Protocols

Question 1

Airway - BVM

Answer 1

~~~~~~~~~~~~~~~~~~~~ EMR CARE ~~~~~~~~~~~~~~~~~~~~~
A. Attempt to open the airway using head tilt-chin lift or jaw thrust maneuver.
B. Oropharyngeal (OPA) or nasopharyngeal (NPA) airways should be used for patients who are unable to maintain their own airway.
C. Have suction immediately available and use as needed to clear secretions.
D. Provide supplemental oxygen as indicated. All patients with altered mental status or respiratory distress should receive supplemental oxygen, preferably via non-rebreather mask. Titrate to maintain SaO2 ≥ 95%.
1. Low flow (2-4 L/min) via NC for patients with COPD.
2. Moderate flow (4-6 L/min) via NC
3. High flow (10-15 L/Min) via NRB or BVM
E. Bag-Valve-Mask (BVM) should be used when inadequate ventilation is present.
F. “Blow-by” oxygen (1 - 4 L/min) may be used for infants & toddlers who do not tolerate mask but require supplemental oxygen.

Question 2

Airway-CPAP

Answer 2

I. INDICATIONS - MEDICAL patients complaining of moderate to severe respiratory distress meeting ALL the following criteria:
B. Is awake and oriented and has the ability to maintain an open airway (SIC)
C. Has signs and symptoms consistent with either CHF/pulmonary edema/RAD/COPD
D. Has a systolic blood pressure above 90 mmHg (MAP of 65 mmHg)
E. Is over 12 years old and is able to fit the CPAP mask
II. CONTRAINDICATIONS
A. Respiratory arrest
B. Non-cooperativepatient
C. Suspected pneumothorax
D. Hemodynamically unstable
E. Presence of tracheostomy
F. Inability to maintain mask seal
G. Active vomiting
III. CAUTIONS
A. CPAP can cause air-trapping in some patients with severe asthma, so these patients should be monitored closely for signs of worsening respiratory distress/decreased air movement
IV. SETTING UP SYSTEM
A. Select mask size for proper patient use per manufacturers recommendations:
B. Ensure adequate oxygen supply to ventilate device.
C. Connect Oxygen source to device.
D. Attach mask to device via tubing.
E. Start with oxygen flow at the manufacturer’s recommended rate
F. Set initial PEEP (peak end expiratory pressure) to 5cm H2O where applicable
V. INITIATING TREATMENT
A. Place the patient on continuous pulse oximetry and end-tidal CO2.
B. Explain to the patient how the CPAP will help their breathing.
C. Gently hold or have the patient hold the mask to the patients face insuring a good face/ mask seal.
D. Adjust the mask and/or head strap accordingly.
E. Check for air leaks.
F. Monitor and document the patient’s respiratory response to the treatment.
G. Gradually adjust the flow to achieve the desired level of CPAP.
H. Increase PEEP if needed up to 10 cm H2O to assist alveolar expansion and improve gas exchange. PEEP should not be increased to the point it causes CO2 retention or the patient cannot overcome the resistance during exhalation.
I. Continue to coach patient to keep mask in place and readjust as needed.
J. Once in the ambulance, switch to the ambulance main oxygen system at the desired flow rate.
K. IF RESPIRATORY STATUS DETERIORATES, REMOVE DEVICE AND CONSIDER BAG VALVE MASK VENTILATION AND/OR ENDOTRACHEAL INTUBATION.
VI. NEBULIZER TREATMENT - nebulizers can be administered through some CPAP systems. If manufacturer approves:
A. Set up the nebulizer as prescribed.
B. Insert the nebulizer into the face mask.
C. Connect the nebulizer tubing to an Oxygen source and run at 6 l/min to power the nebulizer.
D. Maintain O2 flow to CPAP system at desired flow
E. Monitor patient for improvement.
F. If patient does not improve, be prepared to assist patient ventilation with BVM and call for ALS.

VII.REMOVAL OF CPAP
A. CPAP therapy needs to be continuous and should not be removed unless the patient cannot tolerate the mask or experiences continued or worsening respiratory failure.

VIII.ADDITIONAL NOTES:
A. If unable to maintain oxygen saturation > 90%, administer positive airway pressure via BVM and PEEP valve.
B. Reassessment of the patient’s status is critical and documentation should be performed every 5-10 minutes until patient is stable.
C. Remove CPAP mask temporarily to administer nitroglycerin.
D. Suctioning of secretions may be required on some patients. This may be done thru the opening in the front of the CPAP without disrupting the treatment or pressures.
E. Watch for gastric distention and/or nausea.

Question 3

Airway - PEAD

Answer 3

A. INDICATIONS:
1. A PEAD may be placed in unconscious patients with no gag reflex.

B. CONTRAINDICATIONS:

 1. Conscious or semi-conscious patients
 2. Intact gag reflex
 3. Airway obstruction
 4. Patients with known or suspected esophageal disease 
 5. Ingestion of caustic substances
 6. Patients with known esophageal varices. 

C. Placement of the PEAD will be confirmed by:

 1. Auscultation of bilateral breath sounds
 2. Absence of breath sounds over the stomach
 3. Positive findings of End-Tidal CO2 detector and/or capnography.

Question 4

Cardiac Arrest - Adult. EMR-EMT

Answer 4

Obtain History when possible, but do not delay CPR to obtain information:
A. Witnessed or unwitnessed collapse
B. Patient down time
C. Bystander CPR
D. DNR status
E. Previous medical history, medications and allergies
F. Potential causes:
1. Airway obstruction
2. Trauma
3. MI
4. CVA
5. Electrocution
6. Diabetes
~~~~~~~~~~~~~~~~~~~~~~~ EMR CARE ~~~~~~~~~~~~~~~~~~~~~~~
A. Establish that patient is unresponsive.
B. Check for pulse.
C. If no pulse, start compressions only CPR at 110 compressions/minute using metronome.
D. Call for AED & ALS backup.
E. As soon as AED is available, apply AED.
F. If unwitnessed arrest, perform CPR for 2 min.
G. If witnessed arrest, perform CPR until defibrillator is attached.
H. Analyze rhythm, if shock indicated, press charge.
I. Complete at least 30 chest compressions while unit is charging.
J. Press Shock.
K. Resume compressions immediately after shock is delivered.
L. Apply high flow O2 (15 L) via nasal cannula when 2nd rescuer arrives or during rhythm analysis
M. Continue CPR until perfusion is restored.
N. Suction as necessary to clear the airway
O. If patient has return of spontaneous circulation, follow ROSC Protocol.

~~~~~~~~~~~~~~~~~~~~~~~ EMT CARE ~~~~~~~~~~~~~~~~~~~~~~~
P. If either below is true, place PEAD and give asynchronous ventilations at 10:1
A. ROSC without spontaneous respiratory effort, or
B. Does not have ROSC after 6 minutes (3 cycles)

Question 5

Cardiac Arrest - Adult

Answer 5

Obtain History when possible, but do not delay CPR to obtain info:
A. Witnessed or unwitnessed collapse
B. Patient down time
C. Bystander CPR
D. DNR status
E. Previous medical history, medications and allergies
F. Potential causes:
1. Airway obstruction
2. Trauma
3. MI
4. CVA
5. Electrocution
6. Diabetes
~~~~~~~~~~~~~~~~~~~~~~~ EMR CARE ~~~~~~~~~~~~~~~~~~~~~~~
A. Establish that patient is unresponsive.
B. Check for pulse.
C. If no pulse, start compressions only CPR at 110/min with metronome.
D. As soon as AED is available, apply AED.
E. If unwitnessed arrest, perform CPR for 2 min.
F. If witnessed arrest, perform CPR until defibrillator is attached.
G. Analyze rhythm and defibrillate if indicated.
H. Resume chest compressions immediately after rhythm check.
I. If shock advised:
1. Press charge and
2. Complete at least 30 chest compressions while unit is charging
3. Press Shock
4. Resume compressions immediately after shock is delivered.
K. If no shock advised, check for pulse, and resume CPR immediately
L. Apply high flow O2 (15 L) via nasal cannula
M. Continue CPR until perfusion is restored.
N. Suction as necessary to clear the airway
O. If patient has return of spontaneous circulation, follow ROSC Protocol.
~~~~~~~~~~~~~~~~~~~~~~~ EMT CARE ~~~~~~~~~~~~~~~~~~~~~~~
P. If either of the below, place PEAD and initiate asynchronous ventilations (10:1) with capnography.
1. ROSC without spontaneous respiratory effort, or
2. Does not have ROSC after 6 minutes (3 cycles)
~~~~~~~~~~~~~~~~~ AEMT/EMT-I/RN CARE ~~~~~~~~~~~~~~~~
Q. Place IV. If not immediately available, establish a humeral or tibial IO.
R. If using a manual defibrillator, consider precharging the defibrillator 15 seconds before each rhythm check. Defibrillator Joule Settings: 360j
S. After 2 minutes of compressions, check cardiac rhythm.
T. If Ventricular Fibrillation persists after 3 cycles
1. If second set of pads available place 2nd pads in AP position.
2. Perform next 2 shocks if indicated using AP position.
3. If still unsuccessful, and second defibrillator is available, consider double sequential defibrillation for 6th shock using both defibrillators simultaneously.
U. If no ROSC and ETCO2 < 10 mmHg after ≥ 20 minutes of resuscitation, discontinue resuscitation efforts.
V. If patient has ROSC
1. Continue cardiac ECG Monitoring
2. Obtain 12-lead EKG if available
3. IV/IO, BSS, TKO or Saline lock
4. Titrate O2 to maintain SaO2 ≥ 95%
5. Initiate cooling measures with chilled saline & icepacks in groin and axillae
6. Transport patient to nearest hospital, or contact aeromedical transport for transfer to closest cath lab if STEMI present.

