EL DORADO COUNTY EMS AGENCY PREHOSPITAL PROTOCOLS

Transcription

1 EL DORADO COUNTY EMS AGENCY PREHOSPITAL PROTOCOLS Effective: July 1, 2017 Reviewed: November 9, 2016 Revised: November 9, 2016 EMS Agency Medical Director ALLERGIC REACTION/ANAPHYLAXIS ADULT ABCs / ROUTINE MEDICAL CARE - Be prepared to support ventilation with appropriate airway adjuncts and circulation with external chest compressions. Administer oxygen at the appropriate flow rate, preferably high flow via non re-breather mask if patient has dyspnea. BLS Personnel: Allow patient to administer their own allergy medications as prescribed by their physician, see Field Policy: BLS Medication Administration. Place patient in position of comfort. If shock signs or symptoms begin, place patient in a supine position with legs elevated. NOTE: If allergen is a stinger, scrape it out of the patient s skin (use a credit card or the dull side of a knife) to prevent the introduction of more venom; a cold pack may also be applied to the sting site to reduce swelling. PROTOCOL PROCEDURE: Flow of protocol presumes that condition is continuing, If the patient is distress, immediate rapid transport is preferred with treatment performed en route. OPTIONAL SKILLS EMT TREATMENT BENADRYL 50 mg PO. Administer only if patient is alert and able to swallow. FOR PATIENTS WITH PROGRESSIVELY WORSENING SYMPTOMS: EPI-PEN AUTOINJECTOR mg IM. (0.3 ml 1;1,000) Repeat dose may be given in 10 minutes if ALS response is delayed and patient is not responding to treatment). NORMAL SALINE establish an IV/IO. give 1000 ml bolus(es) for hypotension. MR as needed. Start a second line if hypotension is present or if patient is severe. BENADRYL 50 mg IV, IO, IM or PO. EPINEPHRINE 1:1, mg IM. Mid-anterolateral thigh is preferred. MR q 10 minutes. NEBULIZED BREATHING TREATMENT(S) (MAY BE GIVEN PRIOR TO IM EPI FOR BRONCHOSPASM): FOR WHEEZING: DUONEB (2.5 mg Albuterol and 0.5 Mg Atrovent in normal saline). Do not repeat Duoneb. If symptoms persist, give single dose of ALBUTEROL 2.5 mg in 3 ml normal saline. FOR STRIDOR: NEBULIZED EPINEPHRINE 1:1,000 5 ml (5 mg) via nebulizer given over 10 minutes. MR q 10 minutes. FOR SEVERE HYPOTENSION/AIRWAY COMPROMISE (IMPENDING ARREST): NORMAL SALINE 2 IVs/IO wide open if hypotension present. INSERT ADVANCED AIWAY - If airway edema is present, intubate as soon as possible. CONTACT BASE STATION EPINEPHRINE 1:10, mg (diluted with NS or SW to 10 ml) slow IV push over 5 minutes. MR as needed. (Dose is equivalent to 1:100,000 after dilution). GLUCAGON If no response to epinephrine, administer 2-4 mg IV/IO push or IM, q 5 minutes.

2 ALLERGIC REACTION/ANAPHYLAXIS FOR ANAPHYLAXIS CAUSED CARDIAC ARREST: REFER TO ADULT PULSELESS ARREST PROTOCOL CARDIAC MONITOR Treat arrhythmias as needed. NORMAL SALINE 2 IVs/IO wide open with pressure bags. Aggressive volume expansion with a goal of up to 4 liters. For Dystonic (Extrapyramidal) reactions: Give BENADRYL 25 mg IV push or IM. (MR to Max. of 50 mg.) Reference: Routine Medical Care, BLS Medication Administration, Optional Skills EMT, Benadryl, EpiPen & EpiPen Jr. Auto Injector, Epinephrine, Albuterol, Atrovent, Glucagon, Pulseless Arrest

3 ALLERGIC REACTION/ANAPHYLAXIS PEDIATRIC ABCs / ROUTINE MEDICAL CARE - Be prepared to support ventilation with appropriate airway adjuncts and circulation with external chest compressions. Administer oxygen at the appropriate flow rate, preferably high flow via non re-breather mask if patient has dyspnea. BLS Personnel: Allow patient to administer their own allergy medications as prescribed by their physician, see Field Policy: BLS Medication Administration. Place patient in position of comfort. If shock signs or symptoms begin, place patient in a supine position with legs elevated. NOTE: If allergen is a stinger, scrape it out of the patient s skin (use a credit card or the dull side of a knife) to prevent the introduction of more venom; a cold pack may also be applied to the sting site to reduce swelling. PROTOCOL PROCEDURE: Flow of protocol presumes that condition is continuing, If the patient is distress, immediate rapid transport is preferred with treatment performed en route. OPTIONAL SKILLS EMT TREATMENT BENADRYL 1 mg/kg (25 mg max) PO. Administer only if patient is alert and able to swallow. FOR PATIENTS WITH PROGRESSIVELY WORSENING SYMPTOMS: EPI-PEN JR AUTOINJECTOR (Only for pediatric patients weighing kg (33-66 lbs): 0.15 mg IM. (0.3 ml 1:2,000) Repeat dose may be given in 10 minutes if ALS response is delayed and patient is not responding to treatment. NORMAL SALINE establish an IV/IO and give 20 ml/kg bolus(es) for hypotension, repeated as needed. BENADRYL 1 mg/kg (25 mg max) IV, IO, IM or PO. EPINEPHRINE 1:1, mg/kg (Max. 0.3 mg) IM. MR q 10 minutes. Mid-anterolateral thigh is preferred. NEBULIZED BREATHING TREATMENT(S) (MAY BE GIVEN PRIOR TO EPI FOR BRONCHOSPASM): FOR WHEEZING: DUONEB (2.5 Mg Albuterol and 0.5 Mg Atrovent in normal saline). Do not repeat Duoneb. If symptoms persist, give single dose of ALBUTEROL 2.5 mg in 3 ml normal saline. FOR STRIDOR: NEBULIZED EPINEPHRINE 1:1, ml/kg (Up to Max. single dose of 5 ml (5 mg)) via nebulizer over 10 minutes. Dilute with NS to 5mL for patients 10 kgs or <. MR q 10 minutes until stridor subsides * continuous monitoring. FOR HYPOTENSION/AIRWAY COMPROMISE (IMPENDING ARREST): NORMAL SALINE 20 ml/kg boluses, repeated as needed. INSERT ADVANCED AIWAY - If airway edema is present, intubate as soon as possible. Consider starting CPR if unresponsive and no palpable BP. CONTACT BASE STATION Reference: Routine Medical Care, BLS Medication Administration, Optional Skills EMT, Benadryl, EpiPen & EpiPen Jr. Auto Injector, Epinephrine, Albuterol, Atrovent, Glucagon, Pulseless Arrest

