2011 PREHOSPITAL CARE MANUAL (For updates throughout the year visit our website at

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1 CONTRA COSTA COUNTY EMERGENCY MEDICAL SERVICES AGENCY 2011 PREHOSPITAL CARE MANUAL (For updates throughout the year visit our website at

2 Table of Contents Prehospital Care Notes Prehospital Care Notes...1 Communications Radio Communications... Page 2 Operations BLS Management of Patients Prior to Activation of Page 3 Load and Go Procedures... Page 4 Patient Care Notes Administration of Oral Glucose... Page 4 Bariatric Patients... Page 5 Dialysis Patients... Page 6 Pain Assessment and Management... Page 6 Pain Assessment Tools... Page 7 Pain Assessment in the Very Young, Non-Verbal Infant/Child... Page 8 Trauma Notes Amputations... Page 8 Geriatric Patients... Page 9 Head Injury... Page 9 Helmet Removal... Page 10 Scope of Practice EMT Scope of Practice... Page 11 Paramedic Scope of Practice... Page 13 Contra Costa Local Optional Scope of Practice... Page 15 Field Manual Adult Treatment Guidelines... Page 16 General Treatment Guidelines... Page 40 Pediatric Treatment Guidelines... Page 73 Interfacility Transfer Treatment Guidelines... Page 90 Procedures and Patient Care Reference... Page 93 Policy Summaries and Hospital References... Page 111 Drug References... Page 130

3 INSTRUCTIONS FOR USE The Contra Costa Prehospital Care Manual contains both treatment guidelines and additional reference materials relevant to EMS care. Updates and corrections to this manual will be posted at Treatment Guidelines are divided into four main groupings: Adult, General, Pediatric, and Interfacility Transfer Guidelines. The General Guidelines include treatment guidelines that pertain to both adult and pediatric treatments. Treatment Guidelines A1 (Adult General Care) and P1 (Pediatric General Care) address basic concepts of care that are pertinent to all patients. This information is not repeated in other treatment guidelines. Policy summaries reflect critical information for field personnel. For full policies, please refer to

4 Communications Operations Patient Care Notes Scope of Practice PREHOSPITAL CARE NOTES

5 COMMUNICATIONS RADIO COMMUNICATIONS Four radio channels are designated for communications with hospitals in Contra Costa County. Receiving hospital communications are done via XCC EMS 2, whereas paramedic base hospital communications may occur via XCC EMS 2 or XCC EMS 3, depending on location. XCC EMS 1 (formerly L9) XCC EMS 2 (formerly L19) XCC EMS 3 XCC EMS 4 T: R: T: R: T: R: T: R: Use for Sheriff s Dispatch-to-ambulance communication Primary channel for base contact for West County paramedic units. Also used county-wide for BLS and helicopter radio traffic Primary channel for base contact for paramedic units operating south of Ygnacio Valley Road and west of I-680 along Highway 24 Primary channel for base contact for paramedic units operating in East County and Central County north of Ygnacio Valley Road. Whenever possible, paramedic personnel should use the XCC EMS channel assigned to the area in which they are responding, for ambulance-to-base hospital communications. XCC EMS 2 is the county-wide backup ALS channel and should be used if XCC EMS 3 or XCC EMS 4 is not available. Ambulance and helicopter personnel are to contact Sheriff s Dispatch on XCC EMS 1 to request the use of XCC EMS 2 prior to utilizing the channel. The dispatcher shall be given unit identification and a description of current traffic (Code 2, Code 3 or trauma destination decision). No request for use is necessary for XCC EMS 3 or XCC EMS 4. However, each unit must monitor the channel prior to use to ensure that other units are not already using the channel. Radio identification procedures must be strictly followed, as more than one call may be occurring at the same time. If traffic is in progress on a XCC EMS channel, other ambulance personnel may either wait until current traffic is finished or find an alternate means of contacting the desired hospital. Any unit may, in cases such as trauma destination decisions, request that Sheriff s Dispatch break into current traffic on XCC EMS 2 to request temporary use of the channel. Units using XCC EMS 3 or XCC EMS 4 may request use of the channel from a unit that is currently on that channel. When making base contact for trauma destination only, the initial transmission should make the purpose of the call clear. Cellular phones may also be used as a means of communication.

6 OPERATIONS BLS MANAGEMENT OF PATIENTS ENCOUNTERED PRIOR TO ACTIVATION OF EMTs who encounter a patient where the system has not been activated should assess the patient to determine whether the care needed by that patient is beyond their scope of practice. If it is determined that the patient may benefit from ALS level care, the system should be activated. After assuring activation of the system, EMT personnel should assess the patient and begin any care required that is allowed in the EMT Scope of Practice. If the EMT unit has transport capabilities, the personnel should determine if the ETA of the paramedic unit is greater than the transport time to the closest appropriate receiving facility. If so, the EMT unit should proceed with patient transport and cancel the ALS unit. If the ETA of the paramedic unit is less than the transport time to the closest appropriate receiving facility, the EMT unit should remain on scene and turn the patient over to the paramedic unit upon their arrival. Documentation of the patient s chief complaint, history of present illness, past medical history, medications, allergies, vital signs, findings from the physical exam and a general assessment and any treatment initiated is to be completed. A copy of the patient documentation should be given to the transport unit prior to transport, if possible. LOAD AND GO PROCEDURES Patients with severe medical conditions or traumatic injuries often need to be transported without delay. Field treatment is to be minimized to essential stabilization and the emphasis is placed on prompt transport to an appropriate receiving facility. Conditions to be considered for "Load and Go" transport include: unmanageable airways in any patient; obstetrical emergencies including prolapsed cord, abnormal presentation, abnormal bleeding, or maternal seizures patients in shock severe trauma, especially to the head, chest, or abdomen; for severe trauma, scene time should not exceed 15 minutes. Reasons for extended scene times should be documented on the patient care report

7 PATIENT CARE NOTES ADMINISTRATION OF ORAL GLUCOSE EMTs may administer an approved oral glucose agent by utilizing the following procedure: 1. Confirm altered level of consciousness in a patient with a known history of diabetes, and that the patient is conscious and able to sit in an upright position. 2. Dispense up to 30 grams of the oral glucose solution into the patient's mouth. Optimally, the patient will self-administer the solution. 3. If the patient has difficulty swallowing the solution, discontinue the procedure. The first priority is keeping an open airway. 4. Record the administration of the oral glucose solution with the time given and any changes in the patient s level of consciousness. BARIATRIC PATIENTS Bariatric patients are morbidly obese individuals who weigh 100 pounds or more than their ideal body weight. Severe obesity can result in patients having difficulty with walking or moving and special equipment may be necessary to transport the patient. AMR has a bariatric unit in Contra Costa County which, when needed, should be requested as soon as possible. The bariatric unit is not dedicated only to service and availability is not guaranteed. When the decision is made to transport the bariatric patient, notify the receiving facility as they need time to prepare equipment for the patient s arrival. Obesity has many health care risks associated with it, including diabetes, cardiovascular respiratory and other problems. Special prehospital considerations are: Airway Management Vascular Access Proper Medication Dosage Obese patients are prone to respiratory insufficiency, airway obstruction and have difficult airways to intubate. Positioning to maintain their airway is very important. Obese patients should be transported in a seated position. CPAP may also be needed more often to support oxygenation and ventilation. Increased subcutaneous tissue makes it difficult to obtain regular IV access. The IO proximal tibia site may be difficult to access due to difficulty in finding appropriate landmarks. In these cases the distal tibia (medial malleolus) is a preferred uio site. Obesity may create a need for increased medication due to the patient s body weight. Increases in medication beyond what is listed in the PHCM should be requested through the Base as needed. DIALYSIS PATIENTS Patients with advanced renal disease requiring dialysis have special medical needs that may deserve specific attention in the pre-hospital setting. Problems that may occur include fluid overload and electrolyte imbalances. Patients may be particularly prone to these problems if they should miss scheduled dialysis sessions. Fluid overload may lead to pulmonary edema. The initial treatment of this is similar to other patients with pulmonary edema, and may include oxygen, nitroglycerin and morphine. Definitive treatment at a center that provides acute dialysis capabilities is often necessary. The preferable transport

8 destination for this type of patient is the hospital at which the patient has received dialysis care. Patients in extremis will need transport to the closest emergency department. Hyperkalemia is also common in renal failure patients, leading to arrhythmia or ventricular fibrillation. Treatment in the field may include sodium bicarbonate and calcium chloride. PAIN ASSESSMENT AND MANAGEMENT Relief of pain and suffering is an important component of quality EMS field care. Pain assessment is the 5 th vital sign and should be performed on each patient using an age appropriate pain scale. Pain is a subjective experience for the patient and should be treated following the appropriate pain treatment guideline. Patients in pain should be assessed before and after pain medication is administered. Appropriate efforts should be made to alleviate pain using both pharmacologic (e.g, Morphine, Nitroglycerin for cardiac cases) and non-pharmacologic (e.g., splinting, immobilization) measures. Assess blood pressure, heart rate, respiratory rate and pain scale during initial assessment and 5 minutes after every medication administration. Assess pain using the same pain scale before and after pain administration and document. Dramatic drops in systolic blood pressure and respiratory rate can occur once pain is relieved. Administer medication cautiously and monitor patient. Use narcotics cautiously in the elderly. Increased sensitivity to drugs and slowed drug metabolism can alter patient response. Allow 10 minutes to assess the full effect of the medication prior to additional narcotic administration. PAIN ASSESSMENT TOOLS FACES Pain Rating Scale: (used in children older than 3 years and adults) Point to each face using the words to describe the pain intensity. Ask the patient to choose the face that best describes how they are feeling. A person does not have to be crying to have the worst pain. RATING English No pain Hurts a little bit Hurts a little more Hurts even more Hurts a lot Hurts worst Spanish No dolor Muy leve Leve Moderada Severa Muy severa 0-10 Numeric Pain Rating Scale: (used in adults and children older than 9 years) Explain scale (0 means no pain and 10 is the most severe pain they have ever had). Ask patients what number on a scale of 0-10 they would give as the level of pain currently.

