMS per Medical Director Page 11

    Trauma - Initial Assessment and Treatment

    Clinical Definition: This guideline establishes priorities in the initial assessment and treatment of trauma patients. The trauma patient must be evaluated and treated in a rapid and orderly fashion in order to achieve the best patient outcome. When a life threatening problem is identified, treatment is initiated for that problem before proceeding with the next step in the guideline. Using this approach, life-threatening injuries are identified and treated in a stepwise manner.

    NOTE: Assume the following in ALL severely injured patients:

    a. The patient has a spinal injury until proven otherwise b. The patient has an immediate threat to life that has not yet been found. c. The patient is going to decompensate at any moment.

    The only aspects of patient care that, in most cases, would be performed prior to the initiation of patient transport include:

    a. Establish and maintain an adequate and appropriate airway with oxygenation and ventilation as required. b. Immobilize and protect the spine as indicated and required c. Initial attempts to control significant external hemorrhage

    AIRWAY: Basic Life Support: 1. Assess level of consciousness 2. Assess, establish, and/or maintain an adequate airway, while also observing C-spine precautions. Apply cervical collar

    if indicated and while doing so, note: a. Is trachea midline? b. Any bruising, swelling, or crepitus in the neck? c. Is carotid pulse present? If no pulse present, begin CPR and immediately refer to Traumatic Arrest Protocol.

    (pg. 15) 3. Insert oral or nasopharyngeal airway as indicated. 4. Administer high flow oxygen (100% by face mask or BVM) and assist patients ventilation as needed. If the patient has a decreased level of consciousness, ventilate:

    a. 13 y/o 10 18 breaths/mi b. 5 12 y/o 20 25 breaths/min c. 0 4 y/o 30 40 breaths/min

    If the patient has a decreased LOC or other signs of a traumatic brain injury: refer to Traumatic Brain Injury Protocol (pg. 23), after completion of the Initial Trauma Assessment and Treatment Protocol. (pg. 11-14)

    5. Reassess patient frequently including adequacy of ventilations. Intermediate and Paramedic I: 6. Establish need for in-line endotracheal intubation. Observe C-spine precautions. 7. If intubation is necessary, it should be performed using the two-man technique with one person stabilizing the cervical spine while the other person performs the intubation. Extreme care must be taken to avoid flexion or extension of the neck.

    8. If intubation is performed, endotracheal tube placement should be assessed and documented using three or more of the

  • These protocols are unique to Cooke County EMS per Medical Director Page 12

    following techniques:

    a. Visualization of endotracheal tube passing through vocal cords. b. Equal breath sounds. c. Absence of ventilated air in the epigastrium d. Rise and fall of chest wall. e. Use of a Bougie f. Fogging of the Endotracheal Tube g. Positive Initial Co2 return with EtCo2 (if available) h. Charting of ETCO2 waveform

    9. End-tidal CO2 monitor. If the patient has a decreased level of consciousness, ventilate to maintain an EtCo2 of 35 45 mmHg, otherwise ventilate at a rate of 12 20 breaths/minute for adults and children at a rate of 20 30 breaths/min for children less than 4 years of age. If the tube cannot be confirmed in the proper position, it should be removed and the patient re-intubated. When proper placement is confirmed, the tube should be properly secured with tube holder and c-collar and CID to minimize the chances of dislodgment. (If unable to fit patient with c-collar, secure head with CID).

    10. Reassess patients airway/ventilation frequently. NOTE: Failure to provide and maintain an adequate airway is the most common cause of preventable pre-hospital morbidity and mortality. The airway should be carefully assessed initially and frequently reassessed to assure a competent airway is maintained during the pre-hospital phase of treatment. BREATHING: Basic Life Support:

    1. Observe chest wall movement for symmetry and auscultate breath sounds on both sides of the chest. Rate, depth, and pattern of breathing as well as the integrity of the chest wall should be assessed. 2. Assist or deliver ventilations as required. All patients with a decreased level of consciousness ventilate:

    a. 13 y/o 16 18 breaths/min b. 5 12 20 24 breaths/min c. 0 4 y/o 20 30 breaths/min

    3. All patients with more than minor injuries (e.g., isolated extremity fractures, minor lacerations, etc.) should receive supplemental 100% oxygen by non-rebreather mask or BVM. 4. If sucking chest wound has been identified, apply dressing as described in Sucking Chest Wound Protocol. (pg. 22) Intermediate: 5. If patient is breathing inadequately, assist ventilations with 100% oxygen through mask or endotracheal tube to maintain a EtCo2 of 35 45 mmHg. Paramedic I: 6. If signs of tension pneumothorax are present, refer to the Needle Chest Decompression Protocol (pg. 132) and contact MEDICAL CONTROL

    CIRCULATION/ BLEEDING:

  • These protocols are unique to Cooke County EMS per Medical Director Page 13

    Basic Life Support: 1. Control serious external bleeding by direct pressure or pressure dressings. 2. If not already done, palpate for a pulse. If not present, initiate CPR and proceed to the Traumatic Arrest Protocol (pg. 15) 3. If pulse is present, then obtain pulse rate and BP. If systolic BP < 90, Heart Rate > 120, and/or clinical evidence of shock is present, refer to Traumatic Shock Protocol. (pg. 16) 4. Palpate abdomen for rigidity or tenderness and pelvis for pain or crepitus (identifying potential sources for significant blood loss). 5. Examine the patients back, if possible, for gross deformities or penetrating injuries prior to placing the patient on the backboard. 6. For penetrating injuries, also see Penetrating Injuries Protocol. (pg. 17)

    Intermediate and Paramedic I: 7. If there is evidence of a significant mechanism of injury, external blood loss, or evidence of possible pelvic or femur fracture or other significant injuries, attempt to establish 2 large bore IVs with NS and run wide open if the patients SBP is less than 90 mmHg systolic. Run IV at TKO rates or at the direction of MEDICAL CONTROL. Attempts to establish IV access are usually made en route. Transport should not be delayed for multiple attempts at initiation of an IV. If long transports are necessary, maximum volumes and flow rates should be determined by MEDICAL CONTROL. Pressurized infusion devices may be used. If the patient has a SBP < 90 or heart rate > 120, see the Traumatic Shock Protocol. (pg. 16)

    DISABILITY (Neurological Exam): All Levels: 1. Evaluate neurological status by noting the following:

    a. Mental status/level of consciousness. b. Presence/absence of movement in extremities, either spontaneously or in response to pain c. Pupillary size and reactivity. d. Evidence of trauma to the head or neck.