Question 6

CARDIAC ARREST - WITH PREGNANCY (>22 WEEKS)

Answer 6

NOTE:
❖ If history of pregnancy with known gestational age, use dates provided
* If dates unclear palpate abdomen. If fundal height (top of the uterus) is at or above the level of the umbilicus, assume gestational age ≥ 20 weeks
❖ Early transport prior to achieving ROSC
❖ Alert the receiving facility early
❖ Lidocaine is preferable to amiodarone in the setting of VF or pVT.
❖ No adjustments need to be made to defibrillation energy settings.
❖ Immediately following defib, resume the left lateral uterine displacement.
❖ If ROSC is achieved continue left lateral uterine displacement by placing the patient in the left lateral decubitus position or by manually displacing the gravid uterus.
❖ High flow oxygen should be maintained in pregnant post-arrest patients.
1. Manage per appropriate cardiac arrest algorithm (VF / pulseless VT, asystole/PEA):
A. Provide CPR with continuous manual left uterine displacement using the two handed method shown below.

Question 7

ROSC

Answer 7

A. Manage and support ABC’s as necessary.
B. Obtain vitals, including BP.
C. Titrate oxygen to maintain SaO2 ≥95%.
D. Optimize ventilation and oxygenation
1. Maintain ETCO2 at 35 – 40 mmhg.
2. Do not hyperventilate; start at 10-12 breaths/minute.
E. Treat hypotension (SBP < 90 mm HG)
1. IV/IO bolus 1-2 L BSS
2. If inducing hypothermia, use 4° C fluid
3. If normotensive, TKO or Saline lock
F. Consider treatable causes: H’s and T’s.
1. Continue cardiac ECG Monitoring
2. Obtain 12-lead EKG if available
3. If STEMI present, contact air transport for transfer to closest cath lab, or
4. Transport patient to nearest hospital
A. Manage and support ABC’s as necessary.
B. Titrate oxygen to maintain SaO2 ≥95%.
C. If patient is unresponsive, initiate therapeutic cooling measures with icepacks in axillae, groin, neck, and around head wrapped in a light towel. Target temperature 32 - 36° C (89.6-96.8 F)

Question 8

ACLS VF/pVT

Answer 8

NOTES:
❖ Use a Pit-Crew approach
❖ Focus on High Performance CPR
❖ Continue resuscitation on scene for a minimum of 30 minutes.
❖ Airway should be secured and IV/IO placed with minimal interruption to CPR.
❖ All medicines should be given during 2 minutes of CPR without interrupting chest compressions and should be followed by 10 ml NS flush.
❖ These instructions assume continuing VF/pVT.
❖ Each Cycle of CPR done over 2 minutes includes:
- Check Rhythm, CPR, CHARGE, CLEAR, Defibrillate – CPR x 2 minutes
❖ Rhythm Check and pulse check simultaneously.
❖ Immediately resume CPR after defibrillation, rotating compressor each round.
❖ If VF/VT:
➡ Defibrillate.
➡ Resume CPR immediately for 2 minutes or 5 cycles
➡ Give drugs immediately after defibrillation, at star of 2 minutes of CPR.
➡ Prepare next drug while performing 2 minutes of CPR.
❖ If using a manual, precharge defibrillator 15 seconds before rhythm check.
❖ Defibrillator Joule Settings: Physio Control Lifepak - 360j All shocks
A. Initiate CPR.
1. For unwitnessed arrest:
a. Give 2 min (5 cycles) of CPR and place pads
2. For witnessed arrest with downtime < 5 minutes:
a. Perform CPR while placing pads.
b. Check rhythm as soon as leads applied.
Cc. Defibrillate as soon as rhythm is determined to be shockable VF/pVT.
B. Check Rhythm – Defibrillate – CPR x 2 minutes.
C. Establish IV/IO access. Prepare Epinephrine. Perform good CPR with capnography 20 mmhg or greater.
D. Check Rhythm – Defibrillate – CPR x 2 minutes.
E. Epinephrine 1:10,000 – 1mg IV/IO. Repeat every 3 – 5 minutes.
Prepare Amiodarone.
F. Check Rhythm – Defibrillate – CPR x 2 minutes.
G. Amiodarone 300 mg IV/IO. Consider reversible causes.
H. Consider PEAD with capnography after 3 rounds of CPR
I. Bring in 2nd defibrillator if available and place pads anterior/posterior
J. Check Rhythm – Defibrillate x 1 through new monitor if available – CPR x 2 minutes. Simultaneously at each rhythm check monitor airway and capnography.
K. Epinephrine 1:10,000 – 1mg IV/IO every 3-5 minutes.
L. Check Rhythm – Defibrillate x 1 through new monitor if available – CPR x 2 minutes.
M. Amiodarone 150 mg IV/IO. (1 If Amiodarone is not available, use Lidocaine, initial dose of 1-1.5 mg/kg IV/IO. Repeat if indicated at 0.5 to 0.75 mg/kg IV/IO over 5-10 min. intervals to a max. dose of 3 mg/kg)
O. Check Rhythm – Double sequential Defibrillate x 1 (2 defibrillators each set at max setting). If second defibrillator unavailable, defibrillate at max dose – CPR x 2 minutes.
P. Epinephrine 1:10,000 – 1mg IV/IO every 3-5 minutes.
Q. Check Rhythm – Repeat double sequential defibrillation until change in rhythm or ROSC.– CPR x 2 minutes.
R. If patient has return of spontaneous circulation, follow ROSC Protocol.
S. Prepare patient for transport as soon as possible. If Lucas device is available, transport with device in place. Consider consultation with OLMC.

Question 9

ACLS - Non-shockable rhythm

Answer 9

NOTE:
❖ Secured and IV/IO placed with minimal interruption to CPR.
❖ All medicines should be given during 2 minutes of CPR without interrupting chest
compressions and should be followed by 10 ml NS flush.
❖ These instructions assume Asystole/PEA. If rhythm changes, switch to the appropriate
algorithm.
❖ Each Cycle of CPR done over 2 minutes includes:
- Check Rhythm - CPR x 2 minutes -
❖ Rhythm Check and pulse check simultaneously.
❖ Immediately resume CPR after defibrillation, rotating compressor each round. ❖ IfAsystole/PEA:
➡ Resume CPR immediately for 2 minutes or 5 cycles.
➡ Give drugs immediately at beginning of 2 minutes of CPR
➡ Prepare next drug while performing 2 minutes of CPR
➡ Confirm Asystole in two leads; increase gain to rule out fine VF; If any question of possible VF, defibrillate as per VF
A. Initiate CPR
1. For unwitnessed arrest, give 2 min (5 cycles) CPR while placing pads.
2. For witnessed arrest with downtime < 5 minutes, perform CPR while placing pads. Check rhythm as soon as leads applied.
B. Check Rhythm – CPR x 2 minutes.
C. Establish IV/IO access. Prepare Epinephrine. Perform good CPR with capnography 20 mmhg or greater.
D. Epinephrine 1:10,000 – 1mg IV/IO. Repeat every 3 – 5 minutes. In non-shockable rhythm, give epinephrine as soon as possible.
E. Check Rhythm – CPR x 2 minutes.
F. If PEA, administer fluid challenge of 2 L BSS.
G. Consider possible causes and treat as indicated:
1. Hypovolemia: establish 2 large bore IV’s/IO’s.
2. Hypoxia: Ensure adequate ventilation
3. Hyperkalemia: Albuterol, 1 unit dose (3 ml ) nebulized
4. Hypoglycemia: check blood sugar and treat as indicated.
5. Hypothermia: (See HYPOTHERMIA Protocol)
6. Tension Pneumothorax: perform unilateral or bilateral chest decompression
7. Toxins, Tamponade, Thrombosis, Trauma
H. Check Rhythm – CPR x 2 minutes.
I. Epinephrine 1:10,000 – 1mg IV/IO.
J. Consider advanced airway with capnography after 3 rounds of CPR
K. Check Rhythm – CPR x 2 minutes.
L. If patient has return of spontaneous circulation, follow ROSC Protocol.
M. Continue resuscitation efforts for at least 20 minutes. Consider termination of resuscitation efforts in field if asystole continues after 20 minutes.
Run wide open up to 2 L BSS.