9 PAIN ASSESSMENT IN THE VERY YOUNG, NON-VERBAL INFANT AND CHILD Pain assessment in infants, non-verbal young children or developmentally delayed children is more complex and presents special challenges. Despite this, pain medication should be considered in cases where the infant or child is in severe pain. This includes evidence of painful mechanisms such as burns, limb fractures or other events. Using pain medication in these children requires judgment and caution. Signs and symptoms of pain in non-verbal young or developmentally delayed children include: Inconsolable crying, screaming that cannot be distracted from by a caregiver High pitched crying Any pain face expression that is continual o Grimace o Quivering chin Constant tense/stiff body tone and/or guarding Whatever is painful to adults, is painful to children until proven otherwise TRAUMA NOTES Amputations For partial amputations, splint in anatomic position and elevate the extremity. If the part is completely amputated, place the amputated part in a sterile, dry container or bag. Seal or tie off the bag, and place it in a second container or bag. Seal or tie off the second bag and place on ice. DO NOT PLACE THE AMPUTATED PART DIRECTLY ON ICE OR IN WATER. Elevate the extremity involved and dress with dry gauze. Geriatric Patients and Trauma Due to the physiologic changes of aging, a mechanism of injury that might be less damaging to a younger person can cause grave injury in the geriatric patient. Undertriage (failure to identify serious injury and transport directly to the trauma center) in the patient over 65 is three times greater than with younger patients. The decreased perception of pain can mask injury they can have many injuries but rate their pain very low. Vital signs may be deceptive a patient whose blood pressure is normally very elevated may be in a low normal range, but be significantly injured. Due to medications or heart disease, many elderly patients do not develop significant tachycardia in response to hemorrhage and hypovolemia. The most common mechanisms of severe injury are falls, motor vehicle crashes and auto vs. pedestrian. Anticoagulant sue (particularly Coumadin or warfarin) in the elderly is relatively common and may add risk. Aspirin and other anti-platelet agents are also very common. Direct pressure to hemorrhage is the best way to deal with control of bleeding. The elderly are also more prone to environmental thermal emergencies avoid hypothermia.

10 Head Injury Priorities for treatment of head-injury patients include maintenance of adequate oxygenation and blood pressure as well as appropriate attention to possible cervical spine injury. Hyperventilation of headinjury patients should be avoided, as it may worsen delivery of oxygen to the brain. Patients with adequate ventilatory effort (10-12 breaths per minute in adults) should receive 100% oxygen by mask. Patients with poor ventilatory effort (either in terms of slow rate or shallow breathing) may need assisted ventilations at normal rate. Deeply comatose patients may require intubation to assure an adequate airway. Capnography and end-tidal CO 2 levels should guide ventilation rate (levels of mm Hg are optimal). Patients with a dilated pupil on one side, or who have decerebrate or decorticate posturing likely have severe brain injury and swelling that may lead to brain herniation. For these patients, an increase in respiratory rate of 2-4 per minute is appropriate to provide the small degree of increased ventilation advised for these most severe cases. Fluid administration should not be withheld in hypotensive head injury patients, as hypotension also worsens brain injury. Rapid transport of trauma patients is essential, and it is appropriate to obtain IV access and administer fluids during transport. Helmet Removal Patients wearing helmets present special management needs regarding airway maintenance and monitoring. There are generally two types of helmets, and the type of helmet determines how easily or difficult it may be to maintain or monitor the airway with the helmet in place: Sports Helmets (football, hockey, etc) - these helmets are generally open anteriorly and allow for easy airway access. The face mask should be removed to facilitate easy airway access. If spinal immobilization is required, the helmet should not be removed. If the helmet must be removed, the shoulder pads must also be removed to maintain neutral spinal alignment. Motorcycle Helmets - these helmets may have full face shields, which makes airway assessment and management very difficult. As a general guideline DO NOT REMOVE HELMETS, unless: - the helmet interferes with airway management. - the helmet has improper fit, which allows the head to move within the helmet. - the helmet interferes with proper spinal immobilization. - the patient is in cardiac arrest.

11 EMS SCOPES OF PRACTICE EMERGENCY MEDICAL TECHNICIAN (EMT) SCOPE OF PRACTICE "Emergency Medical Technician" or "EMT" means a person who has successfully completed an EMT course which meets the requirements of this Chapter, has passed all required tests, and who has been certified by the EMT certifying authority Scope of Practice of Emergency Medical Technician (EMT) a) During training, while at the scene of an emergency, during transport of the sick or injured, or during interfacility transfer, a supervised EMT student or certified EMT is authorized to do any of the following: 1) Evaluate the ill and injured. 2) Render basic life support, rescue and emergency medical care to patients. 3) Obtain diagnostic signs to include, but not be limited to the assessment of temperature, blood pressure, pulse and respiration rates, level of consciousness, and pupil status. 4) Perform cardiopulmonary resuscitation (CPR), including the use of mechanical adjuncts to basic cardiopulmonary resuscitation. 5) Use the following adjunctive airway breathing aids: A) oropharyngeal airway; B) nasopharyngeal airway; C) suction devices; D) basic oxygen delivery devices; and E) manual and mechanical ventilating devices designed for prehospital use. 6) Use various types of stretchers and body immobilization devices. 7) Provide initial prehospital emergency care of trauma. 8) Administer oral glucose or sugar solutions. 9) Extricate entrapped persons. 10) Perform field triage. 11) Transport patients. 12) Set up for ALS procedures, under the direction of an Advanced EMT or Paramedic. 13) Perform automated external defibrillation when authorized by an EMT AED service provider. 14) Assist patients with the administration of physician prescribed devices, including but not limited to, patient operated medication pumps, sublingual nitroglycerin, and self-administered emergency medications, including epinephrine devices. 15) In addition to the activities authorized by subdivision (a) of this section, the medical director of the local EMS agency may also establish policies and procedures to allow a certified EMT or a supervised EMT student in the prehospital setting and/or during interfacility transport to: A) Monitor intravenous lines delivering glucose solutions or isotonic balanced salt solutions including Ringer s lactate for volume replacement; B) Monitor, maintain, and adjust if necessary in order to maintain, a preset rate of flow and turn off the flow of intravenous fluid; and

12 C) Transfer a patient who is deemed appropriate for transfer by the transferring physician, and who has nasogastric (NG) tubes, gastrostomy tubes, heparin locks, foley catheters, tracheostomy tubes and/or indwelling vascular access lines, excluding arterial lines; D) Monitor preexisting vascular access devices and peripheral lines delivering intravenous fluids with additional medications pre-approved by the Director of the EMS Authority (not currently allowed in Contra Costa County). The scope of practice of an EMT-I shall not exceed those activities authorized in this Section, Section , and Section PARAMEDIC SCOPE OF PRACTICE California Code of Regulations, Title 22, Division 9, Chapter 4: Scope of Practice of Paramedic. a) A paramedic may perform any activity identified in the scope of practice of an EMT in Chapter 2 of the Division, or any activity identified in the scope of practice of an Advanced EMT in Chapter 3 of this Division. b) A paramedic shall be affiliated with an approved paramedic service provider in order to perform the scope of practice specified in this Chapter. c) A paramedic student or a licensed paramedic, as part of an organized EMS system, while caring for patients in a hospital as part of his/her training or continuing education under the direct supervision of a physician, registered nurse, or physician assistant, or while at the scene of a medical emergency or during transport, or during interfacility transfer, or while working in a small and rural hospital pursuant to section of the Health and Safety Code, may perform the following procedures or administer the following medications when such are approved by the medical director of the local EMS agency and are included in the written policies and procedures of the local EMS agency. 1) Basic Scope of Practice: A) Perform defibrillation and synchronized cardioversion. B) Visualize the airway by use of the laryngoscope and remove foreign body(ies) with forceps. C) Perform pulmonary ventilation by use of lower airway multi-lumen adjuncts, the esophageal airway, stomal intubation, and adult endotracheal intubation. D) Institute intravenous (IV) catheters, saline locks, needles, or other cannulae (IV lines), in peripheral veins; and monitor and administer medications through pre-existing vascular access. E) Administer intravenous glucose solutions or isotonic balanced salt solutions, including Ringer's lactate solution. F) Obtain venous blood samples. G) Use glucose measuring device. H) Utilize Valsalva maneuver. I) Perform needle cricothyroidotomy. (not currently used in Contra Costa County) J) Perform needle thoracostomy. K) Monitor thoracostomy tubes L) Monitor and adjust IV solutions containing potassium, equal to or less than 20 meq/l. M) Administer approved medications by the following routes: intravenous, intramuscular, subcutaneous, inhalation, transcutaneous, rectal, sublingual, endotracheal, oral or topical. N) Administer, using prepackaged products when available, the following medications:

13 (1) 25% and 50% dextrose; (2) activated charcoal; (not currently used in Contra Costa County) (3) adenosine; (4) aerosolized or nebulized beta-2 specific bronchodilators; (5) aspirin; (6) atropine sulfate; (7) pralidoxime chloride; (8) calcium chloride; (9) diazepam; (not currently used in Contra Costa County) (10) diphenhydramine hydrochloride; (11) dopamine hydrochloride; (12) epinephrine; (13) furosemide; (not currently used in Contra Costa County) (14) glucagon; (15) midazolam; (16) lidocaine hydrochloride; (17) morphine sulfate; (18) naloxone hydrochloride; (19) nitroglycerin preparations, except intravenous, unless permitted under (c)(2)(a) of this section; (20) sodium bicarbonate 2) Local Optional Scope of Practice: A) Perform or monitor other procedure(s) or administer any other medication(s) determined to be appropriate for paramedic use, in the professional judgment of the medical director of the local EMS agency, that have been approved by the Director of the Emergency Medical Services Authority when the paramedic has been trained and tested to demonstrate competence in performing the additional procedures and administering the additional medications. CONTRA COSTA LOCAL OPTIONAL SCOPE OF PRACTICE The following medications and procedures are approved for use in the Contra Costa County local optional scope of practice: Pediatric Endotracheal Intubation (limited to patients > 40 kg) Intraosseous Infusion External Cardiac Pacing Amiodarone Esophageal Airway (King LTS-D) Heparin Infusion (CCT-P Only) Lidocaine Infusion (CCT-P Only) Nitroglycerin Infusion (CCT-P Only) KCL Infusion (CCT-P Only) Ipratropium (CCT-P Only) Midazolam Infusion (CCT-P Only) Blood/Blood Product Infusion (CCT-P Only) Glycoprotein IIb/IIIa Receptor Inhibitor Infusion (CCT-P Only) Morphine Sulfate Infusion (CCT-P Only) Sodium Bicarbonate Infusion (CCT-P Only) Total Parenteral Nutrition (TPN) Infusion (CCT-P Only)