4 ALLERGIC REACTION/ANAPHYLAXIS EPINEPHRINE 1:10, mg/kg (diluted with NS or SW to 10 ml) slow IV push over 5 minutes. MR as needed. (Dose is equivalent to 1:100,000 after dilution). GLUCAGON If no response to epinephrine, administer 0.1mg/kg IV/IO push or IM, q 5 minutes. FOR ANAPHYLAXIS CAUSED CARDIAC ARREST: REFER TO PEDIATRIC PULSELESS ARREST PROTOCOL CARDIAC MONITOR Treat arrhythmias as needed. For Dystonic (Extrapyramidal) reactions: Give BENADRYL 1 mg/kg IV push or IM. (Max. of 25 mg.) Reference: Routine Medical Care, BLS Medication Administration, Optional Skills EMT, Benadryl, EpiPen & EpiPen Jr. Auto Injector, Epinephrine, Albuterol, Atrovent, Glucagon, Pulseless Arrest

5 ALLERGIC REACTION/ANAPHYLAXIS Reference: Routine Medical Care, BLS Medication Administration, Optional Skills EMT, Benadryl, EpiPen & EpiPen Jr. Auto Injector, Epinephrine, Albuterol, Atrovent, Glucagon, Pulseless Arrest

6 EL DORADO COUNTY EMS AGENCY PREHOSPITAL PROTOCOLS Effective: July 1, 2017 Reviewed: February 8, 2017 Revised: February 8, 2017 EMS Agency Medical Director ALTERED LEVEL OF CONSCIOUSNESS ADULT ABCs / ROUTINE MEDICAL CARE - administer oxygen at appropriate flow rate. Be prepared to support ventilation with appropriate airway adjuncts. If hypoglycemia is suspected in a conscious, known diabetic who is able to follow simple commands, give the patient 15 grams of prepared oral dextrose solution (may repeat in 10 minutes) or encourage drinking/eating a sugar-containing beverage or food. PROTOCOL PROCEDURE: Flow of protocol presumes that condition is continuing. Consider etiology: shock, toxic exposure, insulin shock, seizure, or head trauma. If patient is in distress, immediate, rapid transport is preferred with treatment performed en route. NORMAL SALINE establish IV/IO. BLOOD SAMPLE/GLUCOSE LEVEL ASSESSMENT - obtain blood sample via finger stick or venipuncture. Rule out diabetic emergency. Consider confirming test results with second glucose check with blood from a different site (and different meter, if available) if reading is abnormal or the patient s presentation doesn t match the test results. For symptomatic HYPOGLYCEMIA (b.s. < 60 mg/dl): DEXTROSE - Administer 100cc of a 250cc bag of Dextrose 10% (10g), May repeat to a max of 50g. After each 10g (100cc) bolus check BG, LOC and patency of line.. GLUCAGON - if no IV access, give 1 mg IM/IN. Recheck blood glucose 5 minutes after administration of dextrose or glucagon. For RESPIRATORY DEPRESSION: NARCAN*: IV: 0.5 mg in 1 minute increments slow IV push, titrated to effect (Max. 2 mg). IN: 0.5 mg. May repeat in 5 minutes if no response (Max. 1 ml per nostril). IM: 1 mg if unable to establish IV. May repeat in 5 minutes if no response. ET: 1 mg diluted to 5-10 ml. May repeat in 5 minutes if no response. *The goal of Narcan administration is to improve respiratory drive, NOT to return patient to their full mental capacity. *If no response to normal doses or if patient is in extremis, administer 2 mg IV/IM/IO/ET/IN

7 ALTERED LEVEL OF CONSCIOUSNESS q 5 minutes. CONTACT BASE STATION References: Formulary Dextrose, Narcan, Glucagon Routine Medical Care

8 ALTERED LEVEL OF CONSCIOUSNESS PEDIATRIC ABCs / ROUTINE MEDICAL CARE - administer oxygen at appropriate flow rate. Be prepared to support ventilation with appropriate airway adjuncts. If hypoglycemia is suspected in a conscious, known diabetic who is able to follow simple commands, give the patient 15 grams of a prepared oral dextrose solution (may repeat in 10 minutes) or encourage drinking/eating a sugar-containing beverage or food. PROTOCOL PROCEDURE: Flow of protocol presumes that condition is continuing. Consider etiology: shock, toxic exposure, insulin shock, seizure, or head trauma. If patient is in distress, immediate, rapid transport is preferred with treatment performed en route. NORMAL SALINE establish IV/IO. BLOOD SAMPLE/GLUCOSE LEVEL ASSESSMENT - obtain blood sample via finger stick or venipuncture. Rule out diabetic emergency. Consider confirming test results with second glucose check with blood from a different site (and different meter, if available) if reading is abnormal or the patient s presentation doesn t match the test results. Hypoglycemia in pediatrics is defined as: Neonate < 1 month: (b.s. < 50 mg/dl) Infant/child >1 month: (b.s. < 60 mg/dl) For HYPOGLYCEMIA: DEXTROSE: Less than 1m/o: D10W 2 ml/kg IV/IO may repeat every 5 min until b.s. is at a normal limit. Greater than 1m/o: D10W 5 ml/kg IV/IO may repeat every 5 min until b.s. is at a normal limit. GLUCAGON - if no IV access, give 0.1 mg/kg IM/IN (Max. 1 mg). Recheck blood glucose 5 minutes after administration of dextrose or glucagon. For RESPIRATORY DEPRESSION: NARCAN mg/kg IV/IN/IO/IM titrated to effect (Max. 2 mg). May repeat initial dose, if no response, within 5 minutes. (Maximum IN dose of 1 ml per nostril; If no response to normal doses contact base station). Avoid use in neonates CONTACT BASE STATION References: Formulary Dextrose, Narcan, Glucagon Routine Medical Care

9 EL DORADO COUNTY EMS AGENCY PREHOSPITAL PROTOCOLS Effective: January 2012 Reviewed: July 2013 Revised: July 1, 2016 Scope: ALS Adult/Pediatric EMS Agency Medical Director BRADYCARDIA ADULT ALGORITHM ABCs / ROUTINE MEDICAL CARE - Be prepared to support ventilation with appropriate airway adjuncts and circulation with external chest compressions. Administer oxygen if indicated at the appropriate flow rate. Place patient in position of comfort. Obtain and transmit 12 lead EKG (Do not delay therapy). PROTOCOL PROCEDURE: Flow of protocol presumes that bradycardia is continuing. If response or condition changes, see appropriate protocol. If at any time a stable patient becomes unstable, go to the unstable section of this protocol. If patient is in severe distress, immediate, rapid transport is preferred with treatment performed enroute. STABLE HR < 50; SBP > 100; GCS >14; NO SEVERE CHEST PAIN/DYSPNEA UNSTABLE HR < 50; SBP <100; GCS <14; SEVERE CHEST PAIN/DYSPNEA Cardiac Monitor Establish IV Moved to unstable section if condition deteriorates Consider 2 nd IV or IO if difficult access. Consider 250 ml Fluid Bolus Give Atropine IV/IO: 0.5 mg q 3-5 min (Max 3 mg) Adolescents: 1mg IV/IO (Max. Single dose) Max total dose 2mg IV/IO If Atropine is ineffective or if delay in IV/IO Begin TCP at 80 bpm Do not delay if high degree block is present Consider pain Management Fentanyl 50mcg slow IV/IO over 2 min Withhold if Systolic BP < 100 mm Hg CONTACT BASE Dopamine infusion may be ordered for hypotension µg/kg/min IV/IO. Titrate to patient response. Taper slowly References: Prehospital Formulary, Transcutaneous Pacing Procedure,12 Lead EKG Procedure