    2. If evidence of head trauma, have suction ready and observe for any seizure activity. 3. If altered level of consciousness, assist or ventilate patient (if patient will allow).

    a. 13 y/o 16 18 breaths/min b. 5 12 y/o 20 26 breaths/min c. 0 4 y/o 30 40 breaths/min

    End-tidal CO2 monitor, ventilate to maintain an EtCo2 of 35 45 mmHg. 4. If evidence of closed head injury, see Traumatic Brain Injury Protocol. (pg. 23-24)

    NOTE: The patients status must be reassessed at frequent intervals to detect changes and these changes should be immediately reported to Medical Control. The ABCs including vital signs should be repeated every 15 minutes in potentially stable patients and every 5 minutes in unstable patients.

    EXPOSE AND EXAMINE:

  • These protocols are unique to Cooke County EMS per Medical Director Page 14

    All Levels:

    1. Examine for specific injuries burns, chemicals, drowning, eye, etc. If present, see specific protocol.

    2. Assess extremities by inspection and palpation for present of tenderness, gross deformity, soft tissue swelling, lacerations, or

    abrasions. Also, note motor, sensory, and vascular integrity in each extremity. Appropriately dress and splint extremity injuries as

    required and as time will allow. Elevate injured extremities when possible.

    3. If possible, when patient is log rolled onto backboard, palpate and inspect back for evidence of trauma.

    4. Calculate Glasgow Coma Score and Revised Trauma Score.

    GLASGOW COMA SCORE

    REVISED TRAUMA SCORE

    Eye Opening

    Spontaneously

    To verbal Command

    To Pain

    No Response

    Score:

    Best Verbal Response

    Oriented

    Confused

    Inappropriate words

    Incomprehensible sounds

    No Response

    Score:

    Best Motor Response

    Obeys

    Localized Pain

    Withdraws to pain

    Abnormal Flexion to pain

    Extension to pain

    No Response

    Score:

    Total

    4

    3

    2

    1

    5

    4

    3

    2

    1

    6

    5

    4

    3

    2

    1

    Score

    _____

    Respiratory Rate

    10 29 =

    > 29 =

    6 9 =

    1 5 =

    0 =

    Score:

    Systolic Blood Pressure

    > 89 =

    76 89 =

    50 75 =

    1 49 =

    0 =

    Score:

    Glasgow Coma Score

    13 15 =

    9 12 =

    6 8 =

    4 5 =

    3 =

    Score:

    Total

    4

    3

    2

    1

    0

    4

    3

    2

    1

    0

    4

    3

    2

    1

    0

    Score

    _____

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    Traumatic Arrest

    Clinical Definition: This protocol should be used for the treatment of a patient who has suffered a traumatic cardiac arrest. Patients with a blunt mechanism of injury and who have a cardiac arrest have minimal, if any, chance of survival, and many pre-hospital providers do not attempt resuscitation. For those providers who attempt resuscitation, the following protocol should be used. Resuscitation should be attempted in all patients with a penetrating mechanism of injury. Basic Life Support: 1. If not already done, evaluate/treat ABCs according to Trauma assessment and Treatment Protocol. (pg. 11-14) 2. Initiate CPR and prepare for rapid transport. Immobilize spine, if appropriate. Intermediate: 3. Establish patent airway using in-line cervical spine stabilization, if appropriate. 4. Identify correctable causes of hypoxia and initiate treatment:

    a. Administer 100% oxygen. b. For sucking chest wounds, treat according to Sucking Chest Wound Protocol. (pg. 22)

    5. End-tidal CO2 monitor. If the patient has a decreased level of consciousness, ventilate to maintain an EtCo2 of 35 45 mmHg, otherwise ventilate at 12 20 breaths/minute for adults and children at 20 30 breaths/min for children less than 4 years of age. 6. Attempt to establish 2 large bore IVs with Normal Saline and run wide open. Attempts at IV access should be made en-route. Transport should not be delayed for multiple attempts at initiation of an IV. If long transports are necessary, maximum volumes and flow rates should be determined by MEDICAL CONTROL. Pressurized infusion devices may be used. If unable to obtain IV, IO may be used.

    Paramedic I: 7. Apply ECG electrodes and determine cardiac rhythm. 8. If rhythm other than PEA, treat cardiac arrhythmia per protocol during transport. 9. Continue evaluation as per Initial Trauma Assessment and Treatment Protocol. (pg. 11-14)

    10. Evaluate for tension pneumothorax, Contact Medical Control and refer to the Needle Chest Decompression Protocol. (pg. 132)

    Note: PEA in a trauma patient is most likely due to hypovolemia from blood loss. Definitive therapy is usually required to

    stop the source of hemorrhage and blood transfusions are needed usually ASAP. Hence rapid extrication and transport is essential. Remember that Normal Saline helps expand the circulating blood volume BUT DOES NOT CARRY OXYGEN.

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    Trauma - Traumatic Shock

    Clinical Definition: This protocol should be used for the treatment of patients with traumatic shock SBP < 90 & HR > 120, but with a palpable pulse. If no pulse is palpable, proceed to (Traumatic Arrest Protocol) (pg. 15). Frequently, shock in a trauma patient is due to internal or external bleeding. Hemorrhagic shock can be recognized by hypotension, tachycardia, diaphoresis, pallor, cyanosis, tachypnea, and other clinical signs of shock. Fluid resuscitation should be aimed at maintaining a SBP 70 90 mm/hg and no higher. Basic Life Support: 1. If not already done, evaluate/treat ABCs according to the Initial Trauma Assessment and Treatment Protocol. (pg. 11) 2. Prepare for rapid transport. Intermediate: 3. Establish a patent airway using C-spine precautions. Use End-tidal CO2 monitor to maintain an EtCo2 of 35 45

    mmHg, otherwise ventilate at 12 20 breaths/minute for adults and larger children and at 20 30 breaths/min for children less than 4 years of age.

    4. Attempt to establish 2 large bore IVs with Normal Saline and run wide open. Attempts at IV access should be made en route. Transport should not be delayed for multiple attempts at initiation of an IV. If long transports are necessary, maximum volumes and flow rates should be determined by MEDICAL CONTROL. Pressurized infusion devices may be used. If unable to obtain IV, IO may be used.