14 A1 Adult Patient Care A2 Chest Pain / Suspected ACS A3 Cardiac Arrest Initial Care and CPR A4 Ventricular Fibrillation / Ventricular Tachycardia A5 PEA / Asystole A6 Symptomatic Bradycardia A7 Ventricular Tachycardia with Pulses A8 Supraventricular Tachycardia A9 Other Dysrhythmias A10 Shock A11 Post-Cardiac Arrest Care A12 Public Safety Defibrillation ADULT TREATMENT GUIDELINES A1 ADULT ADULT PATIENT CARE These basic concepts should be addressed for all adult patients (age 15 and over) Scene Safety Body Substance Use universal blood and body fluid precautions at all times Isolation Systematic Assessment Assure open and adequate airway. Management of ABC s is a priority. Place patient in position of comfort unless condition mandates other position (e.g. shock, coma) Consider spinal immobilization if history or possibility of traumatic injury exists Determine Primary Impression Base Contact Transport Document Apply appropriate field treatment guideline(s) Explain procedures to patient and family as appropriate Contact base hospital if any questions arise concerning treatment or if additional medication beyond dosages listed in treatment guidelines are considered Use SBAR to communicate with base Minimize scene time in critical trauma, STEMI, stroke, shock, and respiratory failure Transport patient medications or current list of patient medications to the hospital Give report to receiving facility using SBAR Document patient assessment and care per policy

15 A2 CHEST PAIN ADULT SUSPECTED ACUTE CORONARY SYNDROME OXYGEN Low flow Caution: Do not administer or allow patient to take Nitroglycerin if patient has taken erectile PRECAUTION dysfunction meds Viagra or Levitra within 24 hrs or Cialis within 36 hrs. In these situations, severe hypotension may occur as a result of NTG administration. Nitroglycerin BLS Personnel: Allow patient to take own if BP greater than 90 CARDIAC MONITOR 12 LEAD ECG ASPIRIN IV NITROGLYCERIN Consider MORPHINE SULFATE Consider FLUID BOLUS STEMI Alert if appropriate. Perform right-sided lead (V4R) if inferior MI noted. Repeat ECGs are encouraged. 325 mg po to be chewed by patient DO NOT administer if patient has allergies to aspirin or salicylates or has apparent active gastrointestinal bleeding TKO 0.4 mg sl if systolic BP above 90. May repeat every 5 minutes until pain subsides, maximum 6 doses or BP less than 90 systolic. Do not administer Nitroglycerin if Right Ventricular MI suspected 2-20 mg IV in 2-4 mg increments for pain relief if BP greater than 90 and NTG not effective. Consider earlier administration to patients in severe distress from pain. Titrate to pain relief, systolic BP greater than 90, and adequate respiratory effort. If persistent pain, continue NITROGLYCERIN to maximum of 6 doses. Do not administer Morphine Sulfate if Right Ventricular MI suspected 250 ml NS if BP less than 90, lungs clear and unresponsive to positioning. May repeat X 1. Patients with Right Ventricular MI may require multiple fluid boluses. Key Treatment Considerations Classic symptoms: Substernal pain, discomfort or tightness with radiation to jaw, left shoulder or arm, nausea, diaphoresis, dyspnea (shortness of breath), anxiety Diabetic, female or elderly patients frequently present atypically Atypical symptoms can include syncope, weakness or sudden onset fatigue Rapid identification of STEMI to speed intervention is the goal of 12-lead ECG 12-lead ECG should be acquired as soon as possible after arrival (ideally within 5 minutes) 12-lead ECG should be acquired before initial NTG administration 12-lead ECG should be acquired prior to treatments for bradycardia if condition permits Minimize scene time in STEMI patients If STEMI noted and ST elevation is noted in inferior distribution (leads II, III, and avf), the possibility for right ventricular MI (RVMI) exists o Perform ECG with right-sided lead (V4R) mirrored in the same orientation as V4. RVMI should be suspected if ST elevation of 1 mm or greater in V4R. o Patients with RVMI may present with shock or poor perfusion in the presence of clear lungs and may have jugular venous distention. o Nitroglycerin and Morphine should not be administered in the setting of RVMI. Trendelenburg positioning and fluid bolus is appropriate treatment for shock in this setting. If STEMI noted and ST elevation is noted in anterior distribution (V1-V4), patient is at higher risk for pump failure and CHF on presentation Many STEMI s evolve during prehospital period and are not noted during first ECG, so repeat 12-lead ECGs are encouraged (avoid artifact by patient or vehicle movement) IV placement prior to NTG recommended in patients who have not taken NTG previously

16 A3 ADULT COMPRESSIONS AED or MONITOR/ DEFIBRILLATOR BASIC AIRWAY MANAGEMENT and VENTILATION CARDIAC ARREST INITIAL CARE AND CPR Begin compressions at a rate of at least 100 per minute Compress chest at least 2 inches and allow full recoil of chest (lift heel of hand) Change compressors every 2 minutes Minimize interruptions in compressions. If necessary to interrupt, limit to 10 seconds or less Do not stop compressions while defibrillator is charging Resume compressions immediately after any shock If available, place mechanical compression device (LUCAS or Auto-Pulse) after first rhythm assessment (or after subsequent rhythm assessments) Priority of second rescuer is to apply pads while compressions in progress Determine rhythm (or allow AED analysis) and shock if indicated Follow specific treatment guideline based on rhythm Open airway and provide 2 breaths after every 30 compressions AVOID EXCESSIVE VENTILATION - Provide no more than 8-10 ventilations per minute Ventilations should be about one second each, enough to cause visible chest rise Use two-person BLS Airway management (one holding mask and one squeezing bag). If available, use ResQPOD with basic airway management and two-person approach that allows firm mask seal IO / IV ACCESS ADVANCED AIRWAY MANAGEMENT and END-TIDAL CO2 MONITORING TREATMENT ON SCENE Initial use of IO access is preferred unless no suitable site available If IV site used - antecubital vein is preferred Hand veins and other smaller veins should be avoided in cardiac arrest Placement of advanced airway is not a priority during the first 5 minutes of resuscitation unless no ventilation is occurring with basic maneuvers. King Airway is the preferred device if an advanced airway is required during the first 5 minutes of resuscitation as no interruption in CPR is required. Laryngoscopy for endotracheal tube placement must occur with CPR in progress and compressions should be halted only for advancement of tube through the cords. Advanced airway placement should not interrupt compressions for a period of more than 10 seconds Continous monitoring of End-Tidal CO2 with waveform capnography is mandatory for all patients with advanced airway device in place. Treat reversible causes Provide resuscitative efforts on scene up to 30 minutes to maximize chances of return of spontaneous circulation (ROSC). Movement of a patient for transport may interrupt or affect quality of compressions and may be detrimental to patient outcome.

17 A4 VENTRICULAR FIBRILLATION ADULT INITIAL CARE DEFIBRILLATION CPR VENTILATION/AIRWAY IO or IV DEFIBRILLATION EPINEPHRINE DEFIBRILLATION AMIODARONE DEFIBRILLATION ADVANCED AIRWAY Consider repeat AMIODARONE TRANSPORT Consider SODIUM BICARBONATE PULSELESS VENTRICULAR TACHYCARDIA See Cardiac Arrest Initial Care and CPR (A3) 200 joules (low energy 120 joules) For 2 minutes or 5 cycles between rhythm check BLS airway is preferred method during first 5-6 minutes of CPR If no ventilation occurring with basic maneuvers, proceed to advanced airway TKO. Should not delay shock or interrupt CPR 300 joules (low energy 150 joules) 1:10,000-1 mg IV or IO every 3-5 minutes 360 joules (low energy 200 joules) 300 mg IV or IO 360 joules (low energy 200 joules) as indicated after every CPR cycle Should not interfere with initial 5-6 minutes of CPR minimize interruptions Do not interrupt compressions more than 10 seconds to obtain airway If rhythm persists, 150 mg IV or IO, 3-5 minutes after initial dose If indicated 1 meq/kg IV or IO for suspected hyperkalemia or pre-existing acidosis If Return of Spontaneous Circulation, see Post-Cardiac Arrest Care (A11) Key Treatment Considerations Uninterrupted CPR and timely defibrillations are the keys to successful resuscitation. Their performance takes precedence over advanced airway management and administration of medications. To minimize CPR interruptions, perform CPR during charging, and immediately resume CPR after shock administered (no pulse or rhythm check). Rotate compressors every 2 minutes. Avoid excessive ventilation. Provide no more than 8-10 ventilations per minute. Ventilations should be about one second each, enough to cause visible chest rise. If advanced airway placed, perform CPR continuously without pauses for ventilation. If available, ResQPOD impedance threshold device may be used with BLS airway or King / ET tube. If utilizing Endotracheal Tube, minimize CPR interruptions by positioning airway and laryngoscope, and performing airway visualization prior to cessation of CPR for tube passage. Immediately resume CPR after passage. Confirm placement of advanced airway (King Airway or ET tube) with end-tidal carbon dioxide measurement. Continuous monitoring with ETCO2 is mandatory if values less than 10 mm Hg seen, assess quality of compressions for adequate rate and depth. Rapid rise in ETCO2 may be the earlist indicator of return of circulation. Prepare drugs before rhythm check and administer during CPR Give drugs as soon as possible after rhythm check confirms VF/pulseless VT (before or after shock) Follow each drug with 20 ml NS flush Sodium bicarbonate should only be given for listed indications, and should not be given if ventilation ineffective