10 BRADYCARDIA ABCs / ROUTINE MEDICAL CARE - Be prepared to support ventilation with appropriate airway adjuncts and circulation with external chest compressions. Begin ventilation with BVM if HR < 60; if no improvement in 1 minute begin CPR. Administer oxygen if indicated at the appropriate flow rate. Place patient in position of comfort. PEDIATRIC ALGORITHM Obtain and transmit 12 lead EKG (Do not delay therapy). PROTOCOL PROCEDURE: Flow of protocol presumes that bradycardia is continuing. If response or condition changes, see appropriate protocol. If at any time a stable patient becomes unstable, go to the unstable section of this protocol. If patient is in severe distress, immediate, rapid transport is preferred with treatment performed enroute. STABLE NO HYPOTENSION, NO DELAYED CRT, NO SEVERE CHEST PAIN/DYSPNEA UNSTABLE ALOC, HYPOTENSION, DELAYED CRT, SEVERE CHEST PAIN/DYSPNEA Cardiac Monitor Establish IV Moved to unstable section if condition deteriorates If HR < 60 Perform CPR Consider 2 nd IV or IO if difficult access. Give Epinephrine 0.01 mg/kg IV/IO 1:10,000 = 0.1 ml/kg Repeat every 3 5 min. If increased vagal tone or primary AV block: Give Atropine 0.02 mg/kg IV/IO May repeat dose once in 5 min. Minimum dose 0.1mg. Max. total dose of 1 mg. Consider TCP at 80 bpm Do Not delay if high degree block is present Consider pain management if BP adequate Fentanyl 50mcg slow IV/IO over 2 min Treat underlying causes Contact Base References: Prehospital Formulary, Transcutaneous Pacing Procedure,12 Lead EKG Procedure

11 EL DORADO COUNTY EMS AGENCY PREHOSPITAL PROTOCOL Effective: July 1, 2017 Reviewed: February 8, 2017 EMS Agency Medical Director BRIEF RESOLVED UNEXPLAINED EVENT General Info: A Brief Resolved Unexplained Event was formerly known as An Apparent Life Threatening Event. An ALTE is an episode that is frightening to the observer (may think infant has died) and involves some combination of: 1. Apnea 2. Color change 3. Marked change in muscle tone. (Limpness, loss of tone) 4. Choking or gagging Usually occurs in infants <12 months old. However, any child < 2 years old who exhibits symptoms of apnea may be considered an ALTE 50% have a possible identifiable etiology (e.g., abuse, SIDS, swallowing dysfunction, infection, bronchitis, seizures, CNS abnormalities, tumors, cardiac diseases, chronic respiratory disease, upper airway obstruction, metabolic abnormalities, anemia, or other ROUTINE MEDICAL CARE - administer oxygen at appropriate flow rate. Keep patient warm. Assume history of event is accurate. Obtain a detailed history of event: o Apnea? o Color change? o Change in muscle tone? o Choking or gagging? o Was any resuscitation required? o Seizure activity? o Was infant sleeping? Position? Obtain detailed medical history: o Any chronic diseases (including seizures)? o Current or recent infections? o Gastroesophageal reflux? o Recent trauma? o Inappropriate mixture of formula? o Medications? PROTOCOL PROCEDURE: All cases of ALTE should be transported to the hospital for further evaluation. If parent/guardian is refusing medical care and/or transport, consult with the base station prior to completing an AMA. GLUCOSE LEVEL ASSESSMENT rule out hypoglycemia. NORMAL SALINE establish IV when indicated. Treat any identifiable causes by referring to the appropriate protocol. CONTACT BASE STATION

12 EL DORADO COUNTY EMS AGENCY PREHOSPITAL PROTOCOLS Effective: July 1, 2017 Reviewed: November 9, 2016 Revised: November 9, 2016 EMS Agency Medical Director BRONCHOSPASM ADULT ABCs / ROUTINE MEDICAL CARE place patient in position of comfort. If indicated, administer oxygen at the appropriate flow rate. Be prepared to support ventilation with appropriate airway adjuncts. If patient is in severe distress, attempt to assist breathing with BVM after explaining procedure to patient. (For patients with severe asthma use a slower ventilation rate (6-8 VPM) and smaller tidal volume). BLS Personnel: Allow patient to administer their own respiratory medications as prescribed by their physician, see Field Policy: BLS Medication Administration. PROTOCOL PROCEDURE: Flow of protocol presumes that condition is continuing, If the patient is distress, immediate rapid transport is preferred with treatment performed en route. OPTIONAL SKILLS EMT TREATMENT IF PATIENT IS IN EXTREMIS (LOW SP02, INABILITY TO SPEAK, AND/OR ALOC): CPAP - start with valve at 7.5 cm setting and 100% O2 flow rate. Titrate to patient s condition. If patient s respiratory status does not improve, change valve setting to 10.0 cm. Be prepared to support ventilations with appropriate airway adjuncts. Monitor and record vital signs every 5 minutes. Be prepared for possible hypotension. If hypotension develops, decrease valve setting. FOR ASTHMA PATIENTS: Administer EPI-PEN AUTOINJECTOR- 0.3 mg IM. (Repeat dose may be given in 10 minutes if ALS response is delayed and patient is not responding to treatment). CPAP - start with valve at 7.5 cm setting and 100% O2 flow rate. Adjust valve as necessary. Start with DUONEB (2.5 Mg Albuterol and 0.5 Mg Atrovent in normal saline). Do not repeat. If severe symptoms persist, initiate continuous ALBUTEROL 2.5 mg in 3 ml normal saline (Max. 15 mg/hr). Breathing treatments may be given concurrently with CPAP. Breathing treatments may be given concurrently with CPAP. NORMAL SALINE establish an IV/saline lock. FOR PATIENTS IN EXTREMIS (LOW SP02, INABILITY TO SPEAK, OR ALOC): administer EPINEPHRINE 1:1, mg IM. (Repeat doses may be given in 10 minute intervals). FOR STRIDOR (croup/airway burns/laryngeal edema/anaphylaxis): administer NEBULIZED EPINEPHRINE 1:1,000 5 ml (5 mg) via nebulizer given over 10 minutes. (MR q 10 minutes). CONTACT BASE STATION Note: If base line vital signs have increased 20%, visible tremors, or increased arrhythmias/palpitations occur discontinue treatment and contact base station.