Question 10

ACLS Cardiac Arrest - Peds

Answer 10

PEDIATRIC CONSIDERATIONS: AEMT/EMT-I/RN/EMT-P:
Cardiac arrest in children is often secondary to respiratory failure. Ventilation may cause spontaneous return of cardiac function!
Ventricular Fibrillation and Pulseless Ventricular Tachycardia
Follow adult cardiac arrest algorithm except as noted.
**Defibrillate in the following sequence: 2 joules/kg, 4 joules/kg and 4 joules/kg.
Substitute the following drug dosages.
1. **Epinephrine 0.01 mg/kg IV/IO ((0.1 ml/kg) NMT 1 mg (10 ml 1:10,000 IV/IO).
2. **Amiodarone 5 mg/kg IV/IO; MRx1 2.5 mg/kg
3. **Lidocaine 1.0 mg/kg IV/IO up to 3 mg/kg.
4. ****Sodium bicarbonate 1 mEq/kg (1 ml/kg) IV/IO; 0.5 mEq/kg for subsequent doses. 5. ****Magnesium sulfate 25 mg/kg IV/IO NMT 4 gm
Asystole
1. **Epinephrine every 3-5 minutes.

Pulseless Electrical Activity

1. ***Epinephrine every 3-5 minutes.
2. Consider and treat other possible causes:
   a. **Acidosis – consider sodium bicarbonate 1 mEq/kg (1 ml/kg) IV/IO.
   c. *Cardiac Tamponade – immediate transport
   c. **Cyclic antidepressants – consider sodium bicarbonate 1 mEq/kg (1 ml/kg) IV/IO.
   d. **Hyperkalemia – consider sodium bicarbonate 1 mEq/kg IV/IO e. *Hypothermia – see Hypothermia protocol
   f. **Hypovolemia – fluid challenge.
   g. *Hypoxia – oxygenate and ventilate
   h. *Pulmonary Embolism – immediate transport
   i. **Tension Pneumothorax – needle decompression.
3. Consider therapeutic hypothermia (see ROSC Protocol)
   * =EMT ** = AEMT **= EMT-I/RN ** = EMT-P

Question 11

ACLS - Dysrhythmias

Answer 11

NOTE:
If the patient is asymptomatic, dysrhythmias may not require treatment in the field.
I. Patients with cardiac dysrhythmias should be classified as stable or unstable. An unstable patient is one who presents with (one or more) of these signs or symptoms:
A. SBP < 100 mmhg
B. Altered mental status
C. Pale, cool, diaphoretic skin
D. Chest pain
E. Shortness of breath
F. Feeling of impending doom
G. Nausea & vomiting
II. Obtain the following history:
A. Onset and duration of symptoms
B. Is there associated chest pain or shortness of breath?
C. History of cardiopulmonary disease
D. Medications (especially cardiac and Viagra [erectile dysfunction agents])
E. Recent illness or trauma
F. Substance abuse history
G. DNR status
III. Treatment
A. Administer Oxygen
1. If SOB oxygen at 15 L/m non-rebreather mask
2. Without SOB oxygen 4-6 L/m NC
B. If patient has associated chest pain, give 324 mg (4 baby) ASA.
C. Place patient in position of comfort and reassure.
D. Have AED ready for use and follow AED protocol.
E. If patient has return of spontaneous circulation, follow ROSC
F. If patient is unable to protect airway, establish airway via PEAD.
G. Place patient on cardiac monitor.
H. Establish IV, BSS, TKO.
I. If systolic pressure falls < 100 mmHg
1. administer 250ml BSS bolus and repeat vitals.
2. Rebolus with 250 mL BSS as indicated for SBP ≤ 100 mmHg
K. If patient is having associated chest pain, follow CHEST PAIN Protocol.
L. If unable to protect airway, follow AIRWAY MANAGEMENT Protocol

Question 12

ACLS - Adult Tacycardia

Answer 12

Adult Tachycardia
1. Start Oxygen per Airway Management protocol
2. Monitor vitals, ECG and oxygen saturation, Establish IV/IO access
3. Are S/S of poor perfusion?
A. If Yes, Patient unstable,
B. If no, patient stable
1. Obtain 12 lead ECG
A. Narrow Regular QRS
Attempt vagar maneuvers
B. Irregular
1. Narrow QRS (AFib, AFlutter, Multifocal ATach)
2. Wide QRS (WPW, AFib w/ aberrancy, Torsades)
C. Wide Regular QRS (>0.12 sec)
1. Amiodarone, 150 mg IV/IO over 10 minutes
2. Amiodarone, 150 mg IV/IO over 10 minutes
3. Lidocaine 1.5 mg/kg IV/IO
4. Lidocaine 0.75 mg/kg IV/IO, repeat q 10 min
2. Obtain post-treatment 12-lead ECG
3. Contact OLMC for advice
4. Consider contributing factors and other treatments

Question 13

ACLS - Adult Bradycardia

Answer 13

Adult Bradycardia

1. HR < 60 and inadequate for clinical condition
2. Start oxygen per Airway Management procedure
3. Obtain Vitals, ECG, and oxygen saturation. Establish IV/IO.
4. Are S/S of poor perfusion caused by the bradycardia present?
   A. If Yes, patient unstable
   1. Atropine, 0.5 mg IV, repeat every 3-5 minutes to a max of 3 mg
   B. If No, patient stable
   1. Observe/monitor patient
   2. Consider 12 lead ECG

Goal is to improve perfusion and maintain BP of 90 mmHg systolic.

Question 14

ACLS - Tachycardia - Pediatrics

Answer 14

ACLS - Tachycardia - Pediatrics

1. Start Oxygen per Airway Management protocol
2. Monitor vitals, ECG and oxygen saturation, Establish IV/IO access
3. Are S/S of poor perfusion?
   A. If Yes, Patient unstable,
   B. If no, patient stable
   1. Obtain 12 lead ECG
   A. Narrow Regular QRS, HR > 220 child < 2, HR>180 child 2-10, Probable SVT
   1. Attempt vagal maneuvers
   B. Irregular
   1. Narrow QRS (AFib, AFlutter, Multifocal ATach)
   2. Wide QRS (WPW, AFib w/ aberrancy, Torsades)
   C. Wide Regular QRS (>0.12 sec, HR > 150)
   1. Amiodarone, 150 mg IV/IO over 10 minutes
   2. Amiodarone, 150 mg IV/IO over 10 minutes
   3. Lidocaine 1.5 mg/kg IV/IO
   4. Lidocaine 0.75 mg/kg IV/IO, repeat q 10 min
   2. Obtain post-treatment 12-lead ECG
   3. Contact OLMC for advice
   4. Consider contributing factors and other treatments

Question 15

ACLS - Bradycardia - Pediatric

Answer 15

1. HR < 60 and inadequate for clinical condition
2. Start oxygen per Airway Management procedure
3. Obtain Vitals, ECG, and oxygen saturation. Establish IV/IO.
4. Are S/S of poor perfusion caused by the bradycardia present?
   A. If Yes, patient unstable
   1. Start CPR if HR < 60 with poor perfusion, if bradycardia continues,
   2. Give 1:10,000 epi 0.01 mg/kg IV/IO. Repeat q 3-5 min.
   3. If increased vagal tone or AV block, consider Atropine, 0.02 mg/kg IV/IO. Minimum single dose 0.1 mg, Maximum single dose 0.5 mg. Max total dose 1 mg. Repeat every 3-5 minutes to a max of 3 mg.
   B. If No, patient stable
   1. Observe/monitor patient
   2. Consider 12 lead ECG
   3. Consider OLMC contact.

Goal is to improve perfusion and maintain BP of 90 mmHg systolic.