18 A5 ADULT INITIAL CARE PULSELESS ELECTRICAL ACTIVITY / ASYSTOLE See Cardiac Arrest Initial Care and CPR (A3) EPINEPHRINE ATROPINE 1:10,000 1 mg IV or IO every 3-5 minutes Consider treatable causes treat if applicable: Consider FLUID BOLUS VENTILATION Asystole or PEA with rate less than 60: 1 mg IV or IO. Repeat every 3-5 minutes to total dose of 3 mg For hypovolemia: 500 ml NS IV or IO For hypoxia: Ensure adequate ventilation (8-10 breaths per minute) Consider SODIUM BICARBONATE Consider CALCIUM CHLORIDE For pre-existing acidosis (e.g. kidney failure), hyperkalemia, or tricyclic antidepressant overdose are suspected: 1 meq/kg IV or IO if indicated Should not be used routinely in cardiac arrest For hyperkalemia or calcium channel blocker overdose: 500 mg IV or IO may repeat in 5-10 minutes WARMING MEASURES Consider NEEDLE THORACOSTOMY For hypothermia For tension pneumothorax If Return of Spontaneous Circulation, see Post-Cardiac Arrest Care (A11) Patients who have all of the following criteria are highly unlikely to survive: Consider TERMINATION OF RESUSCITATION Unwitnessed Arrest and No bystander CPR and No shockable rhythm seen and no shocks delivered during resuscitation and No return of spontaneous circulation (ROSC) during resuscitation Patients with asystole or PEA whose arrests are witnessed and/or who have had bystander CPR administered have a slightly higher likelihood of survival. If unresponsive to interventions these patients also should be considered for termination of resuscitation. Key Treatment Considerations Pre-existing acidosis or hyperkalemia should be suspected in patients with renal failure or dialysis or if suspected diabetic ketoacidosis

19 A6 - ADULT SYMPTOMATIC BRADYCARDIA - Heart rate less than 60 with signs or symptoms of poor perfusion (e.g., acute altered mental status, hypotension, other signs of shock) OXYGEN High flow. Be prepared to support ventilation as needed CARDIAC MONITOR 12-LEAD ECG Consider pre- and post-treatment if condition permits TKO. If not promptly available, proceed to external cardiac pacing. Consider IO ACCESS IV if patient in extremis and unconscious or not responsive to painful stimuli. Set rate at 80 TRANSCUTANEOUS PACING Start at 10 ma, and increase in 10 ma increments until capture is achieved If pacing urgently needed, sedate after pacing initiated. Consider MIDAZOLAM - initial dose 1 mg IV or IO, titrated in 1-2 mg increments (maximum SEDATION dose 5 mg), and/or MORPHINE SULFATE 1-5 mg IV or IO in 1 mg increments for pain relief if BP 90 systolic or greater Consider ATROPINE TRANSPORT Consider FLUID BOLUS Consider DOPAMINE 0.5 mg IV or IO if availability of pacing delayed or pacing ineffective Consider repeat 0.5 mg IV or IO every 3-5 minutes to maximum of 3 mg Use with caution in patients with suspected ongoing cardiac ischemia. Atropine should not be used in wide-qrs second- and third-degree blocks ml NS if clear lung sounds and no respiratory distress Begin infusion at 5 mcg/kg/min if not responsive to pacing or atropine (see table) Key Treatment Considerations Sinus bradycardia in the absence of key symptoms requires no specific treatment (monitor / observe) Sedation prior to starting pacing is not required. Patients with urgent need should be paced first. The objective of sedation in pacing is to decrease discomfort, not to decrease level of consciousness. Patients who are in need of pacing are unstable and sedation should be done with great caution. Monitor respiratory status closely and support ventilation as needed Atropine is not effective for bradycardia in heart-transplant patients (no vagus nerve innervation in these patients) Patients with wide-qrs second- and third-degree blocks will not have a response to atropine because these heart rates are not based on vagal tone. An increase in ventricular arrhythmias may occur.

20 A7 ADULT VENTRICULAR TACHYCARDIA WITH PULSES Widened QRS Complex (greater than or equal to 0.12 sec) generally regular rhythm OXYGEN CARDIAC MONITOR 12-LEAD ECG IV AMIODARONE Consider repeat AMIODARONE INITIAL THERAPY High flow. Be prepared to support ventilation as needed. Consider pre- and post treatment if condition permits TKO STABLE VENTRICULAR TACHYCARDIA 150 mg IV over 10 minutes (intermittent IV push or IV infusion of 15 mg/min) If rhythm persists and patient remains stable, 150 mg IV over 10 minutes UNSTABLE VENTRICULAR TACHYCARDIA Poor perfusion, moderate to severe chest pain, dyspnea, blood pressure less than 90 or CHF Consider SEDATION SYNCHRONIZED CARDIOVERSION Prepare for CARDIOVERSION: If awake and aware, sedate with MIDAZOLAM - initial dose 1 mg IV, titrate in 1-2 mg increments (max. dose 5 mg) 100 joules (low energy setting 75 W/S) 200 joules (low energy setting 120 W/S) 300 joules (low energy setting 150 W/S) 360 joules (low energy setting 200 W/S) If VT recurs, use lowest energy level previously successful Key Treatment Considerations Document rhythm during treatment with continuous strip recording Rhythm analysis should be based on recorded strip, not monitor screen Be prepared for previously stable patient to become unstable Give AMIODARONE via Infusion or slow IV push only Caution with administration of AMIODARONE. May cause hypotension, especially if given rapidly. AMIODARONE should not be used in unstable patients. Patients with pre-existing hypotension should be considered unstable and should not receive AMIODARONE. If sedation done for cardioversion, monitor respiratory status closely and support ventilations as needed

21 A8 ADULT SUPRAVENTRICULAR TACHYCARDIA Heart rate greater than 150 beats per minute regular rhythm usually with narrow QRS complex OXYGEN CARDIAC MONITOR 12-LEAD ECG IV INITIAL THERAPY High flow. Be prepared to support ventilation as needed. Consider pre- and post-treatment if condition permits TKO May have mild chest discomfort VALSALVA Consider ADENOSINE STABLE SUPRAVENTRICULAR TACHYCARDIA (SVT) 6 mg rapid IV - followed by 20 ml normal saline flush If not converted, 12 mg rapid IV 1-2 minutes after initial dose, followed by 20 ml normal saline flush. May repeat dose once. UNSTABLE SVT May need immediate synchronized cardioversion Signs of poor perfusion, moderate to severe chest pain, dyspnea, blood pressure less than 90 or CHF If rhythm not regular, SVT unlikely If wide QRS complex, consider ventricular tachycardia Consider ADENOSINE Consider SEDATION SYNCHRONIZED CARDIOVERSION 6 mg rapid IV - followed by 20 ml normal saline flush. If not converted, 12 mg rapid IV 1-2 minutes after initial dose, followed by 20 ml normal saline flush. May repeat dose once. Prepare for CARDIOVERSION. If awake and aware, sedate with MIDAZOLAM - initial dose 1 mg IV, titrate in 1-2 mg increments (max. dose 5 mg) 50 joules (low energy setting 50 W/S) 100 joules (low energy setting 75 W/S) 200 joules (low energy setting 120 W/S) 300 joules (low energy setting 150 W/S) 360 joules (low energy setting 200 W/S) Key Treatment Considerations Document rhythm during treatment with continuous strip recording Rhythm analysis should be based on recorded strip, not monitor screen Be prepared for previously stable patient to become unstable Proceed to cardioversion if patient becomes unstable Do not administer Adenosine if poison - or drug-induced tachycardia If sedation used for cardioversion, monitor respiratory status closely and support ventilation as needed

22 A9 ADULT OTHER CARDIAC DYSRHYTHMIAS SINUS TACHYCARDIA Heart rate , regular ATRIAL FIBRILLATION Heart rate highly variable, irregular ATRIAL FLUTTER Variable rate depending on block. Atrial rate , saw-tooth pattern OXYGEN CARDIAC MONITOR Consider 12-LEAD ECG Consider IV Low flow. High flow if unstable. INITIAL THERAPY 12-lead ECG pre- and post-treatment if patient symptomatic and condition permits TKO UNSTABLE ATRIAL FIBRILLATION OR ATRIAL FLUTTER Ventricular rate greater than 150, and: BP less than 80, or unconsciousness / obtundation, or severe chest pain or dyspnea OXYGEN High flow. Be prepared to support ventilation. Consider SEDATION SYNCHRONIZED CARDIOVERSION Prepare for CARDIOVERSION. If awake and aware, sedate with MIDAZOLAM - initial dose 1 mg IV, titrate in 1-2 mg increments (max. dose 5 mg) Atrial Flutter and Atrial Fibrillation: 100 joules (low energy setting 75 joules) 200 joules (low energy setting 120 joules) 300 joules (low energy setting 150 joules) 360 joules (low energy setting 200 joules) Key Treatment Considerations Sinus tachycardia commonly present because of pain, fever, hypovolemia Atrial fibrillation may be well-tolerated with moderately rapid rates ( ) and often requires no specific treatment other than observation (oxygen, monitoring and transport) If sedation used for cardioversion, monitor respiratory status closely and support ventilation as needed Computerized rhythm analysis on 12-lead ECG is frequently incorrect and requires review of the ECG to verify rhythm Computerized analysis for Acute MI (STEMI) may be incorrect with very fast rhythms. If ***Acute MI*** or ***Acute MI Suspected*** message encountered, the patient s heart rate is important information to relate to the STEMI center at time of activation.