13 BRONCHOSPASM PEDIATRIC ABCs / ROUTINE MEDICAL CARE place patient in position of comfort. Be prepared to support ventilation with appropriate airway adjuncts. If indicated. administer high flow oxygen via non re-breather mask OR may attempt high flow humidified oxygen via nasal cannula If patient is in severe distress, attempt to assist breathing with BVM after explaining procedure to patient. (For patients with severe asthma use a slower ventilation rate (6-8 VPM) and smaller tidal volume). BLS Personnel: Allow patient to administer their own respiratory medications as prescribed by their physician, see Field Policy: BLS Medication Administration. PROTOCOL PROCEDURE: Flow of protocol presumes that condition is continuing. If patient is in distress, immediate, rapid transport is preferred with treatment performed en route. OPTIONAL SKILLS EMT TREATMENT FOR ASTHMA PATIENTS IN EXTREMIS (LOW SPO2,INABILITY TO SPEAK, AND/OR ALOC): EpiPen JR (Only for pediatric patients weighing kg (33-66 lbs): 0.15 mg (0.3 ml, 1:2,000) IM (lateral thigh is preferred). May repeat in 10 minutes if ALS response is delayed and patient condition warrants. NEBULIZED BREATHING TREATMENTS: Start with DUONEB (2.5 Mg Albuterol and 0.5 Mg Atrovent in normal saline). Do not repeat. If severe symptoms persist, initiate continuous ALBUTEROL 2.5 mg in 3 ml normal saline (Max. 15 mg/hr). Breathing treatments may be given concurrently with CPAP. NORMAL SALINE establish an IV/saline lock. FOR PATIENTS IN EXTREMIS (LOW SP02, INABILITY TO SPEAK, OR ALOC): administer EPINEPHRINE 1:1, mg/kg IM. (Repeat dose may be given in 10 minutes). FOR STRIDOR (croup/airway burns/laryngeal edema/anaphylaxis): administer NEBULIZED EPINEPHRINE 1:1, ml/kg (Up to Max. single dose of 5 ml (5 mg)) via nebulizer over 10 minutes. Dilute with NS to 5mL for patients 10 kgs or <. (MR q 10 minutes). CONTACT BASE STATION Note: If base line vital signs have increased 20%, visible tremors, or increased arrhythmias/palpitations occur discontinue treatment and contact base station. Reference: Routine Medical Care, BLS Medication Administration, Optional Skills, CPAP, Asthma, EpiPen & EpiPen Jr. Auto Injector, Albuterol, Atrovent, Epinephrine

14 EL DORADO COUNTY EMS AGENCY PREHOSPITAL PROTOCOLS Effective: July 1, 2017 Reviewed: February 8, 2017 Revised: February 8, 2017 EMS Agency Medical Director BURNS ADULT ABCs / ROUTINE MEDICAL CARE Stop burning process. Remove all clothing and jewelry. Administer high-flow oxygen for any patient in respiratory distress. Be prepared to support ventilation with appropriate airway adjuncts. BURN CARE: Thermal Burns: Stop the burning process with water or saline, if indicated. Use dry sterile burn dressings to avoid hypothermia. Cover patient with sterile burn sheet(s) and blanket(s) to preserve body heat. Caustic and Chemical Burns: Wear protective clothing and gloves and consider the presence of hazardous materials. Remove source of burn and all of the patient s clothing, then for: Liquid Substances (acids, alkalis): Flush with copious amounts of water. Do not scrub. Dry Chemicals: Brush powders off then flush with copious amounts of water (Exception: dry lime, metallic sodium or lithium). Electric Burns: May produce extensive damage not apparently visible from surface wounds. For this reason, all patients suffering from an electric burn should be placed on a cardiac monitor. For arrhythmias following electrical burns, refer to appropriate protocol. CPAP Consider for patients with respiratory distress. PROTOCOL PROCEDURE: Consider early notification of base station for destination decision. ADVANCED AIRWAY - Consider early if evidence of airway burns. FREQUENT BLOOD SAMPLE/GLUCOSE LEVEL ASSESSMENTS - obtain blood sample via finger stick or venipuncture. Rule out hypoglycemia. Refer to ALOC protocol/formulary for dextrose/glucagon dosing. NORMAL SALINE establish warm IV or IO. If partial or total thickness burns > 10% TBSA, give fluid challenge ml NS, reassess and repeat if indicated. CONSIDER PAIN MANAGEMENT refer to formulary for pain control options. CONSIDER DUONEB IF BRONCHOCONSTRICTION IS PRESENT - administer ALBUTEROL 2.5 mg

15 BURNS in normal saline mixed with ATROVENT 0.5 mg in normal saline via nebulizer. If severe symptoms persist, initiate continuous ALBUTEROL via nebulizer (Max. 15 mg/hr). Do not repeat Atrovent. CONTACT BASE STATION DISPOSITION - Burn victims should be transported to the closest trauma center (level I, II, or III). Burn victims do not necessarily need to be transported to a burn center for initial care. Consider utilizing an air ambulance or rapid ground transport to closest ER for the following patients: Airway involvement (consider need for RSI) Facial Burns (consider possible airway involvement) Unable to establish IV/IO access in significant (> 25% TBSA) burns Adult Rule of Nines Chart: References: Formulary, Albuterol, Atrovent, Normal Saline, Hypoglycemia