    5. Continue evaluation as per Initial Trauma Assessment and Treatment Protocol. (pg. 11-14) Paramedic I: 6. Evaluate as to need for Tranexamic acid infusion. (pg. 136)

    7. Apply ECG electrodes and determine cardiac rhythm. Note: Fluid resuscitation in children is performed according to weight. Definitive therapy is usually required to stop the

    source of hemorrhage and blood transfusions are needed usually ASAP. Rapid extrication and transport is essential. Remember that Normal Saline helps expand the circulating blood volume; BUT DOES NOT CARRY OXYGEN.

    MINIMIZE ON - SCENE TIME

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    Trauma Penetrating Injuries (Truncal Wounds)

    Clinical Definition: Any injury in which there is evidence for penetration of the skin by an object that could result in injury to underlying structures. Examples include gunshot wounds, stab wounds, ice pick wounds, impaled objects, sucking chest wounds, etc. Other protocols may apply in cases of penetrating injuries, such as traumatic shock and traumatic arrest. Refer to all of the appropriate protocols that apply.

    General Guidelines: Truncal Wounds

    Chest / Abdomen / Back / Proximal Extremities Basic Life Support: 1. Evaluate patient according to Initial Trauma Assessment and Treatment Protocol. (pg. 11-14) 2. Prepare for rapid transport, even if vital signs are stable. 3. If impaled object - do not remove; refer to Impaled Object Protocol. (pg. 21) 4. Treat open chest wounds according to guidelines for sucking chest wounds; refer to Sucking Chest Wounds Protocol (pg. 22) 5. Treat evisceration of abdominal contents by covering tissue with saline-moistened gauze sponges or sterile towels. DO NOT attempt to replace abdominal contents through the wound. Intermediate: 6. Attempt to establish 2 large bore IVs with Normal Saline and run at appropriate rate to be aimed at maintaining a SBP between 70 90 mm/hg and no higher. Attempts at IV access should be made en route but may be attempted at the scene if approved by MEDICAL CONTROL. Transport should not be delayed for multiple attempts at initiation of an IV. Paramedic I: 7. Apply ECG electrodes and determine cardiac rhythm.

    MINIMIZE ON - SCENE TIME

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  • These protocols are unique to Cooke County EMS per Medical Director Page 18

    Trauma Penetrating Injuries (Neck Wounds)

    General Guidelines: Head / Neck / Face Wounds

    Basic Life Support: 1. Evaluate patient according to the Initial Trauma Assessment and Treatment Protocol. (pg. 11-14) Maintain high index of suspicion for C-spine injury, tracheal injury, blood vessel injury, and lung injury. 2. Prepare for rapid transport, even if vital signs are stable. 3. If impaled object - do not remove; refer to Impaled Object Protocol. (pg. 21) 4. Monitor closely for signs of soft tissue swelling in the neck that could lead to airway obstruction. 5. Have suction set up and ready to clear airway of blood or secretions. 6. Observe closely for signs of a tension pneumothorax. Intermediate: 7. Attempt to establish 2 large bore IVs and Normal Saline and run at appropriate rate to be aimed at maintaining a SBP 70 90 mm/hg and no higher. Attempts at IV access should be made en route but may be attempted at the scene if approved by MEDICAL CONTROL. Transport should not be delayed for multiple attempts at initiation of an IV. Paramedic I: 8. Apply ECG electrodes and determine cardiac rhythm. Paramedic II: 9. Prophylactic intubation (MAI or RSI) may be required if airway compromise from neck swelling occurs.

    Consult MEDICAL CONTROL. Contact Medical Control:

    .

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    Trauma Penetrating Injuries (Head & Face Wounds)

    General Guidelines: Head / Face Wounds Basic Life Support: 1. Evaluate patient according to the Initial Trauma Assessment and Treatment Protocol. (pg. 11-14) Maintain high index of suspicion for C-spine injury, tracheal injury, and/or blood vessel injury. 2. Prepare for rapid transport, even if vital signs are stable. 3. If impaled object - do not remove; refer to Impaled Object Protocol. (pg. 21) 4. Have suction set up and ready to clear airway of blood or secretions. 5. Elevate head of backboard 15 to 30 degrees - DO NOT elevate head by flexing neck! Intermediate:

    6. If patient is unconscious or has a decreased LOC without a gag reflex and or rising ICP is suspected, an advance airway should be performed to secure the airway. Use End-tidal CO2 monitor with an advance airway.

    Ventilate to maintain an EtC02 of 35 45 mmHg, otherwise ventilate at 12 20 breaths/minute for adults and larger children and at 20 30 breaths/min for children less than 4 years of age. 7. Attempt to establish 2 large bore IVS with Normal Saline and run at rate to be aimed at maintaining a SBP 70 90 mm/hg and no higher. 8. Attempts at IV access should be made en route but may be attempted at the scene if approved by MEDICAL

    CONTROL. Transport should not be delayed for multiple attempts at initiation of an IV. Paramedic I: 9. Apply ECG electrodes and determine cardiac rhythm. Paramedic II: 10. Prophylactic intubation (MAI or RSI) may be required if airway compromise occurs. Contact Medical Control:

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    Trauma Penetrating Injuries (Isolated Extremity Wounds)

    General Guidelines: Isolated Extremity Wounds Basic Life Support: 1. Evaluate patient according to the Initial Trauma Assessment and Treatment Protocol. (pg. 11-14) Check neurovascular status distal to wound (presence of pulse, feeling, and movement). 2. If impaled object do not remove; refer to Impaled Object Protocol. (pg. 21) 3. Control external bleeding with direct pressure first, then pressure dressings. 4. Splint affected extremity. 5. Elevate affected extremity 15 to 30 degrees. 6. Prepare for rapid transport, even if vital signs are stable. Intermediate: 7. If significant blood loss at the scene, significant soft tissue swelling, heart rate > 120, or wound close to trunk or thigh

    area, attempt to establish 2 large bore IV with Normal Saline and run at appropriate rate to be aimed at maintaining a systolic blood pressure between 70 90 mm/hg and no higher.

    8. Attempts at IV access should be made en-route but may be attempted at the scene if approved by MEDICAL

    CONTROL. Transport should not be delayed for multiple attempts at initiation of an IV. Paramedic I: 9. Apply ECG electrodes and determine cardiac rhythm.