23 A10 ADULT SHOCK HYPOVOLEMIC OR SEPTIC SHOCK - Signs and symptoms of shock with dry lungs, flat neck veins May have poor skin turgor, history of GI bleeding, vomiting or diarrhea May be warm and flushed, febrile May have history of high fever (sepsis) OXYGEN Keep patient warm CARDIAC MONITOR EARLY TRANSPORT CODE 3 IV or IO FLUID BOLUS BLOOD GLUCOSE Consider DOPAMINE SHOCK (NOT CARDIOGENIC) High flow. Be prepared to support ventilations as needed. Treat dysrhythmias per specific treatment guideline ml NS Recheck vitals every 250 ml to a maximum of 1 liter Check and treat if indicated Begin infusion at 5 mcg/kg/min if hypotension persists (see table) Related guidelines: Altered level of consciousness (G2), Respiratory Depression or apnea (G12) CARDIOGENIC SHOCK Signs and symptoms of shock, history of CHF, chest pain, rales, shortness of breath, pedal edema OXYGEN High flow. Be prepared to support ventilations as needed. Keep patient warm CARDIAC MONITOR Treat dysrhythmias per specific treatment guideline EARLY TRANSPORT CODE 3 IV or IO TKO BLOOD GLUCOSE Check and treat if indicated Consider DOPAMINE Begin infusion at 5 mcg/kg/min if hypotension persists (see table) 12 LEAD ECG Perform if time and condition permits Related guideline: Altered Level of Consciousness (G2)

24 A11 ADULT Following resuscitation from cardiac arrest in adults OXYGEN END-TIDAL CO2 MONITORING CARDIAC MONITOR POST-CARDIAC ARREST CARE Titrate to keep oxygen saturation above or equal to 94%. Be prepared to support ventilations as needed. Avoid excessive ventilation. If intubated, monitor and maintain respirations to keep ETCO2 between 35 and 40 Treat dysrhythmias per specific treatment guideline 12-LEAD ECG Evaluate for possible STEMI. Transport to STEMI center if ECG indicates ***ACUTE MI*** or equivalent STEMI message TRANSPORT CODE 3 IV or IO BLOOD GLUCOSE Consider FLUID BOLUS Consider DOPAMINE Consider THERAPEUTIC HYPOTHERMIA If not previously established Treat if indicated For BP less than 90 systolic, begin infusion up to 1 liter NS Begin infusion at 5 mcg/kg/min if hypotension persists (see table) See Indications and contraindications below. Expose patient and apply eight (8) ice packs 2 on head, 2 on the neck over the carotid arteries, 1 on each axilla, 1 over each femoral artery Discontinue ice packs if shivering occurs or increasing level of consciousness Advise Emergency Department that hypothermia has been initiated. THERAPEUTIC HYPOTHERMIA INDICATIONS AND CONTRAINDICATIONS All the following must be present: Must be age 18 or greater Return of spontaneous circulation for at least five minutes GCS < 8 INDICATIONS Unresponsive without purposeful movements. Brainstem reflexes and posturing movements may be present Blood pressure 90 systolic or greater Pulse oximetry 85% or greater Blood glucose 50 or greater Traumatic cardiac arrest Responsive post-arrest with GCS 8 or greater or rapidly improving GCS Pregnancy CONTRAINDICATIONS DNR or known terminal illness Dialysis patient Uncontrolled bleeding Consider and treat other potential causes of altered level of consciousness (e.g. hypoxia or hypoglycemia)

25 A12 ADULT SCENE SAFETY / BSI CONFIRM COMPRESSIONS PUBLIC SAFETY DEFIBRILLATION BLS / LAW ENFORCEMENT Use universal blood and body fluid precautions at all times Unconscious, pulseless patient with no breathing or no normal breathing Begin compressions at a rate of at least 100 per minute Compress chest at least 2 inches and allow full recoil of chest (lift heel of hand) Change compressors every 2 minutes Minimize interruptions in compressions. If necessary to interrupt, limit to 10 seconds or less Stop compressions for analysis only resume compressions while AED is charging Resume compressions immediately after any shock If available, place mechanical compression device after first rhythm analysis or after subsequent rhythm analysis (LUCAS or Auto-Pulse) AUTOMATED EXTERNAL DEFIBRILLATOR (AED) Priority of second rescuer is to apply pads while compressions are in progress If 1 8 years of age, attach pediatric electrodes, if available. If not, attach adult electrodes if able to do so without electrodes touching (*) Allow AED to analyze heart rhythm o If the rhythm is shockable Clear bystanders and crew Deliver shock Resume CPR for 2 minutes, beginning with chest compressions then return to (*) o If the rhythm is NOT shockable ( No Shock Advised ) Resume CPR for 2 minutes, beginning with chest compressions then return to (*) BASIC AIRWAY MANAGEMENT AND VENTILATION Open airway and provide 2 breaths after every 30 compressions AVOID EXCESSIVE VENTILATION Provide no more than 8 10 ventilations per minute Ventilations should be about one second each, enough to cause visible chest rise Use two-person BLS Airway management (one holding mask and one squeezing bag compressor can squeeze the bag) If patient begins to breathe or becomes responsive Maintain airway Assist ventilations, as necessary Check blood pressure, if equipment available

26 All Patients G1 Allergy and Anaphylaxis G2 Altered Level of Consciousness G3 Behavioral Emergency G4 Burns G5 Childbirth G6 Dystonic Reaction G7 Envenomation G8 Heat Illness/Hyperthermia G9 Hypothermia G10 Pain Management G11 Poisoning/Overdose G12 Respiratory Depression or Apnea G13 Respiratory Distress G14 Seizure G15 Stroke G16 Trauma G17 Vomiting and Severe Nausea GENERAL TREATMENT GUIDELINES

27 G1 GENERAL ALLERGY / ANAPHYLAXIS Serious reactions involve upper or lower respiratory tract - dyspnea, stridor, wheezing, anxiety, tachycardia, tightness in chest Some reactions involve only skin (hives, itching) Marked, sudden swelling of head, face neck and airway represents a serious systemic reaction (angioedema) OXYGEN EPI-PEN CARDIAC MONITOR High flow. Be prepared to support ventilations. May assist with administration of patient s auto-injector Treat dysrhythmias per specific treatment guidelines If upper or lower respiratory tract symptoms or hypotension: EPINEPHRINE Adult mg IM (use 0.3 mg in elderly, small patients or mild symptoms) 1:1000 IM Pediatric 0.01 mg/kg IM maximum dose 0.3 mg ALBUTEROL IV Adult and pediatric - 5 mg/6 ml saline via nebulizer may repeat as needed TKO If itching or hives, consider: Adult - 50 mg slow IV or IM Consider 25 mg dose if patient has taken po diphenhydramine DIPHENHYDRAMINE Pediatric 1 mg/kg IV or IM Maximum dose 50 mg Consider 0.5 mg/kg dose if patient has taken po diphenhydramine MONITOR PATIENT Carefully monitor vital signs, respiratory status, and response to treatments If serious progression of symptoms after treatment with IM epinephrine: Includes profound hypotension, absence of palpable pulses, unconsciousness, cyanosis, severe respiratory distress or respiratory arrest. In pediatric patients, hypotension is late sign of shock. Consider IO If IV access not immediately available FLUID BOLUS Consider EPINEPHRINE 1:10,000 IV Adult - wide open NS. Recheck vitals after every 250 ml Pediatric - 20 ml/kg NS bolus, may repeat X 2 If patient not responsive to IM epinephrine treatment: Adult - titrate in 0.1 mg doses slow IV or IO to a maximum dose of 0.5 mg. Use extreme caution with patients with cardiac history, angina, hypertension. Pediatric - titrate in up to 0.1 mg doses slow IV or IO to a maximum of 0.01 mg/kg Key Treatment Considerations Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose.

28 G2 GENERAL ALTERED LEVEL OF CONSCIOUSNESS Glasgow Coma Scale less than 15 uncertain etiology. Consider AEIOU/TIPPS OXYGEN SPINAL IMMOBILIZATION ORAL GLUCOSE CARDIAC MONITOR BLOOD GLUCOSE IV DEXTROSE GLUCAGON BLOOD GLUCOSE DEXTROSE High flow. Be prepared to support ventilations as needed. Consider need for spinal precautions Consider if known diabetic, conscious, able to sit upright, able to self-administer Adult - 30 g po Pediatric g po Check level TKO If glucose 60 or less: Adult DEXTROSE 50% 25 g IV Pediatric DEXTROSE 10% 0.5 g/kg IV (5 ml/kg) If unable to establish IV: Adult 1 mg IM Pediatric 24 kg or more 1 mg IM Pediatric Less than 24 kg 0.5 mg IM Recheck if symptoms not resolved Repeat initial IV dose if glucose remains 60 or less Related guideline: Respiratory Depression or Apnea (G12) Key Treatment Considerations Naloxone should not be given as treatment for altered level of consciousness in the absence of respiratory depression (respiratory depression = rate of less than 12 breaths per minute) Patients with hypoglycemia as a result of oral diabetic medications are at higher risk of recurrent hypoglycemia and transport is highly recommended in these patients With prolonged hypoglycemia and in many elderly patients, increase in level of consciousness after dextrose given may not be as rapid as in others. Recheck glucose before considering repeat treatment. In patients with starvation, poor oral intake, or alcohol intoxication/alcoholism, glucagon may not be effective because of poor glycogen stores in liver Glucagon may take minutes or longer to increase glucose level (peak effects in minutes). Recheck glucose before considering additional treatment. Consider transport earlier in patients with poor vascular access who are not responding to glucagon or have reasons listed above for possible impaired response to glucagon Most patients with hypoglycemia have diabetes. Other causes of hypoglycemia include renal failure, starvation, alcohol intoxication, sepsis, rare metabolic disorders, aspirin overdoses and sulfa drugs. Hypoglycemia may also occur rarely following gastric surgery for weight loss. For diabetics with insulin pumps, the amount of insulin administered by the pump is very small and should not impede treatment of hypoglycemia. Insulin pumps should not be discontinued because of the development of hypoglycemia. The presence of the pump should be identified during patient report at the hospital. Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for D10 dose.