16 BURNS PEDIATRIC ABCs / ROUTINE MEDICAL CARE Stop burning process. Remove all clothing and jewelry. Administer high-flow oxygen for any patient in respiratory distress. Be prepared to support ventilation with appropriate airway adjuncts. BURN CARE: Thermal Burns: Stop the burning process with water or saline, if indicated. Use dry sterile burn dressings to avoid hypothermia. Cover patient with sterile burn sheet(s) and blanket(s) to preserve body heat. Caustic and Chemical Burns: Wear protective clothing and gloves and consider the presence of hazardous materials. Remove source of burn and all of the patient s clothing, then for: Liquid Substances (acids, alkalis): Flush with copious amounts of water. Do not scrub. Dry Chemicals: Brush powders off then flush with copious amounts of water (Exception: dry lime, metallic sodium or lithium). Electric Burns: May produce extensive damage not apparently visible from surface wounds. For this reason, all patients suffering from an electric burn should be placed on a cardiac monitor. For arrhythmias following electrical burns, refer to appropriate protocol. PROTOCOL PROCEDURE: Consider early notification of base station for destination decision. Pediatric burn victims should be transported to the closest trauma center (level I, II, or III). Burns in combination with serious trauma should be transported to a pediatric trauma center. Advanced Airway - Consider early if evidence of airway burns. FREQUENT BLOOD SAMPLE/GLUCOSE LEVEL ASSESSMENTS - obtain blood sample via finger stick or venipuncture. Rule out hypoglycemia. Refer to ALOC protocol/formulary for dextrose/glucagon dosing. Hypoglycemia in pediatrics is defined as: Neonate < 1 month: (b.s. < 50 mg/dl) Infant/child >1 month: (b.s. < 60 mg/dl) NORMAL SALINE establish warm IV or IO. If partial or total thickness burns > 10% TBSA, give fluid challenge 20 ml/kg NS, reassess and repeat if indicated. For hypotension/signs of compensatory shock refer to the pediatric SHOCK protocol. CONSIDER PAIN MANAGEMENT refer to formulary for pain control options. CONSIDER DUONEB IF BRONCHOCONSTRICTION IS PRESENT - administer ALBUTEROL 2.5 mg References: Formulary, Albuterol, Atrovent, Normal Saline, Hypoglycemia

17 BURNS in 3ml NS mixed with ATROVENT 0.5 mg in normal saline via nebulizer. If severe symptoms persist, initiate continuous ALBUTEROL via nebulizer (Max. 15 mg/hr). Do not repeat Atrovent. CONTACT BASE STATION DISPOSITION - Burn victims should be transported to the closest trauma center (level I, II, or III). Burns in combination with serious trauma should be transported to a pediatric trauma center. Burn victims do not necessarily need to be transported to a burn center for initial care. Consider utilizing an air ambulance or rapid ground transport to closest ER for the following patients: Airway involvement (consider need for RSI) Facial Burns (consider possible airway involvement) Unable to establish IV/IO access in significant (> 25% TBSA) burns Pediatric Rule of Nines Charts: References: Formulary, Albuterol, Atrovent, Normal Saline, Hypoglycemia

18 EL DORADO COUNTY EMS AGENCY PREHOSPITAL PROTOCOLS Effective: July 1, 2017 Reviewed: January 11, 2017 Revised: January 11, 2017 EMS Agency Medical Director CHEST PAIN/ACUTE CORONARY SYNDROME (ACS) ROUTINE MEDICAL CARE - administer oxygen at appropriate flow rate. Keep patient in position of comfort and don t allow patient to walk. ASPIRIN* Give 324 MG PO. BLS personnel may assist patient with own medications (NTG), see Field Policy: BLS Medication Administration. PROTOCOL PROCEDURE: Possible thrombolytic/stemi candidates should be identified and transported immediately with treatment performed en route. Not all AMI/ACS patients present with chest pain; other signs or symptoms (such as: feelings of impending doom, diaphoresis, palpitations, nausea, dyspnea, pain in back, arm, or jaw) may be present that could also indicate an ACS/AMI. Contact the base station for all STEMI patients and for orders in all suspected AMI/ACS cases not presenting with chest discomfort, pain, or pressure. Consider air transport for STEMI patients in remote areas or for long ground transport times. 12 lead EKGs cannot solely diagnose an AMI, treat all potential cardiac symptoms as such, regardless of 12 lead findings. Obtain and transmit 12 Lead EKG SBP over 100/ NTG** 0.4 mg SL q 5 min x 3 (withhold if SBP <100 or CP is relieved completely) Establish IV*** Apply 1 NTG** paste after reaching max of three SL NTG Consider pain management with Fentanyl/MS for CP not relieved with NTG SBP under 100/ Establish IV*** Consider 250cc bolus(es) x 2 If BP increases begin treatment with NTG** Refer to Shock Protocol if SBP <100 If STEMI IS CONFIRMED on ECG go to this STEMI TRANSPORT SECTION while continuing to follow the treatment algorithm PT. IN EXTREMIS? NO Contact BH and advise STEMI ALERT Transmit EKG ASAP Approximate transport time of 45 minutes to SRC? YES Transport to SRC NO YES Transport to Closest ER NOTES: *ASA should be given even if the patient s symptoms have subsided or the patient has self-administered prior to your arrival. **If patient has taken any erectile dysfunction medication in the last 48 hours do not give NTG or apply NTG paste. Go directly to Fentanyl or MS if SBP is >100 in this situation. **NTG paste should be applied after reaching maximum dose of SL NTG and should only be removed if SBP <100. *** Consider second IV and/or Twin Cath with saline lock for suspected STEMI/thrombolytic candidates. References: Formulary; Nitro, Aspirin, Fentanyl, Morphine Routine Medical care, BLS Medication administration

19 EL DORADO COUNTY EMS AGENCY PREHOSPITAL PROTOCOLS Effective: July 1, 2017 Reviewed: January 11, 2017 Revised: January 11, 2017 EMS Agency Medical Director CHF/PULMONARY EDEMA ABCs / ROUTINE MEDICAL CARE place patient in sitting position with legs down. Be prepared to support ventilation with appropriate airway adjuncts. Administer at appropriate flow rate. If patient is in obvious respiratory distress high flow oxygen via non re-breather mask is indicated. If patient is in severe distress: CPAP (If trained and equipped) - start with valve at 7.5 cm setting and 100% O2 flow rate. Titrate to patient s condition. If patient s respiratory status does not improve change valve setting to 10.0 cm. Be prepared to support ventilations with appropriate airway adjuncts. Monitor and record vital signs every 5 minutes. Be prepared for possible hypotension. If hypotension develops, decrease valve setting. If CPAP is not available: Attempt to assist breathing with BVM after explaining procedure to patient. PROTOCOL PROCEDURE: Flow of protocol presumes that condition is continuing. If patient is in severe respiratory distress due to excessive fluid in the lungs, immediate, rapid transport is essential with treatment performed en route. ALS ALGORITHM STABLE (Normal respiratory effort, normal oxygen saturation, speaks in full sentences, and No ALOC) 1) NORMAL SALINE - Establish a saline lock or IV*. 2) Monitor patient s condition and transport. If patient s condition worsens, move to UNSTABLE section. UNSTABLE (Increased/increasing respiratory effort, low oxygen saturation, difficulty speaking, or signs of decreased level of consciousness) If Patient is HYPOTENSIVE: Refer to shock protocol. For NORMOTENSIVE/HYPERTENSIVE patients: 1) NTG** - Apply 1 of NTG Paste to patient s skin. (Systolic BP < 100 mm Hg, NTG should be withheld or discontinued by wiping off with a clean towel). 2) Place patient on CPAP 3) NORMAL SALINE - Establish saline lock, IV, or IO*. Watch for respiratory depression. If respiratory status and drive continues to deteriorate, intubation may be indicated. Contact Base *Establish an IV or IO in lieu of saline lock in patients with tachycardia/consider fluid bolus. References: Formulary; Nitro, Routine Medical Care, CPAP