Question 16

Abdominal Pain

Answer 16

NOTE:
❖ Abdominal pain may be the first warning of catastrophic internal bleeding (ruptured aneurysm, liver, spleen, ectopic pregnancy, perforated viscous, etc.)
❖ Since the bleeding is not apparent, you must think of volume depletion and monitor the patient closely to recognize shock.
~~~~~~~~~~~~~~~~~~~~~ EMR/EMT CARE ~~~~~~~~~~~~~~~~~~~~~
A. Start O2. Follow Airway Management protocol.
B. Place patient in comfortable position.
C. Do not allow the patient to eat or drink.
D. Obtain vital signs frequently
~~~~~~~~~~~~~~~~~~~~~~~AEMT CARE~~~~~~~~~~~~~~~~~~~~~~~
A. IV BSS TKO or Saline lock.
B. Administer fluid bolus if symptomatic and B/P < 90 mmHg. See Shock protocol.
C. ECG Monitor.
~~~~~~~~~~~~~~~~~ EMT-I/RN/EMT-P CARE~~~~~~~~~~~~~~~~~~~~
D. Pain medications may be administered in non-traumatic abdominal pain

Question 17

ACUTE ADRENAL INSUFFICIENCY

Answer 17

NOTE:
❖ Acute adrenal crisis is an immediately life-threatening emergency
❖ Acute adrenal insufficiency (crisis) can occur in the following settings:
❖ During neonatal period (undiagnosed adrenal insufficiency)
❖ In patients with pre-existing adrenal insufficiency (eg, Addison’s disease)
❖ In patients who are chronically steroid dependent
❖ Adrenal crisis can be triggered by any acute stressor
❖ by abrupt cessation of steroid use (for any reason).
❖ Signs/symptoms of adrenal crisis may include altered mental status, seizures, generalized weakness, hypotension, hypoglycemia or hyperkalemia.
❖ Notify hospital you are transporting known/suspected adrenal crisis patient
~~~~~~~~~~~~~~~~~~~~~~~ EMR CARE ~~~~~~~~~~~~~~~~~~~~~~
A. Take thorough history of patient’s steroid use/dependence, PMH
B. Maintain patent airway and support ventilation as required
C. Oxygen therapy, as needed
D. Frequently monitor and document vital signs and patient status
~~~~~~~~~~~~~~~~~~~~~~~ EMT CARE ~~~~~~~~~~~~~~~~~~~~~~
E. Check blood glucose
F. If blood glucose is <60: administer glucose solution orally.
~~~~~~~~~~~~~~~~~~~ AEMT/EMT-I/RN CARE ~~~~~~~~~~~~~~~~~~
G. Initiate IV
H. If blood glucose < 60 give Dextrose
I. Bolus with BSS to achieve target SBP of 90 mmHg
1. Adult - give 500 ml fluid bolus. May repeat to maximum of 3 L NS
2. Pediatric - 20 ml/kg up to 60 ml/kg
3. Neonate - 10 ml/kg if less than 6 months old
J. Repeat fluid boluses if continud s/s of shock and no s/s of pulmonary edema.
K. Initiate ECG Monitoring
L. Obtain 12-lead EKG if available
M. Obtain IO access if indicated

Question 18

ALLERGIC REACTION - Adult

Answer 18

A. Keep patient calm and provide reassurance
B. Evaluate ABC’s and start Oxygen therapy.
C. Administer high flow oxygen for respiratory distress
D. Provide ventilatory assistance as needed.
E. In the case of moderate to severe anaphylaxis (swelling of tongue, face, wheezing, stridor, or evidence of shock) give epinephrine 1:1,000 IM, 0.3 mg (adult), 0.2 mg (pediatric), 0.1mg (infant). NMT two doses. Contact OLMC for additional doses.
F. If patient is wheezing or has poor air movement, administer albuterol
G. Start IV (BSS) enroute as needed
H. If B/P less than 90 mm/hg, follow Shock Protocol.
I. Monitor cardiac rhythm
J. If patient is wheezing or has poor air movement, administer nebulized Duoneb. Subsequent treatments shall be Albuterol, repeat prn
K. Give Benadryl 25-50 mg IM/IV/IO for the adult dose
L. If the reaction is severe, give epinephrine.

Question 19

ALÉRGIC REACTIONS - Peds

Answer 19

Pediatric Considerations:

1. Mild:
   a. Administer 1:1,000 epinephrine, 0.01 mg/kg (0.01 ml/kg) IM/SQ, NMT 0.3 mg (0.3 ml). May repeat once after 20 minutes.
   b. If itching is severe, consider diphenhydramine 1 mg/kg IV/IO/IM, NMT 50 mg.
2. Severe:
   a. No vascular access/ET tube: give epi (1:1,000), 0.01 mg/kg (0.01 ml/kg) IM/SQ NMT 0.3 mg (0.3 ml).
   b. For diminished perfusion, administer 20 ml/kg, fluid bolus NS, IV/IO.
   c. Administer 1:10,000 epinephrine, 0.01 mg/kg (0.1 ml/kg) IV/IO NMT 0.1 mg (1 ml). Repeat every 5 minutes PRN.
   d. If child is intubated and there is no vascular access, give 1:1,000 epinephrine by ET, 0.1 mg/kg (0.1 ml/kg), flushed with 5 ml NS.
   e. If wheezing is present, follow Respiratory Distress protocol.
   f. If itching is severe, consider diphenhydramine 1 mg/kg IV/IO or deep IM, NMT 50 mg

Question 20

Altered Mental Status

Answer 20

NOTE:
❖ This protocol defines the management of the emergency medical patient who has an
altered mental status, i.e., decreased LOC, confusion, disorientation, coma.
❖ Care of the trauma patient is outlined in the appropriate trauma protocol.
❖ The intranasal administration of Narcan can reduce the risk of needle sticks while
delivering effective medication levels.
I. Assessment - ABC’s. Use GLASGOW COMA SCALE (GCS - page 90) or AVPU to categorize level of consciousness.

II. Differential diagnosis:
Cardiac event CVA Postictal Shock
Check for Medic Alert tag.
Hyperglycemia Hypoglycemia Hyperthermia Hypothermia
Drug Overdose Other
ALTERED MENTAL STATUS
NOTE:
❖ This protocol defines the management of the emergency medical patient who has an altered mental status, i.e., decreased LOC, confusion, disorientation, coma.
❖ Care of the trauma patient is outlined in the appropriate trauma protocol.
❖ The intranasal administration of Narcan can reduce the risk of needle sticks while delivering effective medication levels.
I. Assessment
- CVA Postictal Shock
- Check for Medic Alert tag.
- Hyperglycemia Hypoglycemia Hyperthermia Hypothermia
Drug Overdose Other
ALTERED MENTAL STATUS
❖ This protocol defines the management of the emergency medical patient who has an altered mental status, i.e., decreased LOC, confusion, disorientation, coma.
❖ Care of the trauma patient is outlined in the appropriate trauma protocol.
❖ The intranasal administration of Narcan can reduce the risk of needle sticks while delivering effective medication levels.
I. Assessment - ABC’s. Use GLASGOW COMA SCALE (GCS - page 90) or AVPU to categorize
~~~~~~~~~~~~~~~~~~~~~~~~~ EMR CARE ~~~~~~~~~~~~~~~~~~~
A. Airway management has priority. Insert an OPA/NPA
B. Have suction immediately available. All patients with altered mental status should receive supplemental oxygen, preferably via non-rebreather mask or assisted ventilation.
C. If suspected hypoglycemia and patient is able to protect airway, give oral glucose.
D. If no response to above treatment or if respirations are depressed, administer 0.4 - 2.0 mg Naloxone Intranasally. Titrate to LOC & respiratory effort. Consider restraining patient before administration of Naloxone (Narcan). Rebolus at 0.4 - 2.0 mg as needed NMT 8 MG. (Pediatric dose 0.1 mg/kg NMT 2 mg.)
E. BE PREPARED FOR PROJECTILE VOMITING AND HAVE SUCTION IMMEDIATELY AVAILABLE.
F. DOCUMENT PATIENT’S RESPONSE TO MEDICATIONS
~~~~~~~~~~~~~~~~~~~~~~~~~ EMT CARE ~~~~~~~~~~~~~~~~~~~~~
G. If patient is obtunded, unable to protect airway and has no gag reflex, consider placing PEAD to secure airway.
H. Determine blood glucose levels (BGL) if time and patient condition permits.
I. If the BGL is <60, and patient is able to protect airway, give oral glucose paste.
J. If no response to above treatment or if respirations are depressed, administer 0.4 - 2.0 mg Naloxone IM/MAD. Titrate to LOC & respiratory effort. Consider restraining patient before administration of Naloxone (Narcan).
Rebolus at 0.4 - 2.0 mg as needed NMT 8 MG. (Pediatric dose 0.1 mg/kg NMT 2 mg).
K. If aggressive airway management is not required, place the unconscious patient on their side in the recovery position.
~~~~~~~~~~~~~~~~~~~~ AEMT/EMT-I/RN CARE ~~~~~~~~~~~~~~~~~~
L. Start IV enroute as needed.
M. If B/P less than 90 mm/hg, follow Shock Protocol
N. If glucose level is <60
1. Give D10W 0.5 gms/kg in patent IV/IO. Repeat once after 10 minutes.
2. If unable to obtain IV, give Glucagon 1mg IM/SC.
~~~~~~~~~~~~~~~~~~~~ AEMT/EMT-I/RN CARE ~~~~~~~~~~~~~~~~~
O. If no response to above treatment or if respirations are depressed, administer 0.4 - 2.0 mg Naloxone IV/IO/IM/MAD. Titrate to LOC & respiratory effort. Consider restraining patient before administration of Naloxone (Narcan). Rebolus at 0.4 - 2.0 mg as needed NMT 8 MG. (Pediatric dose 0.1 mg/kg NMT 2 mg.)
P. If glucose level is >300 and there is no evidence of pulmonary edema consider a fluid bolus.
Q. B/P < 90 mm/hg, consider a fluid bolus - 500 ml up to 60 ml/kg. If B/P >90 mm/hg, consider IV BSS TKO.
R. Monitor cardiac rhythm and vital signs frequently.