    10. Refer to Pain Management Protocol. (pg. 117)

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    Trauma Impaled Objects

    Basic Life Support: 1. Evaluate patient according to the Initial Trauma Assessment and Treatment Protocol. (pg. 11-14) 2. In general, do not remove impaled object. If impaled object is causing airway compromise resulting in respiratory

    distress, and this distress cannot be corrected without removal of the foreign body, contact MEDICAL CONTROL immediately for further orders.

    3. When possible, stabilize the impaled object on the body so that it does not move around and cause more internal injury. 4. Any impaled object to the torso (chest, abdomen, back, lower neck, or proximal extremities) should be considered a

    potentially life-threatening injury and treated as such. Transportation should be initiated as soon as possible, even if the patient appears stable.

    5. If manpower is available and time exists during transport, continue further evaluation and treatment of patient according

    to the Initial Trauma Assessment and Treatment Protocol. (pg. 11-14) Intermediate: 6. If significant blood loss at the scene, significant soft tissue swelling, heart rate > 120, or wound close to trunk or thigh

    area, attempt to establish 2 large bore IVS of Normal Saline and run at appropriate rate to be aimed at maintaining a SBP between 70 90 mm/hg and no higher.

    7. Attempts at IV access should be made en route but may be attempted at the scene if approved by MEDICAL

    CONTROL. Transport should not be delayed for multiple attempts at initiation of an IV. Paramedic I: 8. Apply ECG electrodes and determine cardiac rhythm. 9. Refer to Pain Management Protocol (pg. 117)

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    Trauma Sucking Chest Wound

    Basic Life Support: 1. Evaluate patient according to Initial Trauma Assessment and Treatment Protocol. (pg. 11-14) 2. If patient is breathing inadequately, assist ventilations with 100% oxygen through mask 3. Seal the wounds as rapidly as possible, preferably with Vaseline-coated gauze or asherman chest seal, to prevent further collapse of the lung. * In general, the dressing should be sealed on two or three sides only. This allows it to act as a one-way valve allowing air in the pleural space (chest cavity) to get out when the lung expands, but preventing air on the outside from entering the chest cavity through the wound.* 4. Watch closely for signs and symptoms of a tension pneumothorax. If these signs develop, usually lifting one corner of the occlusive dressing will relieve the tension pneumothorax. 5. Prepare for rapid transport. 6. As time allows and manpower permits, continue evaluation and treatment of the patient according to the Initial Trauma Assessment and Treatment Protocol. (pg. 11-14) Intermediate: 7. Attempt to establish 2 large bore IVS and Normal Saline and run at rate to maintaining a SBP between 70 90 mm/hg and no higher. Attempts at IV access should be made en route but may be attempted at the scene if approved by MEDICAL CONTROL. Transport should not be delayed for multiple attempts at initiation of an IV. *Note: If patient is awake and cooperative, have him/her cough (this removes as much air as possible from the chest

    cavity), and then apply the Vaseline gauze or Asherman Chest Seal System immediately afterwards.

    8. If patient is breathing inadequately, assist ventilations with 100% oxygen through mask or advanced airway. If an advanced airway is used, End-tidal CO2 monitor, ventilate to maintain an EtCo2 of 35 45 mmHg. Paramedic I: 9. Apply ECG electrodes and determine cardiac rhythm.

    Prophylactic intubation, MAI, may be required if airway compromise occurs Paramedic II:

    Prophylactic intubation (MAI or RSI) may be required if airway compromise occurs

    Contact Medical Control:

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    Trauma Traumatic Brain Injury

    Clinical Definition: Any traumatic injury to the face or head which results in an injury to the brain, as manifested by some degree of impairment in mental function. Typically, these patients rage from being comatose to wild and combative. Basic Life Support: 1. Evaluate patient according to the Initial Trauma Assessment and Treatment Protocol. (pg. 11-14) Maintain high index of suspicion for C-spine injury. Provide supplemental oxygen. 2. If patient is hypoventilating, assist or provide ventilations (with supplemental oxygen) at a rate of 12 20. 3. Have suction hooked up and readily available. Be prepared to roll patient, if necessary, should vomiting occur. 4. Monitor EtC02 5. Monitor Oxygen Saturation 6. Take seizure precautions. 7. Prepare for rapid transport. 8. Elevate head of backboard 15 to 30 degrees. DO NOT elevate the head by flexing the neck! Intermediate: 9. Appropriate airway management may require endotracheal intubation while observing C-spine precautions. If patient is unconscious or has decreased LOC without a gag reflex, endotracheal intubation with in-line cervical spine stabilization and hyperventilation should be performed to decrease increased intracranial pressure.

    If intubated, use, End-tidal CO2 monitor and ventilate to maintain an EtCo2 between 35 45 mmHg, otherwise ventilate at 12 20 breaths/minute for adults and larger children and at 20 30 breaths/min for children less than 4 years of age.

    10. Attempt to establish 2 large bore IVs of Normal Saline and run at appropriate rate to maintaining a SBP 70 90 mm/hg and no higher. Attempts at IV access should be made en route but may be attempted at the scene only if approved by MEDICAL CONTROL. Transport should not be delayed for multiple attempts at initiation of an IV. Paramedic I: 11. Apply ECG electrodes and determine cardiac rhythm. 12. If seizures occur and are prolonged (greater than 15 30 seconds), administer Valium slow IV push in 2 mg increments, (10mg maximum for adult) until seizure stops. If intubation not performed prior to seizure, it should be performed after Valium has been administered so that hyperventilation may be more effectively performed and the airway is better protected.

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    13. If nausea / vomiting:

    Ondansetron (Zofran):

    4 mg IVP, IM or Oral ODT; (Max 8 mg Q 4 hours); may repeat in 15 minutes if no improvement

    Pediatric Dosages of Ondansetron (Zofran):

    Ages 2 7: 1 mg IVP / IM or Oral ODT; (Max 2 mg Q 4 Hours); may repeat in 15 minutes if no improvement

    Ages 7 12: 2 mg IVP, IM or Oral ODT; (Max 4mg Q 4 Hours); may repeat in 15 minutes if no improvement

    Under 2 years of age .15 mg/kg IVP or Oral ODT; may repeat in 15 minutes if no improvement 14. Prophylactic intubation, MAI, may be required if airway compromise occurs

    Paramedic II: 15. Prophylactic intubation (MAI or RSI) may be required if airway compromise occurs

    Contact Medical Control:

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    Trauma Eye Injuries (Corneal Burns & Abrasions)

    Clinical Definition: These injuries usually occur when the eye is exposed to sources of high intensity light or ultraviolet radiation such as associated with tanning booths, or sun lamps, also corneal injuries may be produced by prolonged wearing of contact lenses. Basic and Intermediate: 1. Evaluate patient according to the Initial Trauma Assessment and Treatment Protocol. (pg. 11-14) 2. Lie patient down and have them close both eyes. 3. Bandage as necessary. Paramedic I: 4. Transport patient.