20 **NTG should be withheld in patients who have taken erectile dysfunction medications (Viagra, Cialis, or Levitra) within 48 hours. References: Formulary; Nitro Routine Medical Care, CPAP

21 EL DORADO COUNTY EMS AGENCY PREHOSPITAL PROTOCOLS Effective: July 1, 2009 Reviewed: April 2011 Revised: July 1, 2016 Scope: BLS/ALS - Adult EMS Agency Medical Director CHILDBIRTH ABCs / ROUTINE MEDICAL CARE Be prepared to support ventilation with appropriate airway adjuncts. Position mother in a lateral recumbent position. Inspect the perineum for crowning. The following questions should be asked to determine maternal history: Is the patient under a doctor s care? Past medical history, current medications? What is the due date? Gravida and Para Status, single fetus or twins? Any problems with this or other pregnancy / delivery? When did contractions start, How far apart and How long do they last? Has the patient s water broken? What color was fluid, was there an odor? Is there sensation of fetal activity? Does the patient feel the urge to bear down? DELIVERY IS IMMINENT AND NORMAL PRESENTATION: 1. Encourage mother to breathe through contractions so as to avoid precipitous delivery and vaginal tearing. 2. Prepare OB kit. 3. As head is delivered, observe for any obvious obstructions, suction baby s mouth and nose with the bulb syringe. Note any meconium staining. 4. If cord is around baby s head and cannot be easily slipped off, double clamp the cord and cut the cord between the clamps, with a finger between the cord and the baby, to ensure that the baby is not injured by cutting. 5. Continue delivery, encourage mother to push once head is delivered. 6. After baby is delivered, dry baby thoroughly with towels and wrap in a warm blanket. Keep baby s head warm and dry, and positioned at or below the level of the vagina until the cord is cut. Allow mother to hold baby and breast-feed to facilitate uterine contractions. Note: Placing baby skin to skin with mother is good way to keep baby warm. 7. After 30 seconds, Double clamp cord 6 inches from baby and cut between the clamps, if you have not already done so, as per step Follow NEONATAL RESUSCITATION protocol if signs of distress, cyanosis, bradycardia, or flaccidity occur. Also follow NEONATAL RESUSCITATION protocol if the baby was born preterm (<37 weeks of gestation) or there is evidence of meconium on the baby or in the fetal fluids. Record APGAR at 1 and 5 minutes. Reassess maternal vital signs. 9. Be prepared to deliver the placenta, do not pull on the cord. Bring the placenta to the hospital. After the placenta is delivered, gently massage fundal area. 10. Continue to monitor mother and baby. Keep baby as warm and dry as possible. 11. Reassess airway and vital signs frequently. Re-suction baby s mouth and nose, as needed.

22 CHILDBIRTH FOR ABNORMAL PRESENTATIONS Prolapsed Cord: If cord not pulsating; insert two gloved fingers into vagina and attempt to lift baby off of cord. Place mother in knee chest position. Provide high flow oxygen via non re-breather mask. Encourage mother to breathe through contractions. Breech Birth: Do not attempt to deliver baby by pulling on its legs. Place mother in knee chest position. Provide high flow oxygen via non re-breather mask. If baby is only partially delivered and baby s head has not delivered; insert two gloved fingers into vagina and place over the baby s face to create an air passage. Multiple Births: Clamp cord of first baby before the second baby is born. Care for the babies as you would for a single delivery. Maintain identity of first born. PROTOCOL PROCEDURE: Flow of protocol presumes a woman is in active labor. Imminent delivery with abnormal presentations should be discussed with the base station to decide if delivery should be attempted en route. DELIVERY NOT IMMINENT: NORMAL SALINE Consider IV access. DELIVERY IS IMMINENT: NORMAL SALINE Establish IV access. If patient is in shock, or is compensating for impending shock, refer to SHOCK protocol. CONTACT BASE STATION APGAR SCALE Sign 0 Points 1 Point 2 Points A Activity (Muscle Tone) Absent Arms and Legs Flexed Active Movement P Pulse Absent Below 100 BPM Above 100 BPM G Grimace (Reflex Irritability) No Response Grimace Sneeze, cough, pulls away A Appearance (Skin Color) Blue-gray, pale all over Normal, except for extremities Normal over entire body R Respiration Absent Slow, irregular Good, crying

23 EL DORADO COUNTY EMS AGENCY PREHOSPITAL PROTOCOLS Effective: July 2009 Reviewed: July 2013 Revised: July 1, 2016 Scope: BLS/ALS Adult and Pediatric EMS Agency Medical Director COLD EXPOSURES ADULT/PEDIATRIC ABCs / ROUTINE MEDICAL CARE Remove any wet clothing, dry and cover patient with warm blankets to prevent any further heat loss. Handle hypothermia patients very gently. Be prepared to support ventilation with appropriate airway adjuncts. take care not to hyperventilate as this can cause VFib. Be prepared to defibrillate should the patient arrest. Administer oxygen at appropriate flow rate. Place patient in warm environment. Apply chemical heat packs to axilla, groin, and neck. Do not place directly on patient skin. Patient should be handled gently; avoid patient exertion. Pulse should be taken for 60 seconds. If frostbite is present: Immobilize and wrap affected extremity with thick warm blankets or clothing. Avoid placing chemical heat packs directly on injured area. Do not rub skin to rewarm. Do not allow refreezing. AED Equipped BLS Instructions (Patients > 1 year old only): CARDIAC ARREST (prior to EMS arrival) Perform 2 minutes of CPR while attaching automatic or semiautomatic external defibrillator to patient if so equipped. If defibrillation is indicated, limit shocks to one only. Follow with 2 minutes of CPR. If there is still no pulse or evidence of breathing, continue with CPR until ALS personnel take over care of patient. CARDIAC ARREST (during patient treatment) - Attach automatic or semiautomatic external defibrillator to patient if so equipped. If defibrillation is indicated, limit to only one shock. Follow with 2 minutes of CPR. If there is still no pulse or evidence of breathing, continue with CPR until ALS personnel take over care of patient. If no defibrillator is available perform CPR until return of spontaneous circulation or ALS personnel take over care of patient. PROTOCOL PROCEDURE: Flow of protocol presumes that the patient s condition is continuing. If patient is in severe distress, immediate, rapid transport is preferred with treatment performed en route.