29 G3 GENERAL BEHAVIORAL EMERGENCY A behavioral emergency is defined as combative or irrational behavior not caused by medical illnesses such as hypoxia, shock, hypoglycemia, head trauma, drug withdrawal, intoxicated states or other conditions Combative or irrational behavior may be caused by psychiatric or other behavioral disorder History of event and past history are important in patient evaluation Past history of psychiatric condition does not eliminate need to assess for other illnesses SCENE SAFETY ASSESS PATIENT VITAL SIGNS Consider OXYGEN CARDIAC MONITOR Consider BLOOD GLUCOSE Many patients merit a weapons search by law enforcement Physical restraints may be needed if patient exhibits behavior that presents a danger to him/herself or others Assess for evidence of hypoxia, hypoglycemia, trauma Consider other medical causes for behavioral symptoms Obtain vital signs as possible Provide as possible if there is question of hypoxia or other medical condition Place as possible / safe Obtain as possible / safe Consider CHEMICAL RESTRAINT BASE ORDER REQUIRED Despite verbal de-escalation and physical restraint, if adult patient (15 years or older) remains extremely combative and struggling against restraints, consider: MIDAZOLAM 5 mg IM. Lower doses should be considered in elderly or small patients (under 50 kg) MIDAZOLAM 1-5 IV mg in 1 mg increments if IV established and patent MONITOR PATIENT Monitor closely for respiratory compromise. Assess and document mental status, vital signs, and extremity exams (if restrained) at least every 15 minutes. Related guidelines: Altered Level of Consciousness (G2), Trauma (G16) Key Treatment Considerations Calming measures may be effective and may preclude need for restraint in some circumstances Utilize a single person to establish rapport. Separate patient from crowd and seek quiet environment if possible, but maintain contact with other personnel and ability to exit rapidly. Avoid violating patient s personal space, making direct eye contact or sudden movements. Frequent reassurance and calm demeanor of personnel are important. Enlist assistance of law enforcement if restraint needed. Never transport patient in prone position. Assure adequate resources available to manage patient s needs. Restraint may require up to five persons to safely control patient. Patients with past history of violent behavior are more likely to exhibit recurrent violent behavior In pediatric patients, consider child s developmental level when providing care Sedation with Midazolam intended for adult patients only (age 15 and over) Not all patients will respond to Midazolam. Repeat dosage is not recommended.

30 G4 GENERAL BURNS Damage to the skin caused by contact with caustic material, electricity, or fire Second or third degree burns involving 20% of the body surface area, or those associated with respiratory involvement are considered major burns Move patient to safe area Stop the burning process OXYGEN Protect the burned area Assess for associated injuries Consider IV or IO Consider MORPHINE SULFATE IV Remove contact with agent, unless adhered to skin Brush off chemical powders Flush with water to stop burning process or to decontaminate High flow. Be prepared to support ventilation as needed. Do not break blisters, cover with clean dressings or sheets. Remove restrictive clothing/jewelry if possible. TKO For pain relief in the absence of hypotension (systolic BP less than 90), significant other trauma, altered level of consciousness: Adult 2-20 mg IV or IO, titrated in 2-4 mg increments Pediatric mg/kg IV See Pediatric Drug Chart Consider MORPHINE SULFATE IM If IV or IO access not available: Adult 5-20 mg IM Pediatric 0.1 mg/kg IM See Pediatric drug chart Key Treatment Considerations Airway burns may lead to rapid compromise of airway (soot around nares, mouth, visible burns or edematous mucosa in mouth are clues). Transport to closest receiving facility for advanced airway management if time permits. Do not apply wet dressings, liquids or gels on burns. Cooling may lead to hypothermia. Refer to Rule of Nines to determine burn surface area (in Policy and Hospital Reference section). Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose.

31 G5 GENERAL CHILDBIRTH ROUTINE OR COMPLICATED IMMINENT DELIVERY - Regular contractions, bloody show, low back pain, feels like bearing down, crowning Prepare for Delivery Consider IV Deliver Infant Clamp/Cut Cord Warming Measures Placenta Delivery Post-Delivery Observation Transport Reassure mother, instruct during delivery TKO if time allows As head is delivered, apply gentle pressure to prevent rapid delivery of the infant Gently suction baby's mouth, then nose, keeping the head dependent If cord is wrapped around neck and can't be slipped over the infant's head, double-clamp and cut between clamps Immediately double-clamp cord 6-8 inches from baby and cut between clamps (if not done before delivery) Dry baby and keep warm, placing baby on mother's abdomen or breast If placenta delivers, save it and bring to the hospital with mother and child. DO NOT PULL ON UMBILICAL CORD TO DELIVER PLACENTA. Observe mother and infant frequently for complications. To decrease post-partum hemorrhage, perform firm fundal massage, put baby to mother's breast. Prepare mother and infant for transport. Neonatal care or resuscitation as indicated. COMPLICATED DELIVERY BREECH DELIVERY Presentation of buttocks or feet Allow delivery to proceed passively until the baby's waist appears Rotate baby to face down position (DO NOT PULL) Delivery If the head does not readily deliver in 4-6 minutes, insert a gloved hand into the vagina to create an air passage for the infant Transport Early transport if available notify receiving hospital as soon as possible PROLAPSED CORD - Cord presents first and is compressed, compromising infant circulation Manage Cord Position Patient Transport Insert gloved hand into vagina and gently push presenting part off of the cord Do not attempt to reposition the cord Cover cord with saline soaked gauze Place mother in trendelenburg position with hips elevated Early transport if available notify receiving hospital as soon as possible

32 G6 GENERAL DYSTONIC REACTIONS History of ingestion of phenothiazine or related compounds, primarily anti-psychotic and anti-emetic medications (for nausea/vomiting). Symptoms include restlessness, muscle spasms of the neck, jaw, and back, oculogyric crisis. OXYGEN High flow. Be prepared to support ventilations as needed. IV DIPHENHYDRAMINE TKO Adult mg IV or 50 mg IM if unable to establish IV access Pediatric 1 mg/kg IV or 1 mg/kg IM if unable to establish IV access Key Treatment Considerations Common drugs implicated in dystonic reactions include many anti-emetics and anti-psychotic medications Prochlorperazine (Compazine) Haloperidol (Haldol) Metoclopromide (Reglan) Phenergan (Promethazine) Fluphenazine (Prolixin) Chlorpromazine (Thorazine) Many other antipsychotic and anti-depressant drugs Rarely benzodiazepine drugs have been implicated as a cause of dystonic reaction Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose. G7 GENERAL ENVENOMATIONS Snake Bites, Insect Stings SNAKE BITES If the snake is positively identified as non-poisonous, treat with basic wound care INSECT STINGS Symptoms of stings usually occur at the site of injury and have no specific treatment Allergic reactions can be severe, and may cause anaphylactic shock Keep patient calm Address constricting items WOUND MANAGEMENT OXYGEN Remove rings, bracelets or other constricting items from affected extremity Snake bite: Splint extremity and keep at level of heart Insect Stings: Flick stinger off do not squeeze stinger. Apply cold pack. High flow If signs of shock or allergic reaction Be prepared to support ventilations Monitor vital signs Consider CARDIAC MONITOR Consider IV Consider if patient potentially unstable TKO Related guidelines: Shock (A10, P8), Allergy / Anaphylaxis (G1)

33 G8 GENERAL HEAT ILLNESS / HYPERTHERMIA HEAT EXHAUSTION Presentation: Flu-like symptoms, cramps, normal mental status HEAT STROKE Presentation: Altered level of consciousness, absence of sweating, tachycardia, and hypotension OXYGEN COOLING MEASURES IV Consider FLUID BOLUS Consider BLOOD GLUCOSE Consider DOPAMINE Low flow for heat exhaustion High flow if altered level of consciousness / suspected heat stroke Move patient to cool environment Promote cooling by fanning Remove clothing and splash / sponge with water Place cold packs on neck, in axillary and inguinal areas TKO. Perform if heat stroke or marked symptoms with heat exhaustion. If hypotensive or suspected heat stroke: Adult 500 ml NS bolus May repeat X 1 Pediatric 20 ml/kg NS bolus. May repeat X 1 Check level if altered level of consciousness, treat as indicated For adult patients only if hypotension persists despite fluid boluses Begin at 5 mcg/kg/min (see table) Related guidelines: Altered Level of Consciousness (G2), Seizure (G14) Key Treatment Considerations Seizures may occur with heat stroke treat as per treatment guideline for seizure Increasing symptoms merit more aggressive cooling measures. With mild symptoms of heat exhaustion, movement to cooler environment and fanning may suffice. Conditions that may lead to or worsen hyperthermia include: o Psychiatric Disorders o Heart Disease o Diabetes o Alcohol o Medications o Fever o Fatigue o Obesity o Pre-existent dehydration o Extremes of age (Elderly and pediatric) Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose.