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    Trauma Eye Injuries (Blunt or Penetrating Eye)

    All Levels: 1. Evaluate patient according to the Initial Trauma Assessment and Treatment Protocol. (pg. 11-14) 2. Have the patient lie flat or with the head slightly elevated. 3. DO NOT attempt to open the injured eye(s). 4. Instruct the patient to close both eyes. 5. Bandage as necessary. 6. DO NOT place any type of compressive dressing over the injured eye(s), and be careful not to apply pressure to the eye(s). 7. DO NOT REMOVE any penetrating object from the eye (unless ordered by medical control) 8. Transport the patient.

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    Trauma Eye Injuries(Chemical Injuries to Eye) Basic and Intermediate: 1. Evaluate patient according to the Initial Trauma Assessment and Treatment Protocol. (pg. 11-14) 2. Flush the affected eye(s) with copious amounts of water or Normal Saline, using a minimum of 2 liters or more for each eye continued throughout transport. If the substance is alkaline in nature, perform continuous irrigation during transport. Contact lenses should be removed if present. Paramedic I: 3. Transport patient.

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    Trauma- Burns (Thermal)

    Basic Life Support: 1. Evaluate patient according to the Initial Trauma Assessment and Treatment Protocol. (pg. 11-14) Look closely for any evidence of inhalation injury (hoarseness, stridor, sooty sputum, facial burns, and singed facial hair). If present, provide supplemental oxygen, preferably humidified. 2. Prepare for air transport, if significant burn or inhalation injury. 3. Remove any jewelry, belts, shoes, etc. from areas of burns as these objects may retain heat and increase the burn; also swelling of burned areas may make subsequent removal difficult. In addition, remove any burned or singed clothing that is not stuck to the underlying skin of the patient. 4. Assess depth of burn (first, second, third) as well as the total area of the burn using Lund & Browder burn chart / rule

    of nines (pg. 139-141) or fact that palmar surface of the patients hand usually represents 1% of body surface area. Include only second and third degree burns in the percentage of body surface burnt.

    5. Perform local burn care as follows:

    a. Do not apply ice to burned area. b. Do not apply ointments or solutions to burns. c. Do not attempt to open blisters. d. Small burns (

  • These protocols are unique to Cooke County EMS per Medical Director Page 29

    Paramedic I: 10. Apply ECG electrodes and determine cardiac rhythm. 11. Monitor EtCo2 12. Consider Pain management:

    Morphine 10 mg SIVP (Max Dose 40 mg)

    AND

    Valium 10 mg SIVP (Max Dose 20 mg)

    May be repeated only if SBP is maintained >90 mmHg 13. If evidence of inhalation injury present with progressive airway compromise, monitor ETCO2. Medically Assisted Intubation (MAI) may be required. Refer to the Airway Management for the Burn Victim. (pg. 122) Consult MEDICAL CONTROL Paramedic III: 14. If evidence of inhalation injury present with progressive airway compromise, monitor ETCO2. Medically Assisted Intubation (MAI) or Prophylactic intubation (RSI) may be required. Refer to the Airway Management for the Burn Victim. (pg. 122) Consult MEDICAL CONTROL

    Contact Medical Control:

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    Trauma Burns (Chemical)

    Ensure Crew Safety! Basic Life Support: 1. Evaluate patient according to the Initial Trauma Assessment and Treatment Protocol. (pg. 11-14) Remove

    contaminated clothing and wash all exposed skin unless Lime exposure is suspected. DO NOT USE WATER ON LYE. Contact Poison Control and Medical Control for instructions on specific chemicals.

    2. Splint any fractures or deformities as required. Intermediate: 3. Start IV with Normal Saline and run TKO unless hypotension or clinical evidence of shock exists. 4. Run IV (mL/h) at rate equal to (1/4) X (Weight in kg) X (% BSA). Paramedic I: 5. Apply ECG electrodes and determine cardiac rhythm. Refer to appropriate arrhythmia protocol as required. 6. Consider Pain Management:

    Morphine 10 mg SIVP (Max Dose 40 mg)

    AND

    Valium 10 mg SIVP (Max Dose 20 mg)

    May be repeated only if SBP is maintained >90 mmHg

    Contact Medical Control

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    Trauma Burns (Electrical & Electrocution)

    Basic Life Support: 1. Evaluate patient according to Initial Trauma Assessment and Treatment Protocol. (pg. 11-14) 2. Cover entrance and/or exit wounds with dry sterile dressings. 3. Splint any fractures or deformities as required. Intermediate: 4. Start IV with Normal Saline and run TKO unless hypotension or clinical evidence of shock exists 5. Run IV (mL/h) at rate equal to (1/4) X (Weight in kg) X (% BSA). Paramedic I: 6. Apply cardiac monitor and determine rhythm. Refer to appropriate arrhythmia protocol as required. 7. Consider Pain Management:

    Morphine 10 mg SIVP (Max Dose 40 mg)

    AND

    Valium 10 mg SIVP (Max Dose 20 mg)

    May be repeated only if SBP is maintained >90 mmHg

    Contact Medical Control

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    Trauma - Amputation

    Basic Life Support: 1. Evaluate patient according to the Initial Trauma Assessment and Treatment Protocol. (pg.11-14) 2. Control bleeding with direct pressure or pressure points. Tourniquet is used only as a last resort. 3. Remove gross contaminants on part by rinsing with saline solution. No other attempt should be made to debride the part. 4. Wrap amputated part in moistened saline gauze and place in plastic bag or container. Seal the plastic tightly, so fluid cannot come in contact with the amputated part. Place sealed container in iced solution of water or saline. Intermediate: 5. Initiate IV Normal Saline if indicated. Run TKO unless hypotensive or clinical evidence of shock exists. Paramedic I: 6. Apply ECG electrodes and determine cardiac rhythm. 7. Consider Pain Management; refer to the Pain Management Protocol. (pg. 117) Contact Medical Control:

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    Trauma - Pregnant Trauma Patient

    In order to adequately care for the mother and unborn child that have been traumatized, one MUST be aware of the following facts: 1. The average maternal heartbeat will increase by 10 to 15 beats per minute when compared to the non-pregnant patient. 2. The systolic and diastolic blood pressure of the pregnant patient will often decrease by 10 to 15 mmHg in the second trimester of pregnancy and then return to normal by term. 3. The pregnant patient undergoes a significant increase in circulating blood volume - about 40 to 50%. This represents as increase in both plasma and red blood cells. However, there is usually a greater increase in plasma compared to the increase in red blood cells, thereby resulting in a relative anemia for many pregnant patients. 4. The pregnant patient may lose 30% to 45% of her circulating blood volume before hypotension develops. 5. When the pregnant patient is lying flat on her back, the enlarged uterus can cause significant compression of the inferior vena cava, thereby reducing venous return to the heart by up to 25% or 30%. This can then result in hypotension. Therefore when possible, pregnant patients should be transported in the left lateral recumbent position. If it is necessary to immobilize the patient supine, then the backboard should be tilted upward 20 to 30 degrees towards the patients left. This will help to roll the pregnant uterus away from the inferior vena cava. 6. Gastric emptying and motility are decreased during pregnancy. This, combined with the compressive effects of the enlarging uterus on the stomach, increases the risk of aspiration in patients with a decreased level of consciousness. 7. Trauma to the pregnant patient can result in very significant amounts of occult bleeding - either intrauterine or retroperitoneal. 8. Abruptio placenta is the leading cause of traumatic fetal death. Vaginal bleeding is seen in about 75% of cases. Maternal hemorrhage that does not result in decreased blood pressure can still reduce fetal blood flow by 90-95%. Trauma significant enough to cause shock in the mother is associated with Fetal Death. Contact Medical Control: Consider: NG tube

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    Trauma - Pediatric Trauma Patient

    Clinical Definition: This protocol applies to pediatrics < 18 y/o & 14 years 7.5 8

  • These protocols are unique to Cooke County EMS per Medical Director Page 35

    Shock: 1. Shock in a child is demonstrated by a faster than normal heart rate; cool and pale extremities; evidence of poor perfusion; and a systolic blood pressure less than 70 mmHg. Children have excellent compensatory systems and the appearance of a fall in blood pressure represents severe shock. 2. A child in traumatic shock has lost at least 25% of their total blood volume. 3. Treatment of shock: Basic: 4. High flow 100% oxygen. Intermediate: 5. At least one large bore IV with Normal Saline.

    As with adults, attempts to establish IV access are usually made enroute but may be made at the scene, if long transport are anticipated after consulting MEDICAL CONTROL. Transport should not be delayed for multiple attempts at initiation of an IV. If long transports are necessary, maximum volumes and flow rates should be determined by MEDICAL CONTROL

    6. When replacing volume loss in a child suffering from hemorrhagic shock, give an initial fluid bolus of 20 cc/kg.

    If the vital signs then stabilize and the child no longer appears to be in shock, run the IV at a TKO rate while continuing to transport. If the first fluid bolus of 20 cc/kg does not stabilize the childs vital signs, then give a second fluid bolus of 20 cc/kg. This means that the child has probably lost at least one half of his/her total blood volume and will need blood transfusions upon arrival at a health care facility.

    Paramedic I: 7. Apply ECG electrodes and determine cardiac rhythm.

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    Trauma - Isolated Musculo-Skeletal Injury

    Clinical Criteria: Muscular skeletal injuries with absolutely no potential for head, abdominal, chest or multi-system injury. Examples, isolated extremity fracture, crush injury and / or burn. Mechanism of injury consistent of an isolated muscular skeletal event with deformity, swelling and ecchymosis to the injured site. Pain present upon movement or palpation of the injury site and is normotensive patient without allergies or other contraindications. Basic: 1. C-spine control ABCs 2. Hemorrhage control 3. Oxygen as needed, SpO2 (if available) 4. Serial Vital signs 5. Splint/Immobilize appropriately 6. If the patient has no signs of the following, than C-Collar should be applied, but not placed on backboard:

    a. No Neck or Back Pain b. No Numbness or Tingling c. No Weakness of Extremities d. No Pain upon Palpation of Neck or Back e. No Pain on Motion of Neck or Back

    7. If the patient has any of the above sign and/or symptoms or if there is significant mechanism, FULL C-SPINE

    PRECATIONS INCLUDING C-COLLAR AND BACKBOARD must be utilized.

    Intermediate: 8. IV of Normal Saline, large bore if:

    a. Open or closed femur Fracture b. Hypotension or other S/S of shock c. Obvious gross deformity

    Paramedic I: 9. Apply ECG electrodes and determine cardiac rhythm. 10. Consider Pain Management; refer to the Pain Management Protocol. (pg. 117) Contact Medical Control:

    If possible multi-system trauma, abdominal and / or head injury, must contact medical control for pain management

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    Trauma - Acute Blunt Spinal Cord Injury

    Clinical Definition: This protocol should be used for treatment of the patient with acute blunt spinal cord injury

    Basic:

    1. Establish and maintain manual c-spine stabilization 2. Determine the nature of the injury. 3. Evaluate and treat ABCs according to protocol. 4. Assess for defining characteristics of SCI including: Partial, complete or suspected Loss of sensory and / or motor function in the upper and / or lower Extremities. 5. Immobilize and stabilize spine. 6. Prepare for rapid transport. Intermediate: 7. Establish 2 large bore IVs with NS, infuse at TKO rate. Paramedic I: 8. If indicated, intubate using C-Spine precautions.

    9. Apply ECG electrodes and determine cardiac rhythm, treat per arrhythmia protocol if indicated.

    10. Continue evaluation as per the Initial Trauma Assessment and Treatment Protocol (pg. 11-14), with frequent

    neurologic assessments. 11. Prophylactic intubation (MAI) may be required if airway compromise occurs.

    Paramedic II:

    Prophylactic intubation (MAI/RSI) may be required if airway compromise occurs.