Question 21

BURNS - Thermal

Answer 21

NOTE:
❖ Defined here is the prehospital evaluation and management of major burns.
❖ Remember that age (infants and the elderly), underlying medical conditions, smoke inhalation and associated trauma can complicate the condition and care of the acutely burned individual.
❖ Evaluation of all major burns should include using the “Rule of Nines” to assess the extent of the burns.
I. GENERAL
~~~~~~~~~~~~~~~~~~~ EMR/EMT CARE ~~~~~~~~~~~~~~~~~~~~
A. STOP THE BURNING!
B. Remove the patient from the source of the burn if you can do so safely.
C. Remove smoldering or hot clothing, bedding and restricting jewelry if it can be done without removing burned skin.
D. In the case of an acid or chemical burn, brush any powder material from burn, then flush with water or Normal Saline. Note: Alkali burns (cement, anhydrous ammonia, lye) require flushing with large volumes of water until all the feeling of “soapiness” is gone.
E. Wrap the disrobed patient in clean, dry sheets and/or dressings. Remember to wrap burned limbs and digits separately so that tissue does not become adherent.
F. DO NOT!!!
* Do not apply ice directly to the skin.
* Do not break blisters.
* Do not remove material that firmly adheres to burned skin.
* Do not use ointments, creams or sprays on any burn that will require further medical treatment.
G. Conserve patient’s body warmth with sheet/blankets (avoid cold/ice for large area burns).
H. Elevate burned extremities.
I. Give nothing by mouth (NPO).
J. LOOK FOR ADDITIONAL TRAUMA! Injuries should be treated using other appropriate protocols.
K. Follow Airway Protocol.
L. Administer high flow oxygen to:
M. Any burned patient with possible respiratory involvement.
N. All suspected carbon monoxide poisonings.
O. Continually reassess the patient for signs of respiratory distress and treat early.
P. Remember that pulse oximeter readings may be falsely high in CO poisonings.
Q. Evaluate risk factors for airway compromise:
1. Closed space fire
2. Burns to face or singed nasal hairs/blackened rim of nares
3. Hoarseness/inspiratory stridor
4. Carbon deposits on tongue/oropharynx
R. ALL PATIENTS WITH RISK FACTORS RECEIVE HIGH FLOW O2.
S. Start a minimum of one large bore IV-IO line. Start the line as far from the burn as possible, but if necessary, the IV/IO may be started through the burned tissue.
T. Run the IV, BSS, wide open if pulmonary edema is not present; monitor lung sounds.
U. Cardiac Monitoring.
~~~~~~~~~ EMT-I/RN/EMT-P CARE~~~~~~~~~~~
V. If there is no respiratory compromise, pain relief may be managed with Morphine Sulfate 2.0-5.0mg IV/IO/IM every 3-5 minutes for desired effect. Max. total dose is 20 mg in burn patient. (May consider Fentanyl as alternate to Morphine Sulfate. Start at 25 mcg. titrate PRN NMT 200 mcg. Consult OLMC for additional dosage.)
W. MONITOR RESPIRATORY STATUS CLOSELY

Question 22

Burns - Electrical

Answer 22

Electrical burns are frequently more severe than they appear; remember that deep injury is predominant.
All electrical burn patients should have cardiac monitoring and IV, BSS for drug route.

Question 23

Burns - Chemical

Answer 23

HEMICAL BURNS
❖
USE CAUTION: PROTECT YOURSELF!
A. Unless specifically advised otherwise, all chemicals should be washed with copious amounts of water.
B. Dry powder chemicals should be brushed off first, then flushed.
C. Caustic burns of the eye should be immediately rinsed with the cleanest water available.
D. If available, get MSDS for industrial chemicals; follow MSDS recommended procedure.
E. Contact poison control at 1-800-222-1222.

Question 24

Chest Pain

Answer 24

NOTE:
❖ Non-traumatic chest pain in any patient ≥ 40 yo should be treated as cardiac in origin until
proven otherwise, and should be considered in patients < 40 yo with typical symptoms.
❖ Chest pain associated with shortness of breath, diaphoresis, vomiting, previous cardiac
disease, and/or hypotension has a frequent association with myocardial ischemia.
❖ For all patients with presumed cardiac chest pain, complete the Chest Pain/STEMI
checklist and transfer paperwork with patient.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ EMR CARE ~~~~~~~~~~~~~~~~~~~~~~~~~~~
A. Place patient in position of comfort.
B. Administer supplemental oxygen via nasal cannula at 2 - 4 liters/minute. Titrate to SaO2 ≥95%.
C. Give patient 4 (81 mg each) chewable baby aspirin (ASA) if the patient has not already taken
ASA today and has no allergies to ASA or NSAIDS.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ EMT CARE ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
D. Consider additional oxygen by mask if the patient is in respiratory distress, has an irregular pulse, a decreased level of consciousness or oxygen saturation of <95%.
E. Monitor Oxygen saturation.
F. EMT-Basics may assist a patient with his/her own nitroglycerin under the following
circumstances:
1. The Nitroglycerin is prescribed to the patient by his/her own doctor. The EMT cannot give a patient Nitroglycerin from the ambulance supply.
2. The patient has taken less than 3 Nitroglycerin with this episode of chest pain.
3. The patient is conscious and alert
4. Blood pressure must be >100 systolic.
If the chest pain persists and the above circumstances do not change, the EMT may assist the patient with up to a total of 3 Nitroglycerin: 0.4 mg SL q 5 min PRN NTE total 3 doses
G. If patient is unstable, or having persistent pain suspicious for acute coronary syndrome, call for intermediate backup.
H. If available, run 12-lead ECG strip for intercepting EMS unit or transmit to OLMC if so equipped.
I. Complete Thrombolytic Checklist. (See page 40).
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~AEMT CARE~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
J. IV, Balanced Salt Solution TKO or saline lock.
K. CardiacMonitor
L. For agencies with capability, perform 12-lead ECG.
(Target is within 5 minutes of patient contact).
M. If machine reads:
**ACUTE MYOCARDIAL INFARCTION* or
**MEETS ST ELEVATION MI CRITERIA*
Activate Lifeflight to initiate STEMI treatment. Consultation with OLMC is not required.
If still suspicious for MI, but EKG does not confirm, contact OLMC, speak directly with on duty physician and relay:
1. Leads with elevation
2. mm of elevation

3. Fax or email EKG to OLMC if possible.
4. If estimated transport time to closest medical facility exceeds 30 minutes, or if directed by OLMC, arrange for intercept with aeromedical transport.
5. Complete the STEMI checklist.
   N. Check bilateral B/P if suspected dissecting aortic aneurysm.
   O. Nitroglycerin 0.4 mg SL q 5 min PRN NTE 3 doses as long as systolic B/P>100 and no history of erectile dysfunction meds in last 48 hours.
6. Observe the patient closely for hypotension.
7. If IV attempt is unsuccessful, admin. NTG SL then reattempt IV.
8. If hemodynamically unstable an IO may be considered.
9. If systolic B/P remains >100 and chest pain continues, administer additional doses of nitroglycerin 0.4mg SL 1,2
10. If the chest pain resolves with SL NTG, but SBP remains >160 mm Hg and/or the DBP is > 100 mm Hg, consider application of 1” of nitropaste to ACW (anterior chest wall).
    ~~~~~~~~~~~~~~~~~~~~~~~~ EMT-I/RN~~~~~~~~~~~~~~~~~~~~~
    P. Morphine: 1 - 2 mg every 5 minutes NMT 10 mg IV/IO for ischemic chest pain relief if systolic B/P remains >100.

Question 25

CVA

Answer 25

NOTE:
❖ Cerebrovascular accidents (CVA or stroke) are relatively common neurovascular events, which
can present with a range of neurologic signs and symptoms.
❖ Do not treat hypertension or administer aspirin to patients with suspected stroke
❖ This protocol does not apply to patients with traumatic brain injury. See Trauma Protocol
❖ Acute Stroke Interventions include Thrombolytics (TPA) which can be administered up to 4.5 hours from LKN (Last Known Normal), and interventional radiology for thrombectomy in LVO (Large Vessel Occlusion) stroke up to 24 hours after LKN
❖ The PPSS (Portland Prehospital Stroke Screen) is useful in assessing whether symptoms may be due to a stroke that would be eligible for thrombolytics if administered within 4.5 hours of the onset of symptoms.
❖ The C-STAT is used to determine if the stroke is due to LVO occlusion. These strokes cause severe and often debilitating symptoms, and may benefit from treatment by thrombectomy up to 24 hours after onset of symptoms.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ EMR CARE ~~~~~~~~~~~~~~~~~~~~~~~~~~~
A. Perform primary survey.
B. If patient has altered mental status, treat per Altered Mental Status Protocol.
C. Protect airway, as loss of gag reflex is common. If LOC is decreased and injuries don’t
contraindicate it, place patient on his/her side in the recovery position. If LOC is not decreased, patient can be kept in a seated position. Avoid laying patient flat if possible since this may increase risk of aspiration. Suction as required.
D. If hypoxemic, administer oxygen per nasal cannula 2-4 L/min. Titrate to SaO2 ≥95%.
E. Assist ventilation as necessary.
F. Maintain verbal contact and be reassuring. Although the patient may not be answering, or may
appear confused, he/she may comprehend what is happening.
G. Try to ascertain the time of onset acute change in neurologic changes or last known normal
(LKN)
H. Protect affected limbs from injury.
I. Allow patient to seek position of comfort.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ EMT CARE ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
I. Check blood glucose via finger stick. If BG level is <60, treat per Diabetic Emergency protocol. Avoid inducing hyperglycemia as this may worsen injury to brain.
J. Note and document changes in the patient’s level of consciousness and vital signs.
K. Assess for signs of stroke:
1. Perform PPSS (Portland Prehospital Stroke Screen) - see following pages
2. If PPSS is positive, continue to C-STAT (Cincinnati Stroke Triage Assessment Tool)
evaluation for LVO (Large Vessel Occlusion) stroke - see following pages
L. Obtain 12-lead EKG to look for signs of ACS