34 G9 GENERAL HYPOTHERMIA MODERATE HYPOTHERMIA Conscious and shivering but lethargic, skin pale and cold SEVERE HYPOTHERMIA Stuporous or comatose, dilated pupils, hypotensive to pulseless, slowed to absent respirations Severe hypothermia patients may appear dead. When in doubt, begin resuscitation OXYGEN SPINAL PRECAUTIONS WARMING MEASURES Low flow. High flow if decreased level of consciousness (warm humidified oxygen if available). Be prepared to support ventilations. For patients with possible trauma or submersion Gently move to sheltered area (warm environment) Minimize physical exertion or movement of the patient Cut away wet clothing and cover patient with warm, dry sheets or blankets CARDIAC MONITOR Consider EARLY TRANSPORT Do not delay transport if patient unconscious IV TKO BLOOD GLUCOSE Check and treat if indicated Consider NALOXONE If respiratory rate less than 12 and narcotic overdose suspected Consider ADVANCED AIRWAY Only if unable to ventilate using BVM Related guidelines: Altered Level of Consciousness (G2), Respiratory Depression or Apnea (G12) Key Treatment Considerations Avoidance of excess stimuli important in severe hypothermia as the heart is sensitive and interventions may induce arrhythmias. Needed interventions should be done as gently as possible. o Check for pulselessness for seconds to avoid unnecessary chest compressions o Defer ACLS medications until patient warmed o If Ventricular Fibrillation or Pulseless Ventricular Tachycardia present, shock X 1 and defer further shocks Patients with prolonged hypoglycemia often become hypothermic blood glucose check essential Patients with narcotic overdose may develop hypothermia

35 G10 GENERAL PAIN MANAGEMENT (NON-TRAUMATIC) Patients of all ages expressing verbal or behavioral indicators of pain shall have an appropriate assessment and management of pain Morphine should be given in sufficient amount to manage pain but not necessarily to eliminate it Consider Low flow OXYGEN IV ASSESS PAIN PAIN RELIEF MEASURES Consider MORPHINE SULFATE IV Consider MORPHINE SULFATE IM TKO Assess and document the intensity of the pain using the visual analog scale Reassess and document the intensity of the pain after any intervention that could affect pain intensity Psychological measures and BLS measures, including cold packs, repositioning, splinting, elevation, and/or traction splints, are important considerations for patients with pain If pain cannot be managed using above measures, consider MORPHINE SULFATE, especially in patients reporting pain levels of 5 or greater. See contraindications and cautions below: For pain relief: Adult 2-20 mg IV, titrated in 2-5 mg increments to pain relief Pediatric mg/kg IV See Pediatric Drug Chart If no IV access: Adult mg IM Pediatric 0.1 mg/kg IM See Pediatric Drug Chart Contraindications and Cautions for Morphine Sulfate Closed head injury Altered level of consciousness Headache Respiratory failure or worsening respiratory status Childbirth or suspected active labor Contraindications for Morphine: Hypotension o Adults - Systolic BP less than 90 o Pediatric - Hypotension or impaired perfusion (e.g. capillary refill > 2 seconds) Infants 1mo-1yr systolic BP < 60 mmhg Toddler 1-4 yrs systolic BP < 75 mmhg School age 5-13 yrs systolic BP < 85 mmhg Adolescent >13 yrs systolic BP < 90 mmhg Cautions for Morphine: Use with caution in patients with suspected drug or alcohol ingestion or with suspected hypovolemia Key Treatment Considerations Have Naloxone available to reverse respiratory depression should it occur Preferred route of administration for Morphine Sulfate is IV Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose.

36 G11 GENERAL POISONING - OVERDOSE If possible, determine substance, amount ingested, time of ingestion. Bring in container or label. Be careful not to contaminate yourself and others DECONTAMINATION OXYGEN Remove contaminated clothing, brush off powders, wash off liquids. Irrigate eyes if affected. Low flow. Be prepared to support ventilations. CARDIAC MONITOR Consider IV TKO if unstable patient or suspected serious ingestion Related guidelines: Respiratory Depression or Apnea (G12), Altered Level of Consciousness (G2), Seizures (G14), Shock (A10, P8) TRICYCLIC ANTIDEPRESSANT OVERDOSE Frequently associated with respiratory depression, usually tachycardia. Widened QRS complexes and associated ventricular arrhythmias are generally signs of a life-threatening ingestion. SODIUM BICARBONATE For adults only: For life-threatening hemodynamically significant dysrhythmias, 1 meq/kg slow IV or IO ORGANOPHOSPHATE POISONING Hypersalivation, sweating, bronchospasm, abdominal cramping, diarrhea, muscle weakness, small/pinpoint pupils, muscle twitching, and/or seizures may occur ATROPINE For adults only: 1-2 mg IV Repeat every 3-5 minutes as necessary until relief of symptoms Large doses of Atropine may be required HYDROFLUORIC ACID EXPOSURE CALCIUM CHLORIDE For adults only: For tetany or cardiac arrest, 500mg IV (5 ml of 10% solution) Consider MORPHINE SULFATE IV Consider MORPHINE SULFATE IM For adults only: In the absence of hypotension, significant other trauma or altered level of consciousness: 2-20 mg IV titrated in 2-5 mg increments to pain relief For adults only: If no IV access, 5-10 mg IM Key Treatment Considerations Few overdoses have specific antidotes. Supportive care is the mainstay of treatment. Contact Base Hospital if any questions concerning treatment of overdose in pediatric patients Contact Base Hospital for other suspected overdoses that may have specific treatment (e.g. Calcium Channel Blocker overdose) Poison Control Center can offer information but cannot provide medical direction to EMS

37 G12 GENERAL RESPIRATORY DEPRESSION OR APNEA Absence of spontaneous ventilations or respiratory rate less than 12 without cardiac arrest BVM VENTILATION OXYGEN CARDIAC MONITOR NALOXONE INTRANASAL or IM Consider IV NALOXONE IV Repeat NALOXONE Titration of Diluted NALOXONE IV ADVANCED AIRWAY Assist ventilation or provide ventilation if no spontaneous respirations High flow Adult not in shock: 2 mg IN (intranasal) if narcotic overdose suspected Adult not in shock but unsuitable for IN (copious secretions): 1-2 mg IM Pediatric 0.1 mg/kg IM - maximum dose 2 mg TKO if intravenous treatment indicated If patient in shock, if IN or IM routes ineffective (within 3 minutes), or if IV access already available for another reason: Adult 1-2 mg IV Pediatric 0.1 mg/kg IV maximum dose 2 mg IV or IM if no response and narcotic overdose suspected maximum dose 10 mg Consider for patients with chronic narcotic use for terminal disease or chronic pain: Dilute 1:10 with normal saline and administer in 0.1 mg (1 ml) increments titrate to increased respiratory rate Consider when indicated - only if naloxone ineffective and BVM ventilation not adequate Related guidelines: Altered Level of Consciousness (G2), Respiratory Distress (G13) Key Treatment Considerations SAFETY WARNING! Naloxone will cause acute withdrawal symptoms in patients who are habituated users of narcotics (whether prescribed or from abuse) Use of diluted Naloxone IV and titration with small increments may help decrease adverse effects of naloxone in patients who have chronic narcotic usage for terminal disease or pain relief Naloxone treatment should only be given to patients with respiratory depression (rate less than 12) Patients who are maintaining adequate respirations with decreased level of consciousness do not generally require Naloxone for management Naloxone can cause cardiovascular side effects (chest pain, pulmonary edema) or seizures in a small number of patients (1-2%) Older patients are at higher risk for cardiovascular complications Be prepared for patient agitation or combativeness after naloxone reversal of narcotic overdose Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose.

38 G13 GENERAL RESPIRATORY DISTRESS Wheezing may be noted in asthma, COPD exacerbation, or pulmonary edema Rales may be present in pneumonia, pulmonary edema, and many other conditions INITIAL THERAPY OXYGEN Low flow increase as indicated. Be prepared to support ventilation. CARDIAC MONITOR Consider CPAP If respiratory rate greater than 25, accessory muscle use, pulse ox less than 94% Consider IV ALBUTEROL Consider EPINEPHRINE 1:1000 SC (subcutaneously) EPINEPHRINE 1:1000 IM ALBUTEROL NITROGLYCERIN Consider MORPHINE SULFATE TKO. Do not delay transport for vascular access if in extremis. ASTHMA Adult and Pediatric 5 mg in 6 ml NS via nebulizer. Repeat as needed. For use in asthma only: Use only if respiratory status deteriorating despite repeat treatment with Albuterol and transport time more than 10 minutes. Do not use in patients with history of coronary artery disease or hypertension. Adult mg SC Pediatric mg/kg SC - max dose 0.3 mg Never give Epinephrine 1:1000 intravenously! If respiratory arrest from asthma or bronchospasm: Adult mg IM Pediatric mg/kg IM - max dose 0.3 mg COPD EXACERBATION 5 mg in 6 ml NS via nebulizer. Repeat as needed. SUSPECTED PULMONARY EDEMA (ADULTS ONLY) 0.4 mg sublingual if systolic BP between 90 and mg sublingual if systolic BP 150 or greater Repeat every 5 minutes until symptoms improve Maximum dose 4.8 mg ( mg doses) Discontinue if hypotension develops Caution: Do not administer if patient has taken erectile dysfunction medications Viagra or Levitra within prior 24 hours or Cialis within 36 hours 2-5 mg IV in 1-2 mg increments for relief of anxiety. Do not administer if BP less than 90, if patient has altered mental status or decreased respiratory effort. Related guidelines Chest pain / Suspected ACS (A2), Shock (A10) Key Treatment Considerations CPAP is not a ventilation device. Patients with inadequate respiratory rate or inadequate depth of respiration will need assistance with BVM. Patients with potential respiratory failure should be transported emergently. Patients requiring advanced airway management in these situations are best handled in the hospital setting and CPAP may be a valuable bridge in care to potentially delay need for emergent intubation. IV access should not delay transport. For suspected pulmonary edema, re-evaluate blood pressure between each dose of nitroglycerin. If blood pressure initially over 150, then between 150 and 90 after treatment, lower dosage to 0.4 mg. If cardiac ischemia suspected in addition to pulmonary edema, treat as per chest pain protocol (Aspirin, 12-lead ECG if possible). Consider cardiac etiology for diabetic patients with respiratory distress Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose.