    Contact Medical Control:

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    Trauma - Domestic Violence

    1. Call for law enforcement support, stage if necessary until law enforcement secures the scene.

    2. Assess the scene for safety. 3. Treat injuries per trauma protocol. 4. Talk to patient alone in a safe, private environment. Use direct simple questions such as: Who caused these injuries?

    Are you in a relationship with someone who hurts or threatens you? 5. Look for history of domestic violence, behavioral and physical clues.

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    Medical

    Protocols

  • These protocols are unique to Cooke County EMS per Medical Director Page 40

    Medical Abdominal Pain / Nausea / Vomiting

    Clinical Definition: Non-traumatic abdominal pain. Basic:

    Assess and treat ABCs

    Oxygen per patient

    VS, including SpO2

    Consider Orthostatic VS (if possible) (pg. 153) Intermediate:

    IV, Normal Saline Paramedic I:

    EKG

    For severe nausea and vomiting:

    Ondansetron (Zofran): 4mg IVP, IM or Oral ODT (Max 8mg every 4 hours); May repeat in 15 minutes if no improvement

    OR

    Promethazine: 12.5 IVP; 25 mg IM; (do not use if patient is >65 years old)

    Contact Medical Control:

    Must contact medical control for pain management consideration

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    Medical Allergic Reaction (Mild)

    Clinical Definition: Urticaria and itching without dyspnea or hypotension.

    Basic:

    Assess and treat ABCs

    VS, including SpO2

    Oxygen per patient Intermediate:

    IV, Normal Saline

    Paramedic I:

    EKG, 12 lead

    Benadryl: 25 mg IVP or 50 mg IM

    Contact Medical Control

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    Medical Allergic Reaction (Moderate)

    Clinical Definition: Urticaria, itching and dyspnea without hypotension. Note: if significant wheezes see Asthma Protocol. (pg. 64) Basic:

    Assess and treat ABCs

    VS, including SpO2

    Oxygen per patient

    EPIPEN, if patient prescribed.

    Intermediate:

    IV, Normal Saline Paramedic I:

    EKG, 12 lead & ETCO2

    Epinephrine (1:1,000): 0.5 mg SQ

    Benadryl: 50 mg IVP or 50 mg IM

    If patient is in moderate to severe dyspnea, initial medications may be given prior to IV access

    Dexamethasone: 8 mg IVP

    OR

    Methylprednisolone: 125 mg IVP

    Contact Medical Control:

    Repeat Epinephrine (1:1,000): 0.3 mg SQ

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    Medical Allergic Reaction Severe (Anaphylaxis)

    Clinical Definition: Urticaria, edema, dyspnea and hypotension (BP < 90 systolic). Note: if significant wheezes see Asthma Protocol. (pg. 64) Basic:

    Assess and treat ABCs

    VS, including SpO2

    Oxygen per patient

    EPIPEN, if patient prescribed. Intermediate:

    IV, Normal Saline Paramedic I:

    EKG, 12 lead & ETCO2

    Epinephrine (1:10, 000): 0.5 mg IVP or IN; may repeat once during transport OR

    Epinephrine (1:1000): 0.5 mg SQ; may repeat once during transport

    Benadryl: 50 mg IVP or 50 mg IM

    Dexamethasone: 8 mg IVP OR

    Methylprednisone: 125 mg IVP

    Be prepared to intubate should patients condition decline. Contact Medical Control

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    Medical Cardiac Arrest

    Clinical Definition: Unresponsive, no respirations, no pulse Basic:

    Assess ABCs

    AED, as soon as available

    CPR (Utilize Lucas as soon as available)

    Maintain airway with appropriate adjunct and ventilate with 100% O2 Intermediate:

    Establish vascular access, Normal Saline

    Advanced airway, apply ETCO2 Paramedic I:

    (Utilize Ventilator as soon as available) Refer to appropriate protocol:

    Asystole PEA VF and Pulseless VT

    Contact Medical Control

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    Medical Asystole

    Paramedic I:

    CPR (Utilize Lucas and Ventilator as soon as available)

    Confirm asystole in two leads

    Establish vascular access

    Vasopressin: 40 units IVP; may repeat in 20 minutes

    AND

    Epinephrine (1:10,000): 1 mg IVP or IN; 3 5 minutes apart; 2 mg via ET; repeat every 3 5 minutes

    Place an advanced airway and ventilate with 100% O2, apply EtC02 Consider and treat possible causes:

    Hypoxia ventilate Acidosis ventilate very well, Sodium Bicarbonate 1 meq/kg IVP during prolonged CPR

    Overdose. Narcan if suspected narcotic overdose Diabetic reactions.. See diabetic emergencies Hyperkalemia.. Sodium Bicarbonate 1 AMP Hypokalemia Hypothermia. Passive re-warming, warmed fluids Hyperthermia... Aggressive external cooling, cooled fluids

    End tidal CO2 monitoring maintain at 35 45 mmHg. Do not over ventilate

    SpO2 may help confirm tube placement and adequate ventilations

    Consider NG tube placement Contact Medical Control After 10 minutes of EtC02 Monitoring with persistent readings of less than 10 mmHg with confirmed tube placement;

    Contact Medical Control to consider termination of efforts.

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    Medical Pulseless Electrical Activity (PEA)

    Paramedic I:

    CPR (Utilize Lucas and Ventilator as soon as available)

    Establish vascular access

    Vasopressin: 40 units IVP; may repeat in 20 minutes AND

    Epinephrine (1:10,000): 1 mg IVP or IN; 3 5 minutes apart; 2 mg via ET, may repeat every 3 5 minutes

    Place an advanced airway and ventilate with 100% O2, Apply EtC02

    Consider and treat cause:

    Hypovolemia fluids and position Hypoxia. oxygenation and airway management Tension Pneumothorax.. needle chest decompression Hypothermia. re-warming with warmed fluids Acidosis. ventilation and Sodium Bicarbonate 1 meq/kg IVP Massive acute myocardial infarction. TCP Cardiac Tamponade

    Hyperkalemia Sodium Bicarbonate 1 AMP Massive pulmonary embolism Drug overdoses such asTricyclics, digitalis, beta-blockers, and calcium channel blockers. Refer to Poisoning and Overdose. (pg. 72)

    Contact Medical Control:

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    Medical VF / Pulseless VT

    Paramedic I: o EKG, quick look with paddles o V-Fib / V-Tach defibrillation immediately o LP12 Defibrillation 200j; followed by 2 full minutes of CPR

    MRx Defibrillation 150j; followed by 2 full minutes of CPR CPR (Utilize Lucas and Ventilator as soon as available)

    o Establish vascular Access

    Vasopressin: 40/U IV; repeat every 20 minutes

    AND

    Epinephrine (1:10,000): 1 mg, IVP or IN; 3 5 minutes; 2 mg via ET, may repeat every 3 5 minutes

    o Place an advanced airway and ventilate with 100% O2 (without delay in chest compressions). Apply EtC02

    LP12 Defibrillation: 300j 30 60 seconds after each administration.