Complete Thrombolytic Checklist if time permits (see following page)~~~~~~~~~~~~~~~~~~~~~~~~~~~~ AEMT/EMT-I/RN CARE ~~~~~~~~~~~~~~~~~~~~~~~~~
O. Start an IV of BSS, TKO or saline lock.
P. Monitor cardiac rhythm.
~~~~~~~~~~~~~~~~~~~~~~~~~

PPSS: Portland Prehospital Stroke Screen
 1. Age over 45 years
Yes
No
 2. No prior history of seizure disorder
Yes
No
Unknown
3. New onset of neurologic symptoms in last 24 hours
Yes
No
Unknown
4. Patient was ambulatory at baseline (prior to event)
Yes
No
Unknown
5. CBG between 60 & 400
Yes
No
Unknown
NEUROLOGICAL EXAMINATION
Normal
Abnormal
FACIAL SMILE/GRIMACE
(ask patient to smile/show teeth)
Normal: both sides of face move equally well
Abnormal: one side of face does not move as well as the other
  Yes
Right
Left
ARM DRIFT
(patient closes eyes and holds both arms out palms up)
Normal: both arms move the same or do not move at all Abnormal: one arm does not move or drifts down compare to other
  Yes
Right
Left
HAND GRIP
(have patient squeeze both hands simultaneously) Normal: equal grip strength
Abnormal: unequal grip strength
  Yes
Right
Left
SPEECH
(have patient repeat “You can’t teach an old dog new tricks”)
Normal: no difficulty repeating
Abnormal: patient has difficulty finding words, speaks in long meaningless sentences, and/or cannot understand or follow simple verbal instructions
  Yes
Difficulty with speech
  If questions 1-5 are all answered “Yes” or “Unknown” and at least 1 of the 4 neurological examination findings are abnormal the patient is considered to have a POSITIVE screen.

Question 26

Diabetic - Hypo

Answer 26

NOTE:
❖ The EMT should check a blood glucose (BGL) analysis before beginning treatment if time
and condition of patient allows.
❖ If the EMT is unable to determine whether or not the patient is hypo or hyperglycemic, the
hypoglycemia protocol should be followed.
❖ Recent research suggests that hyperglycemia may complicate or worsen a number of
medical conditions (i.e., myocardial infarction, stroke)
❖ It is important to determine whether the patient may have taken an accidental or
intentional overdose of insulin or oral hypoglycemic agent. If overdose suspected, attempt to document the name and amount of all medications involved and time of ingestion.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ EMR CARE ~~~~~~~~~~~~~~~~~~~~~~~~~~~
A. Administer oxygen 2 - 4 L/min via nasal cannula, titrate to SaO2 ≥95%.
B. If the patient is unconscious but does not require aggressive airway care or ventilation during
transport, place him/her in the recovery position; on side, knees drawn up, opposite arm under head. If the patient is conscious, transport in position of comfort.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~EMT CARE~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
C. Check the patient’s blood glucose level via finger stick.
I. HYPOGLYCEMIA –TREATMENT (BGL < 60)
A. If the patient is fully conscious, give oral glucose.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~ AEMT/EMT-I/RN CARE ~~~~~~~~~~~~~~~~~~~~~~~~~
B. Start a large bore IV, saline lock.
C. If the patient has a BGL < 60 and altered mental status, administer Dextrose IV/IO. D10W
solution is preferred, (5 ml/kg or 0.5 gm/kg) but can give D50 (10 ml)1 over 2-3 minutes in a patent, free flowing IV. Precautions: Extravasation of dextrose 50% will cause necrosis of tissue.
D. If the patient’s condition does not improve, or improves but he/she does not become fully conscious, the dextrose may be repeated after 10 minutes if a second glucose level test shows the patient to be hypoglycemic.
E. If an IV cannot be established, administer 1 mg Glucagon IM for adults and 0.1 mg/kg pediatrics, NMT 1 mg.
F. Treat other medical/trauma conditions per protocol.

Question 27

Diabetic - Hyper

Answer 27

HYPERGLYCEMIA–TREATMENT (BGL >300 AND SYMPTOMATIC) ~~~~~~~~~~~~~~~~~~~~~~~~~~~~ AEMT/EMT-I/RN CARE ~~~~~~~~~~~~~~~~~~~~~~~~~
A. Start a large bore IV, balanced salt solution TKO. If B/P is < 90 mm/hg, systolic give 500 ml fluid challenge.
B. Treat other medical/trauma conditions per protocol

Question 28

Drowning/Subersion

Answer 28

History
A. Always consider head or neck injury.
B. How long was patient submerged?
C. Approximate water temperature?
D. Associated Trauma. Did patient jump or dive? E. Pertinent medical history
1. Seizure 2. MI
3. Diabetes 4. Other
F. Was SCUBA incident involved?
II. Physical Exam
A. Vital signs. (If absent see Cardiac Arrest Protocol)
B. Temperature to monitor for Hypothermia
C. Breathing
1. Respiratory distress - tachypnea, increased work of breathing 2. Initial presence of crackles as sign of pulmonary edema
3. Ronchi as sign of aspiration
4. Monitor for changes during transport.
D. Head or neck injury
E. Neurologic Status: Record and monitor mental status continuously.
III. Treatment
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ EMR CARE ~~~~~~~~~~~~~~~~~~~~~~~~~~~
A. Clear airway
B. Unknown or traumatic event; stabilize neck prior to removing patient from water.
C. If conscious and no respiratory distress administer high flow oxygen.
D. If unconscious or respiratory distress perform positive pressure ventilation and prepare to aggressively suction
E. If patient is in cardiac arrest see Cardiac Arrest Protocol
F. Treat shock per Shock Protocol.
G. Treat hypothermia per Environmental Emergencies Protocol
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~EMT CARE~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
H. If unconscious consider use of PEAD.
I. If patient is conscious and in severe distress, consider CPAP.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~ AEMT/EMT-I/RN CARE ~~~~~~~~~~~~~~~~~~~~~~~~~
J. Establish large bore IV, 2 if possible.
K. Place monitor for ECG.
L. Treat dysrhythmia per ACLS Dysrhythmia Protocol

Question 29

Cold injuries - Frostbite

Answer 29

COLD INJURIES
A. Frostbite
1. Do not rub affected areas
2. Protect frostbitten areas from further damage.
3. Do not allow re-warming of affected tissue if there is any chance for refreezing. Major
extremity frostbite should be re-warmed only at the hospital.

Question 30

Cold Injuries - Hypothermia

Answer 30

~~~~~~~~~~~~~~~~~~~~~~~~~~ EMR/EMT CARE ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
1. Perform primary survey and include temperature assessment if possible.
2. Alternative methods for determining respiratory status may be needed, such as holding
polished metal or glass under the nostrils.
3. Monitor patient for 60 seconds before determining pulselessness.
4. Provide supplemental oxygen via non-rebreather mask or assisted ventilations.
5. Patient may appear to be lifeless and a pulse may not be felt. If ALS personnel are
immediately available, establish EKG monitoring before beginning chest compressions.
Support ventilation as necessary.
6. Begin passive external re-warming.
b. Remove wet clothing.
c. Dry the patient well.
d. Wrap patient in warm, dry blankets.
e. Give warmed humidified oxygen by mask if available.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~ AEMT/EMT-I/RN CARE ~~~~~~~~~~~~~~~~~~~~~~~~~
7. Start IV/IO of balanced salt solution and run wide open unless pulmonary edema is present.