24 COLD EXPOSURES FOR HYPOTHERMIA MILD/MODERATE: BEGIN RE-WARMING - Remove any wet clothing, dry and cover patient with warm blankets to prevent any further heat loss. Apply hot packs to axilla, groin, and neck; do not place directly on patient s skin CARDIAC MONITORING - Follow appropriate cardiovascular protocol. NORMAL SALINE - Establish IV/IO and give warm NS: 1000 ml bolus (Adult) or 20 ml/kg (Peds) BLOOD SAMPLE/GLUCOSE LEVEL ASSESSMENT - Obtain blood sample via venipuncture. Rule out diabetic emergency. REFER TO ALTERED LEVEL OF CONSCIOUSNESS OR SEIZURE PROTOCOLS AS INDICATED. FOR HYPOTHERMIA (SEVERE/CARDIAC ARREST): PALPATE PULSE - For 60 seconds to determine whether perfusion is present. CARDIAC MONITORING: PEA Do not do CPR or administer medication. Transport as gently as possible. Asystole Begin CPR and refer to ALS pulseless arrest algorithm administer 1 round of medications only and continue CPR. VF/VT Begin CPR and refer to pulseless arrest algorithm administer a single defibrillatory shock and 1 round of medications only and continue CPR. NORMAL SALINE Establish IV/IO and give warm NS: 1000 ml bolus (Adult) or 20 ml/kg (Peds). CONTACT BASE STATION Hypothermic patients appear dead but may be salvageable. In isolated hypothermia, CPR is indicated for situations without a perfusing rhythm (VF or asystole). For PEA chest compressions should be withheld. These patients are usually adequately managed with re-warming as there may be undetectable, yet life-sustaining cardiac function.

25 EL DORADO COUNTY EMS AGENCY PREHOSPITAL PROTOCOLS Effective: July 29, 2013 Reviewed: N/A Revised: July 2013, July 1, 2016 Scope: BLS/ALS Adult EMS Agency Medical Director CRUSH SYNDROME ADULT ABCs / ROUTINE MEDICAL CARE be prepared to support ventilation with appropriate airway adjuncts. FULL SPINAL PRECAUTIONS, if indicated. Administer high flow oxygen via non re-breather mask. Splint the effected limb(s) at heart level. Maintain body temperature. PROTOCOL PROCEDURE: Flow of protocol presumes patient has had a full extremity (or more) crushed, pinned, or otherwise immobile with severely impaired circulation for at least two (2) hours. It is advisable in these situations for BLS personnel to wait for ALS personnel before attempting extrication. Early notification to the hospital is essential for proper triage and a notification of surgical personnel. PRE-EXTRICATION: CONSIDER AIR AMBULANCE RESPONSE TO SCENE EKG- Apply and continuously monitor patient s cardiac rhythm. NORMAL SALINE - Establish 2 large bore IVs via blood administration or macro drip tubing. Use IO if unable to establish IV. Give 20 ml/kg IV/IO bolus, prior to release of compression. If patient is in shock or is compensating for impending shock, refer to SHOCK protocol. PAIN MANAGEMENT As appropriate, refer to Formulary. IMMEDIATELY BEFORE EXTRICATION (IF POSSIBLE): ALBUTEROL mg in 6 ml NS via nebulizer. Run continuously before and after extrication. SODIUM BICARBONATE 1 meq/kg up to 100 meq IVP/IO (Flush line with NS before and after administration). POST EXTRICATION: RAPID TRANSPORT - As soon as possible. CALCIUM CHLORIDE If suspected hyperkalemia (Compression >4 hrs and: absent P waves, Peaked T waves, and/or prolonged QRS) give 1 gm IV/IO slowly over 5 minutes. Repeat at same dose if symptoms persist. (Flush line with NS before and after administration). NOTE: Do not run Sodium Bicarbonate and Calcium Chloride concurrently. Either flush the line well or use a separate line.

26 CRUSH SYNDROME PEDIATRIC ABCs / ROUTINE MEDICAL CARE Be prepared to support ventilation with appropriate airway adjuncts. FULL SPINAL PRECAUTIONS, if indicated. Administer high flow oxygen via non re-breather mask. Splint the effected limb(s) at heart level. Maintain body temperature. PROTOCOL PROCEDURE: Flow of protocol presumes patient has had their lower extremities/pelvis/torso crushed, pinned, or otherwise immobile with severely impaired circulation for at least two (2) hours. It is advisable in these situations for BLS personnel to wait for ALS personnel before attempting extrication. Early notification to the hospital is essential for proper triage and notification of surgical personnel. PRE-EXTRICATION: CONSIDER AIR AMBULANCE RESPONSE TO SCENE NORMAL SALINE Establish IV or IO. Refer to shock protocol if patient is in shock. PAIN MANAGEMENT As appropriate, refer to Formulary. CONTACT BASE STATION- For treatment determination and for early notification of destination and surgical personnel. FLUID BOLUSES (May be ordered) Give initial bolus of 20 ml/kg. If suspected history of volume loss and no improvement with initial bolus give additional fluid boluses at 20 ml/kg to a Max. of 60 ml/kg. IMMEDIATELY BEFORE EXTRICATION (IF POSSIBLE): ALBUTEROL* mg in 6 ml NS via nebulizer. Run continuously before and after extrication. SODIUM BICARBONATE 1 meq/kg up to 100 meq IVP/IO (Flush line with NS before and after administration). POST EXTRICATION: RAPID TRANSPORT - As soon as possible. BASE PHYSICIAN ORDER ONLY If suspected hyperkalemia (Compression >4 hrs and: absent P waves, Peaked T waves, and/or prolonged QRS) CALCIUM CHLORIDE 20 mg/kg IV/IO push over 1 minute may be ordered. Repeat at same dose if symptoms persist. (Flush line with NS before and after administration). NOTES: * Use 2.5 mg of Albuterol in 3 ml of NS/SW if patient is < 2 years old. Do not run Sodium Bicarbonate and Calcium Chloride Concurrently. Either flush the line well or use a separate line.

27 EL DORADO COUNTY EMS AGENCY PREHOSPITAL PROTOCOLS Effective: July 1, 2017 Reviewed: February 8, 2017 EMS Agency Medical Director DROWNING ADULT/PEDIATRIC ABCs / ROUTINE MEDICAL CARE - administer oxygen at appropriate flow rate. Be prepared to support ventilation with appropriate airway adjuncts. IF THE PATIENT IS IN CARDIOPULMONARY ARREST, SEE PULSELESS ARREST PROTOCOL. FULL SPINAL PRECAUTIONS - if there is a suspected diving injury, in the setting of other trauma or if there are signs of intoxication. ADULTS ONLY: CPAP (If trained and equipped) - start with valve at 7.5 cm setting and 100% O2 flow rate. Titrate to patient s condition. If patient s respiratory status does not improve, change valve setting to 10.0 cm. Be prepared to support ventilations with appropriate airway adjuncts. Monitor and record vital signs every 5 minutes. Be prepared for possible hypotension. If hypotension develops, decrease valve setting. PROTOCOL PROCEDURE: Flow of protocol presumes that the patient s condition is continuing. If patient is in severe distress, immediate, rapid transport is preferred with treatment performed en route. All patients should have wet clothing removed and be covered with warm blankets to prevent further heat loss. All patients should be transported for evaluation, no matter how stable they present. Begin resuscitation in all patients with <90 minute submersion time (deviations to this time frame will be at the discretion of the base station). For patients submerged in cold water, refer to COLD EXPOSURE protocol. NORMAL SALINE - establish IV/IO, set rate as per patient s condition. BLOOD SAMPLE/GLUCOSE LEVEL ASSESSMENT - obtain blood sample via venipuncture. Rule out diabetic emergency. REFER TO ALTERED LEVEL OF CONSCIOUSNESS OR SEIZURE PROTOCOLS AS APPROPRIATE. CONTACT BASE STATION