    MRx Defibrillation: 150j 30 60 seconds after each administration.

    Cordarone: 300 MG IVP

    Consider 2nd dose of:

    Cordarone: 150 mg IVP in 3 5 min

    LP12 Defibrillation: 360j 30 60 seconds after each administration. o MRx Defibrillation: 150j 30 60 seconds after each administration.

    Magnesium Sulfate: 1 2 g IV or IO (dilute in 10 ml of D5W for IV bolus) (For Torsades de Pointe only)

    LP12 Defibrillation: 360j 30 60 seconds after each administration

    MRx Defibrillation: 150j 30 60 seconds after each administration.

    Consider NG tube Contact Medical Control:

    Return to Index

  • These protocols are unique to Cooke County EMS per Medical Director Page 48

    Medical Post Resuscitation (ROSC)

    NOTE: If patient in bradycardia, refer to bradycardia protocol. DO NOT treat post resuscitation narrow complex tachycardia, which may be caused by medications given during resuscitation. Basic:

    Assess and treat ABCs

    VS, including EtC02 and SpO2 & O2 Intermediate:

    IV, Normal Saline, D5W Paramedic I:

    EKG, 12 lead & ETCO2, If converted after defibrillation or cardioversion ONLY: Watch closely for lethal dysrhythmias

    If converted after medication, follow bolus with appropriate drip:

    Cordarone: 150 mg in 100 cc D5W, run at 50 ml/hour

    If patient hypotensive (BP < 90 systolic) after 5 min:

    Fluid challenge: 250 cc IV Normal Saline

    Dopamine: 10 mcg/kg/min IVPB to raise BP > 100 systolic; titrated to effect MUST USE IV PUMP (Drip Chart)

    OR

    Levophed: 0.1 0.5 mcg/kg/min IVB; >100 mmHg;

  • These protocols are unique to Cooke County EMS per Medical Director Page 49

    Medical Bradycardia

    Clinical Definition: HR < 60 with one or more of the following: SBP < 90, PVCs, altered LOC, chest pain and dyspnea

    Basic:

    Assess and treat ABCs

    VS, including SpO2

    Oxygen per patient

    Intermediate:

    IV, Normal Saline

    Paramedic I:

    EKG, 12-lead

    Atropine: 1.0 mg Rapid IVP; repeat every 3 5 min to Max 0.04 mg/kg or 3 mg If suspected beta-blocker overdose administer:

    1 mg Glucagon IM and 1 g 10% Calcium Chloride SIVP, may repeat, every 2 minutes max. dose 5 mg

    If suspected calcium channel blocker overdose administer:

    1 gram 10% Calcium Chloride IVP

    TCP (external pacing) highly recommended if available.

    Pre-medicate if time permits Valium: 2 10 mg IVP or IN

    OR

    Ativan: 1 2 mg IVP or IN

    OR

    Versed: 5 mg IVP or IM If hypotensive:

    Dopamine: 10 mcg/kg/min IVPB titrated to raise BP > 100 Systolic; MUST USE IV PUMP

    (Drip Chart) Contact Medical Control: Return to Index

  • These protocols are unique to Cooke County EMS per Medical Director Page 50

    Medical PSVT Stable

    Clinical Definition: BP > 90 without serious signs and symptoms and a pulse of at least 150 Basic:

    Assess and treat ABCs

    VS, including SpO2

    Oxygen per patient

    Vagal maneuvers Intermediate:

    IV, Normal Saline, antecubital vein or higher Paramedic I:

    EKG, 12-lead Adenosine: 6 mg rapid IVP followed by a flush; repeat at 12 mg every 1 2 min (Max 30 mg)

    *Adenosine is contraindicated in patients taking TEGRITOL and PERSANTIN* Contact Medical Control: If wide complex PSVT:

    Cordarone: 150 mg bolus slowly over 10 minutes; Diluted in 20cc of D5W

    Return to Index

  • These protocols are unique to Cooke County EMS per Medical Director Page 51

    Medical PSVT Unstable

    Clinical Definition: SBP < 90, a pulse of at least 150, chest pain, dyspnea, decreased LOC, pulmonary congestion, CHF and MI Basic:

    Assess and treat ABCs

    VS, including SpO2

    Oxygen per patient

    Vagal maneuvers Intermediate:

    IV, Normal Saline, antecubital vein Paramedic I:

    EKG, 12-lead if available Synchronized cardioversion: 100j, 200j

    Premedicate if time permits

    Valium: 2 10 mg IVP,IM or IN OR

    Ativan: 1 2 mg IVP, IM or IN OR

    Versed: 5 mg IVP or IM

    Contact Medical Control:

    Cordarone: 150 mg over 10 minutes; Diluted in 20 cc of D5W; max 300 mg

    May repeat in 10 minutes if needed

    Return to Index

  • These protocols are unique to Cooke County EMS per Medical Director Page 52

    Medical VT- Stable

    Clinical Definition: BP > 90 without serious S/S Basic:

    Assess and treat ABCs

    Cough version

    Oxygen per patient

    VS, including SpO2 Intermediate:

    IV, Normal Saline Paramedic I:

    EKG, 12-lead

    Cordarone: 150 mg over 10 minutes; Diluted in 20cc of D5W; Max 300 mg May repeat in 10 minutes if needed

    OR

    Magnesium Sulfate: 1 2 grams IVP (For Torsades de Pointes only)

    Synchronized cardioversion: 100j, 200j

    Premedicate if time permits

    Valium: 2 10 mg IVP, IM or IN OR

    Ativan: 1 2 mg IVP, IM or IN OR

    Versed: 5 mg IVP or IM Contact Medical Control

    Return to Index

  • These protocols are unique to Cooke County EMS per Medical Director Page 53

    Medical - VT Unstable

    Clinical Definition: BP < 90 systolic altered LOC, dys