Question 31

Heat Emergencies - Heat Exhaustion/Heat Cramps

Answer 31

II. HEAT INJURIES
A. HeatExhaustion/HeatCramps
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ EMR/EMT CARE ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
1. Perform primary survey and include temperature assessment if possible.
2. Move patient to cool environment. Remove excess clothing, apply cool compress to
extremities and forehead. Open windows, fan patient, etc. Do not cool the patient to the
point of shivering.
3. Give cool liquids orally if the patient is fully conscious and alert.
~~~~~~~~~~~~~~~~~~~~~~~~ AEMT/EMT-I/RN/EMT-P CARE ~~~~~~~~~~~~~~~~~~~~~~~~~
4. Apply cardiac monitor.
5. If patient is unable to take liquids orally or if signs of shock are present, start IV of
balanced salt solution and run wide open. Monitor the patient for signs of pulmonary edema.
B. Heat Stroke
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ EMR/EMT CARE ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
1. Perform primary survey and include a temperature assessment if possible.
2. Manage airway as needed. Give oxygen by mask; increase oxygen if indicated by
patient’s respiratory status or SaO2. Manual ventilation if indicated.
3. Move patient to cool environment. Remove excess clothing. Begin aggressive cooling
measures including covering the patient with wet sheets, utilizing fans or open windows
to circulate air and applying wrapped cold packs to axilla and groin.
4. If unconscious, treat per Altered Mental Status Protocol.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~ AEMT/EMT-I/RN CARE ~~~~~~~~~~~~~~~~~~~~~~~~~
5. Apply cardiac monitor.
6. Start IV/IO of Balanced Salt Solution.
~~~~~~~~~~~~~~~~~~~~~~~~~~~EMT-P CARE~~~~~~~~~~~~~~~~~~~~~~~~~~
7. Treat seizures as per the seizure protocol.
Firefighter Dehydration in the field treatment:
A firefighter who becomes dehydrated in the field may be administered up to 2 liter Normal Saline intravenously while vitals, LOC, cardiac monitoring and temperature are monitored. If no improvement is noted, transport immediately. If the patient remains stable, they are to be seen in the hospital emergency room for evaluation as soon as time permits.

Question 32

Heat Injuries - Heat Stroke

Answer 32

B. Heat Stroke
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ EMR/EMT CARE ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
1. Perform primary survey and include a temperature assessment if possible.
2. Manage airway as needed. Give oxygen by mask; increase oxygen if indicated by
patient’s respiratory status or SaO2. Manual ventilation if indicated.
3. Move patient to cool environment. Remove excess clothing. Begin aggressive cooling
measures including covering the patient with wet sheets, utilizing fans or open windows
to circulate air and applying wrapped cold packs to axilla and groin.
4. If unconscious, treat per Altered Mental Status Protocol.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~ AEMT/EMT-I/RN CARE ~~~~~~~~~~~~~~~~~~~~~~~~~
5. Apply cardiac monitor.
6. Start IV/IO of Balanced Salt Solution.

Question 33

EPISTAXIS (Nosebleed)

Answer 33

NOTE:
❖ It is difficult to determine amount of blood loss with epistaxis, bleed may be occurring posteriorly.
❖ Posterior epistaxis can be a true emergency requiring advanced ED techniques such as balloon tamponade or interventional radiology.
❖ Detailed medication hx should be obtained to include the use of NSAIDS, aniplatelets, or anticoagulants medications that may contribute to bleeding.
❖ For patients on home oxygen place the nasal cannula pointing into the patients mouth while the nares are compressed for active bleeding.
I. Physical Exam
A. Document previous episodes of epistaxis, recent trauma, duration of bleed, and noted quantity of bleeding.
B. Evaluate for posterior blood loss by examining the back of the throat.
C. Monitor vital signs closely watching for hypotension and tachycardia.
D. Be prepared for bloody emesis if patient has been bleeding into esophagus and stomach.
E. Do not delay transport with the hope it will self resolve. Often patients have already waited for some time to call for help.
II. Treatment
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ EMR / EMT CARE ~~~~~~~~~~~~~~~~~~~~~~~~~~~
A. Treat per “General orders for all patients” and use universal precautions.
B. Place patient in position of comfort and have them tilt head forward.
C. Compress nose with direct pressure or approved nose clamp device.
D. If signs of shock appear follow “Shock” protocol and call for ALS assistance.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~ AEMT/EMT-I/RN CARE ~~~~~~~~~~~~~~~~~~~~~~~~~
E. Establish large bore IV, 2 if possible. Follow shock protocol.
F. Bolus with BSS to achieve target SBP of 90 mmhg or MAP of 65 mmhg. Monitor for signs of
pulmonary edema.
G. Place monitor for ECG.
H. TreatdysrhythmiaperACLSDysrhythmiaProtocol.
~~~~~~~~~~~~~~~~~~~~~~~~~~~EMT-P CARE~~~~~~~~~~~

Question 34

Poison Oak Exposure

Answer 34

~~~~~~~~~~~~~~~~ EMR/EMT/AEMT/EMT-I/RN CARE ~~~~~~~~~~~~~~
A. The most important and effective treatment for poison ivy dermatitis is identification and avoidance of toxic plants and related allergens
B. Barrier creams are topical preparations that are applied prior to exposure to a contact allergen in an attempt to prevent the development of dermatitis. Organoclay compounds (Ivy Block) appear to be more effective barriers than other preparations. These have to be washed off and reapplied frequently (every 4 - 8 hours)
C. After a known exposure, patients should remove any contaminated clothing and gently wash the skin with mild soap and water as soon as possible. Fingernails should be washed carefully to remove resin that may remain under the nails. Vigorous scrubbing is not useful and can exacerbate impending dermatitis.
D. Clothing, tools, or other items that may have come in contact with the oleoresin also should be washed with warm, soapy water prior to reuse.
E. An oil-removing compound (eg. Goop), topical surfactant (eg. Dial ultra dishwashing soap) or chemical inactivator intended to prevent urushiol dermatitis (eg. Tecnu) may all be useful in removing the oil from the skin if applied within 8 hours of exposure, before the rash has developed. These may still be helpful after rash has developed to remove urushiol that hasn’t been taken up by skin cells, but once urushiol is taken up by cells, these are no longer effective.
F. Topical symptomatic therapy — Soothing measures such as oatmeal baths and cool, wet compresses are anecdotally helpful. Topical treatment with compounds containing menthol and phenol (calamine lotion) may also provide symptomatic relief. Topical astringents such as aluminum acetate (Burow’s solution) or aluminum sulfate calcium acetate (Domeboro) used under occlusion may be useful to dry weeping lesions.
G. A soap mixture of ethoxylate and sodium lauroyl sarcosinate surfactants (Zanfel) appears to provide benefit in reducing duration and severity of reaction.
H. Topical antihistamines, anesthetics containing benzocaine, and antibiotics containing neomycin or bacitracin should be avoided because of their own allergenic potential.

Superpotent topical corticosteroids, such as clobetasol propionate 0.05% cream, are the only topical corticosteroids that can influence the course of poison ivy dermatitis. Low & intermediate potency topical corticosteroids are of little use. High-potency topical corticosteroids should generally not be used on thin skin such as the face, genitals, or intertriginous areas, (groin and armpits) due to the potential for these agents to cause skin atrophy and other adverse effects. However, use of superpotent corticosteroids, even under occlusion, for up to a week on severely involved areas poses little threat for permanent atrophy.
J. Patients with severe dermatitis, particularly involving the face or genital region, may require systemic corticosteroids. EMT’s may benefit from contacting their PCP for prescription for oral prednisone (started at a dose of approximately 1 mg/kg/day with maximum initial dose 60 mg/day then tapered over two weeks) which can be dramatically beneficial for the miserable patient. Rebound dermatitis occurs commonly if too short a course is used, but rarely occurs after 2 weeks of treatment.
K. Exposed personnel should contact their doctor early for treatment with topical or systemic corticosteroids if moderate or severe symptoms occur.

Question 35

Seizures

Answer 35

NOTE:
❖ The goal of seizure management is to identify and treat any immediately reversible causes, to prevent injury from seizure activity, and to stop prolonged seizures (status epilepticus).
❖ Initial history and physical assessment should identify potentially reversible causes such as:
❖ Fever, ❖ Anoxia/hypoxia, ❖ Hypoglycemia (history of diabetes?)
❖ Poisoning, ❖ Cardiac dysrhythmias, ❖ Toxemia in third trimester
~~~~~~~~~~~~~~~~~~~~~~ EMR CARE ~~~~~~~~~~~~~~~~~~~~~
A. AIRWAY, BREATHING, CIRCULATION.
B. Protect patient from injury.
C. Oxygen via nasal cannula or mask depending on patient’s LOC
~~~~~~~~~~~~~~~~~~~~~ EMT CARE ~~~~~~~~~~~~~~~~~~~~~~
D. Check blood glucose levels and treat if indicated.
E. Basic care for the patient with prolonged seizures or with 2 or more seizures without a period of consciousness between (status epilepticus) is early and rapid transport to the hospital.
F. Check temperature.
~~~~~~~~~~~~~~~ AEMT/EMT-I/RN CARE ~~~~~~~~~~~~~~~~~~~
If seizure is persistent, recurrent, or if patient has long postictal period:
H. IV BSS TKO or Saline lock.
I. ECG Monitor.
J. Medications may include (depending on the etiology of the seizure):
1. Dextrose, D10W 0.5gm/kg + Saline Flush
2. Narcan 0.4 - 2.0 mg IV/IO/IM/SQ/SL/ET, NMT 8 mg.
(Pediatric dose 0.1 mg/kg NMT 2 mg.)

Question 36

Respiratory Emergencies

Answer 36

NOTE:
❖ Recognition and Tx of airway and breathing is top priority
❖ Titrate O2 to SaO2 ≥95%.
❖ If patient feels SOB, and has SaO2 ≥95%, may give 2L O2 via NC
~~~~~~~~~~~~~~~~~~ EMR CARE ~~~~~~~~~~~~~~~~~~~~~~
I. GENERAL
A. Support the head and neck as appropriate to patient’s condition. Perform head and or jaw maneuvers as required and appropriate to patient’s condition to secure and maintain a patent airway.
B. Supply supplemental oxygen at concentrations appropriate to the patient’s condition. Use mouth-to-mask or bag-valve-mask with supplemental oxygen to ventilate patient’s who are apneic or have inadequate respirations.
C. Use oral or nasal airways to facilitate airway maintenance. Soft nasal airways may be lubricated with water soluble ointment.
D. Suction the oropharynx as needed to remove secretions, blood and / or vomitus.
II. UPPER AIRWAY OBSTRUCTION (FOREIGN BODY) SEE FB protocol
III. ASTHMA/BRONCHOSPASM/COPD Severity Assessment:

XXXX Insert Table Here XXXX

A. Transport in comfortable position; typ with the head elevated.
B. Supplemental oxygen via nasal cannula or mask.
C. The COPD patient may be sensitive to oxygen
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D. If patient is wheezing or has poor air movement, administer nebulized albuterol (1 unit dose). May repeat in 10 minutes. Contact OLMC for more
E. Duoneb (Mix Albuterol and Atrovent) for initial dose if already taking albuterol treatments or inadequate response to treatment.
F. If available and patient still has severe distress, consider CPAP.
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G. Cardiac Monitor.
~~~~~~~~~~~~~~~~~~~ EMT-I/RN CARE ~~~~~~~~~~~~~~~~~~~~
1. Epinephrine – With upper airway Stridor, consider 1:1,000 (3 mg nebulized). Use with caution if patient is 50 years or older or has history of heart disease. Consider OLMC consult before administration.

Question 37

Respiratory Emergencies - Asthma in Pediatrics

Answer 37

1. **In children 6 months to 6 yrs. With audible stridor at rest, give 3 ml epinephrine 1:1,000 via nebulizer. May repeat in 20 minutes.
2. **The usual cause of respiratory arrest in children with croup, epiglottitis or laryngeal edema is exhaustion, not complete obstruction.
3. ** Avoid IV/IO access if possible.
4. Administer 02 [or nebulized medications] through a familiar object, (e.g., place tubing through the bottom of a paper cup held close to the child’s face by the parent or caregiver.
5. • Do not dilute or reduce the dose of albuterol.
6. ** If needed, the second treatment may be Albuterol/Atrovent mix or Duoneb the same as adult dosage.
7. **Consider Dexamethasone 0.6 mg/kg (NMT10mg) in patients with asthma.
8. **For severe bronchospasm not responding to above consider: Epinephrine 0.01 mg/kg 1:10,000 IV/IM/IO (0.1 ml/kg).
   * = EMT ** = AEMT ** = EMT-I/RN ** = EMT-P

Question 38

Trauma - Hemmorage Control

Answer 38

NOTE:
❖ Be prepared for rapid decline in children and infants
❖ Note approximate blood loss on scene and include in PCR when possible
❖ Alcohol intake and anti-coagulation or anti-platelet medications may make bleeding difficult to control.

I. II.
Mechanism of Injury:
A. Consider blood loss from external bleeding along with potential internal bleeding that may accompany an injury
Signs & Symptoms:
A. Syncope or near syncope, altered mental status, or unconsciousness
B. Hypotension and signs of shock
C. Arterial bleeding will be bright red and more difficult to control
D. Document pulses, sensation, and motion before and after wound care or splinting.
TRAUMA - HEMORRHAGE CONTROL
NOTE:
❖ Be prepared for rapid decline in children and infants
❖ Note approximate blood loss on scene and include in PCR when possible
❖ Alcohol intake and anti-coagulation or anti-platelet medications may make bleeding difficult to
control.
III. Management:
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A. Evaluate ABC’s and administer O2 if indicated (SPO2 <95%).
B. Apply direct pressure with a clean dressing to any active bleeding wound and attempt to
control bleeding. Direct pressure to the proximal artery may be necessary.
C. Elevate the area of the bleed to above the level of the heart when possible
D. Clean open wounds with sterile water or normal saline if bleeding is controlled.
E. Dress the injury site with clean and dry gauze, dressing, and/or Band-aid. Coban, Kerlix, or
tape may be used to secure the gauze or other dressing. Do not apply Kerlix, Coban, or other securing material directly to the wound bed.
F. Document the control of bleeding, pulse/motor/sensory assessment, and patient response both before and after dressing the wound.
G. Rapid transport to the closest medical facility. If the patient is requesting a dressing but refusing transport, assure all bleeding has been controlled prior to dressing the wound.
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H. If direct pressure and elevation do not control the bleeding move immediately to:
1. Tourniquet - for hemorrhage of an extremity. See TOURNIQUET PLACEMENT
Procedure.
2. Hemostatic Dressing - for junctional bleeding (buttock, pelvis, axilla, neck, face, or scalp). See HEMOSTATIC AGENT Procedure.
~~~~~~~~~~~~~~~~~~~ AEMT/EMT-I/RN CARE ~~~~~~~~~~~~~~~~~~~
I. Start a minimum of one large bore (#14 or 16) IV’s enroute.
J. IV fluid BSS if indicated. Unless patient has associated traumatic brain injury (TBI), allow permissive hypotension with traumatic bleeding.
1. Without TBI, titrate fluids to MAP >65, systolic between 70-90 2. With TBI, titrate fluids to SBP >100
K. Monitor EKG.
L. If unable to achieve target B/P, Norepinephrine 4-12 mcg/min IV/IO titrate upward 2 mcg/ min increments

Question 39

Trauma - Fractures & Dislocations

Answer 39

NOTE:
❖ Patient may have fracture without loss of function.
❖ At a multiple injury scene, fractures have low priority
❖ Do not give narcotic pain medications to trauma patients with head or abdominal injuries.
❖ Pelvic fractures may be associated with severe shock

I. History:
A. History of trauma
B. Mechanism of injury C. Time of last oral intake.
II. Physical Findings:
A. Localized pain, tenderness
B. Swelling, discoloration
C. Angulation, deep lacerations, exposed bone fragments
D. Crepitus
E. Loss of function, limitation of motion, guarding
F. Quality of distal pulses, sensation and motion
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III. Management:
A. Assure airway, breathing, circulation, control hemorrhage
B. Vital signs
C. C-spine precautions.
D. Check distal neuro/vascular status
E. Splint
1. Axial stabilization as needed
2. Splint joint above and below fracture
3. Splint where it lays unless compromised neuro or vascular status, then move to anatomical position.
4. Apply axial traction as needed using Sager or other traction splint for suspected femur fracture. (Note - this is not to be used for suspected hip or pelvic fracture)
~~~~~~~~~~~~~~~~~ AEMT/EMT-I/RN/EMT-P CARE ~~~~~~~~~~~~~~~~
F. Establish large bore IV, two (2) if possible.
G. Consider pain management as per the Pain Control Protocol

PEDIATRIC CONSIDERATIONS:

1. Small children may require extra padding under the shoulders.
2. Fentanyl dose for children***:
   a. < 40 kg: initial dose 1 mcg/kg, repeat with 0.5-1 mcg/kg every 3-5 minutes, NMT 4 mcg/kg.
   b. > 40 kg use adult dosing.

Question 40

Trauma - Neurologic

Answer 40

NOTE:
❖ This protocol covers the usual considerations in management of the known or suspected head or spinal injury patient and is to be used in conjunction with other applicable Trauma Protocols.
❖ Most neurologic trauma is associated with other system trauma and should be assessed and managed in light of all known or suspected injuries.
❖ Assume that all head injuries have associated spinal injuries and stabilize
appropriately prior to transport.
❖ Hypotension in a closed head injury should be assumed to have another cause. Remember that spinal injuries can result in hypotension when no obvious source of bleeding is found.

I. Management strategy:
A. ABC’s with spinal stabilization
B. Neurologicassessment(GCSorAVPU)
C. Prevent or reduce increasing intracranial pressure
D. Prevent further spinal cord injury
II. Management:
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A. Evaluate ABC’s and start Oxygen therapy. Consider assisting ventilation’s with BVM.
1. Follow Respiratory and Trauma Protocols as indicated. Do not hyperventilate patient.
B. Maintain spinal precautions.
1. Maintain manual stabilization of the neck while the torso is secured to the board BEFORE securing the head.
2. Transport using a backboard along with an extrication collar, head stabilizers and tape, ties or straps to maintain axial control of spinal column.
3. Always use padded backboard or vacuum mattress to prevent pressure ulcerations.
C. All neurological trauma patients should be evaluated using GCS or AVPU at 5 minute intervals.
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D. If unable to maintain airway, consider PEAD placement.
~~~~~~~~~~~~~~~~~~~ AEMT/EMT-I/RN CARE ~~~~~~~~~~~~~~~~~~~
E. Start two large bore (#14 or 16) IV’s/IO’s enroute, BSS.
F. Give fluid resuscitation, if indicated, in challenges of 20 ml/kg for children or 500 cc for adults
G. Titrate fluid to systolic B/P of 100 and improved skin signs.