28 EL DORADO COUNTY EMS AGENCY PREHOSPITAL PROTOCOLS Effective: July 1, 2017 Reviewed: December 14, 2016 Revised: December14, 2016 GENERAL TRAUMA ADULT/PEDIATRIC EMS Agency Medical Director ABCs / ROUTINE MEDICAL CARE Be prepared to support ventilation with appropriate airway adjuncts. CONTROL BLEEDING: For Uncontrolled Extremity Bleeding: 1) Apply direct pressure/pressure bandage. Use hemostatic agent*, if still not controlled: 2) Apply approved tourniquet device: Apply 2-3 proximal to wound Tighten until control of bleeding Document time and presence/absence of distal pulses If bystanders or first responders placed non-approved or improperly placed tourniquet, assess need for tourniquet and re-apply an approved tourniquet if necessary. For bleeding to head, neck, pelvis, or for penetrating trauma to extremities: Pack wound with an approved hemostatic gauze until external bleeding is controlled (be aware that internal hemorrhage may still occur). SMR*/FULL SPINAL PRECAUTIONS - if indicated. ADMINISTER OXYGEN - at the appropriate flow rate, preferably high flow via non re-breather mask for any major trauma. Attempt to have patient packaged prior to the medic unit s arrival, if possible. PROTOCOL PROCEDURE Flow of protocol presumes patient has, or has the potential for, a significant traumatic injury. Rapid transport with IV(s) established en route is a standard. Consider air ambulance response for rapid transport from rural areas. Amputations not meeting critical trauma criteria should be transported to the closest appropriate hospital. Early notification to the hospital is essential for proper triage and notification of surgical personnel. SPECIFIC TRAUMATIC INJURIES: EXTREMITY INJURIES: Splint extremity in position found. Return extremity to anatomical position only if distal pulse is absent. After splinting, check distal pulse frequently. Apply Traction splint to isolated mid-shaft femur fracture. Clean exposed bone ends prior to applying traction splint to open fractures. Apply pelvic binder device (KED or bed sheet) for suspected open-book pelvic fractures. AMPUTATIONS/AVULSIONS: Place amputated/avulsed part in a dry, sterile, and watertight container/bag. Place the sealed container/bag in ice water and transport with the patient.

29 GENERAL TRAUMA FLAIL CHEST: Closely monitor patient s airway, breathing, and consider CPAP. OPEN CHEST WOUNDS: Cover (do not pack) the wound with occlusive dressing. (Asherman Chest Seal) Continuously evaluate for the development of tension pneumothorax. If the patient s condition worsens after the application of occlusive dressing, remove dressing momentarily during forceful exhalation. Evaluate patient, then re-apply by securing the dressing on three sides only (dressing acts as a one-way-valve allowing air to escape, but not enter the chest). Closely monitor patient s airway and breathing. OPEN NECK WOUNDS: Cover wound with an occlusive dressing and apply direct pressure. If uncontrolled hemorrhage occurs, pack wound with hemostatic gauze before covering wound with occlusive dressing. Closely monitor patient s airway and breathing. IMPALED OBJECTS: Do not remove object unless it interferes with CPR or upper airway. Stabilize object in place. ABDOMINAL EVISCERATIONS: Cover injury with a sterile saline-soaked dressing. Cover saline-soaked dressing with an occlusive dressing. CONTACT BASE STATION- preferably while en route to the scene for early notification of destination and surgical personnel. RAPID TRANSPORT - as soon as possible with ALS procedures performed en route. Ideally, scene times for critical trauma should not exceed 10 minutes. NORMAL SALINE - establish 2 large bore IVs via blood administration or macro drip tubing. Use IO if unable to establish IV. If patient is in shock, or is compensating for impending shock, refer to SHOCK protocol. CONSIDER PAIN MANAGEMENT refer to formulary for pain control options for those hemodynamically stable patients who are in moderate to severe pain. FOR TRAUMATIC ARREST - Treat as per Pulseless Arrest Protocol. Consider immediate bilateral needle chest decompression and aggressive fluid expansion with pressure infusers.

30 EL DORADO COUNTY EMS AGENCY PREHOSPITAL PROTOCOLS Effective: July 2008 Reviewed: July 2009, February 2010 Revised: July 1, 2016 Scope: BLS/ALS Adult/Pediatric EMS Agency Medical Director HEAD TRAUMA ADULT ABCs / ROUTINE MEDICAL CARE : Be prepared to support ventilation with appropriate airway adjuncts. Administer oxygen if indicated at an appropriate flow rate Spinal Precautions as indicated. For eye injuries consider covering both eyes to prevent further trauma of injured eye. Consider possible non-traumatic etiology of ALOC: shock, toxic exposure, insulin shock, or seizures. Refer to appropriate protocol. PROTOCOL PROCEDURE: Flow of protocol presumes patient has, or has the potential for, a significant head injury. Rapid transport with IV(s) established en route is a standard. Early notification to the hospital is essential for proper triage and notification of surgical personnel. CONTACT BASE STATION - Early notification of destination and surgical personnel. RAPID TRANSPORT - ASAP - Ideally, scene times for critical trauma should not exceed 10 minutes. NORMAL SALINE - Establish 2 large bore IVs via macro drip tubing. Place IO if unable to establish IV. If patient is in shock or is compensating for impending shock, refer to SHOCK protocol. Hypotensive patients with head injuries should have IV fluid resuscitation to maintain appropriate systolic BP. BLOOD SAMPLE/GLUCOSE LEVEL ASSESSMENT - Obtain blood sample via venipuncture. Rule out diabetic emergency. Use caution when administering Dextrose/Glucagon to head injured patients, consider contacting base station if blood sugar is borderline or patient is not a known diabetic. REFER TO ALTERED LEVEL OF CONSCIOUSNESS OR SEIZURE PROTOCOLS AS APPROPRIATE. LIDOCAINE 2%* (PRE-INTUBATION ONLY) mg/kg IV push (Max. total dose 100 mg). Administer 2 minutes prior to intubation attempt when feasible, to blunt increased ICP. AVOID HYPERVENTILATION OF HEAD INJURED VICTIMS.