39 G14 GENERAL SEIZURE / STATUS EPILEPTICUS Tonic, clonic movements followed by a period of unconsciousness (post-ictal period) A continuous or recurrent seizure is defined as seizure activity greater than 10 minutes or recurrent seizures without patient regaining consciousness OXYGEN High flow. Be prepared to support ventilations. Protect patient Do not forcibly restrain but protect from injuring self CARDIAC MONITOR Consider IV TKO BLOOD GLUCOSE Check and treat if indicated Consider MIDAZOLAM IV Consider MIDAZOLAM IM MONITOR PATIENT For continuous or recurrent seizures: Adult initial dose 1 mg IV - titrate in 1-2 mg increments max. dose 5 mg Pediatric titrate in up to 1 mg IV increments up to 0.1 mg/kg If IV access unavailable: Adult 0.2 mg/kg IM - maximum dose 10 mg Pediatric 0.2 mg/kg IM - maximum dose 10 mg Carefully observe vital signs, respiratory status support ventilations as needed Related guidelines: Altered Level of Consciousness (G2), Respiratory Depression or Apnea (G12) SAFETY WARNING: Use caution when treating with Midazolam in pediatric patients previously treated by family or caretaker with rectal diazepam (Valium, Diastat) as a higher incidence of respiratory depression may occur. Wait five (5) minutes after last rectal dose to determine effect and need for treatment. Consider using reduced dosage of Midazolam. Key Treatment Considerations Most seizures are self-limiting and do not require prehospital medication Seizures may appear frightening to observers. Provide reassurance to parents/family. Consider spinal immobilization if history of fall or trauma Febrile seizures in children are generally self-limiting For febrile patients, remove or loosen clothing, remove blankets to address cooling measures Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose.

40 G15 GENERAL STROKE Sudden onset of weakness, paralysis, confusion, speech disturbances, visual field deficit, may be associated with headache Determination of time of onset of symptoms is the most crucial historical information needed If patient awoke with symptoms, time patient last seen normal is the time that should be noted OXYGEN CARDIAC MONITOR STROKE SCALE TRANSPORT BLOOD GLUCOSE IV Consider FLUID BOLUS CONTACT RECEIVING HOSPITAL High flow. Be prepared to support ventilations as needed. Note findings of stroke scale and time of onset of symptoms Minimize scene time Check and treat if indicated TKO. Perform enroute ml if hypotensive or poor perfusion reassess Report time of symptom onset (time last seen normal), ETA, physical exam and findings of Cincinnati Stroke Scale using SBAR format Related guidelines: Altered Level of Consciousness (G2), Respiratory Depression or Apnea (G12), Seizure (G14) CINCINNATI STROKE SCALE If any one of the three tests are abnormal and is a new finding, the Stroke Scale is abnormal and may indicate an acute stroke Finding Patient Activity Interpretation Facial Droop Ask patient to smile and show teeth or grimace Normal: Symmetrical smile or face Abnormal: Asymmetry (one side droops or does not move) Arm Weakness Ask patient to close both eyes and extend both arms out straight for 10 seconds Normal: Both arms move symmetrically or do not move Abnormal: One arm drifts down or arms move asymmetrically Testing with patient holding palms upward is most sensitive way to check. Patients with arm weakness will tend to pronate (turn from palms up to sideways or palms down). Speech Abnormality Have the patient say the words, The sky is blue in Cincinnati Normal: The correct words are used and no slurring of words is noted Abnormal: If the patient slurs words, uses the wrong words, or is unable to speak (aphasia)

41 G16 GENERAL SPINAL IMMOBILIZATION OXYGEN EARLY TRANSPORT WOUND / GENERAL CARE Consider NEEDLE THORACOSTOMY IV Consider FLUID BOLUS BLOOD GLUCOSE CARDIAC MONITOR MORPHINE SULFATE IV MORPHINE SULFATE IM As indicated High flow. Be prepared to support ventilations. TRAUMA Limit scene time to less than 10 minutes when possible. Load and go if high risk. Place splints, cold packs, dressings and pressure on bleeding sites as needed. Keep patient warm minimize exposure after assessment Evaluate for and treat tension pneumothorax if indicated TKO. If patient critical, DO NOT DELAY ON-SCENE FOR IV OR IO ACCESS. Start two (2) large bore IV s en route when possible. If stable, single IV acceptable. If markedly hypotensive (absent peripheral pulses or BP less than 90), Adult ml NS, recheck vitals. Titrate to presence of peripheral pulses Pediatric 20 ml/kg NS. If continued poor perfusion, may repeat X 2 Test if GCS less than 15. See Altered Level of Consciousness (G2). See indications and precautions below: Adult 2-20 mg IV in 2-5 mg increments. Titrate to pain relief and systolic BP greater than 100. See precautions below. Pediatric mg/kg IV See Pediatric Drug chart When IV access not available (non-critical patients only): Adult 5-10 mg IM Pediatric 0.1 mg/kg IM See Pediatric Drug chart INDICATIONS AND PRECAUTIONS FOR MORPHINE USE Morphine may be used for relief of extremity pain in the absence of head or torso trauma, hypotension (age-specific), poor perfusion or ALOC. Use with caution in patients with drug or alcohol intoxication. Related guidelines: Altered Level of Consciousness (G2), Respiratory Depression or Apnea (G12) Key Treatment Considerations ALS procedures in the field (IV and advanced airway) do not improve outcome in critical patients. o IV starts should be done en route on these patients o Advanced airway should only be done if patient is unable to be ventilated via BLS maneuvers Repeated IV attempts in non-critical pediatric patients should be avoided Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose. CRUSH INJURY SYNDROME Caused by muscle crush injury and cell death. Most patients have an extensive area of involvement such as a large muscle mass in a lower extremity and/or pelvis. May develop after one hour in severe crush, but usually requires at least 4 hours of compression Hypovolemia and hyperkalemia may occur, particularly in extended entrapments Hyperkalemia should be suspected if ECG monitor reveals peaked T waves, absent P waves or widened QRS complexes FLUID BOLUS 20 ml/kg NS prior to release of compression ALBUTEROL - 5 mg in 6 ml NS continuously via nebulizer IF ECG CHANGES CALCIUM CHLORIDE - 1 gm slow IV over 60 seconds. Note: Flush tubing after administration SUGGEST of calcium chloride to avoid precipitation with sodium bicarbonate. HYPERKALEMIA: SODIUM BICARBONATE - 1 meq/kg IV. Additionally, consider 1 meq/kg added to IV 1L NS - use second IV line as other medications may not be compatible

42 G17 GENERAL VOMITING AND SEVERE NAUSEA Vomiting or nausea may be due to viral illness (gastroenteritis) or other medical conditions including acute coronary syndrome, stroke, head injury, or toxic ingestion. It may be associated with a number of painful abdominal conditions, and may also occur as a result of treatment of pain with morphine. Consider OXYGEN POSITION PATIENT NON-INVASIVE MEASURES Consider IV Consider FLUID BOLUS Low flow. High flow if decreased level of consciousness. Position patient to avoid aspiration. Fresh air, oxygen, and removal of noxious odors may lessen nausea. TKO Consider if patient has prolonged history of vomiting or poor intake, if vital signs or exam suggest volume depletion (rapid pulse, low blood pressure, dry mucous membranes, poor skin turgor, or capillary refill greater than 2 seconds). Adult ml. Recheck vitals may repeat X 1. Pediatric 20 ml/kg. Recheck vitals may repeat X 1. Consider ONDANSETRON For severe nausea or persistent vomiting: Adult 4 mg IV, IM, or po (oral disintegrating tablet - ODT). May repeat every 10 minutes to a total of 12 mg Pediatric limited to patients 4 years of age or older 4 mg IV, IM, or po (ODT). For patients 40 kg and greater only, may repeat every 10 minutes to a total of 12 mg NOTE: Administer IV dosage over 1 minute. Ondansetron is contraindicated if patient has a history of hypersensitivity to other similar drugs (Dolasetron (Anzemet), granisetron (Kytril), or Palonosetron (Aloxi). Related guidelines: Shock (A10), Pain Management (Non-Traumatic) (G10) Key Treatment Considerations Rapid administration of ondansetron has been associated with increased incidence of side effects most notably syncope. Ondansetron must be administered intravenously over 1 minute. Rare side effects of ondansetron include headache, dizziness, tachycardia, sedation, hypotension, or syncope. Rarely QT prolongation has been seen (with higher doses and rapid administration). Ondansetron can be used in pregnancy and with breast-feeding mothers. May be co-administered with MORPHINE SULFATE when used for pain relief Oral disintegrating tablets should be handled with care as moisture may cause premature breakdown of tablets before administration. Oral disintegrating tablets can be placed on tongue and do not need to be chewed. Medication will dissolve and be swallowed with saliva.

43 P1 Pediatric Patient Care P2 Cardiac Arrest Initial Care and CPR P3 Neonatal Resuscitation P4 Ventricular Fibrillation / Ventricular Tachycardia P5 PEA / Asystole P6 Symptomatic Bradycardia P7 Tachycardia P8 Shock PEDIATRIC TREATMENT GUIDELINES

44 P1 PEDIATRIC Scene Safety Body Substance Isolation Systematic Assessment Determine Primary Impression Base Contact Transport Document PEDIATRIC PATIENT CARE Pediatric patient is defined as age 14 or less. Neonate is 0-1 month These basic treatment concepts should be considered in all pediatric patients Use universal blood and body fluid precautions at all times Management and support of ABC s are a priority Identify pre-arrest states Assure open and adequate airway Place in position of comfort unless condition mandates other position Consider spinal immobilization if history or possibility of traumatic injury exists Assess environment to consider possibility of intentional injury or maltreatment Apply appropriate field treatment guidelines Explain procedures to family and patient as appropriate Provide appropriate family support on scene Contact base hospital if any questions arise concerning treatment or if additional medication beyond dosages listed in treatment guidelines is considered Use SBAR to communicate with base Minimize scene time in pre-arrest patient, critical trauma, shock or respiratory failure Transport patient medications or current list of patient medications to the hospital Give report to receiving facility using SBAR Document patient assessment and care per policy Key Treatment Considerations Apparent Life-Threatening Event (ALTE) An Apparent Life-Threatening Event (ALTE) Is an event that is frightening to the observer (may think the infant has died) and involves some combination of apnea, color change, marked change in muscle tone, choking, or gagging. It usually occurs in infants less than 12 months of age, though any child with symptoms described under 2 years of age may be considered an ALTE. Most patients have a normal physical exam when assessed by responding personnel. Approximately half of the cases have no known cause, but the remainder of cases have a significant underlying cause such as infection, seizures, tumors, respiratory or airway problems, child abuse, or SIDS. Because of the high incidence of problems and the normal assessment usually seen, there is potential for significant problems if the child's symptoms are not seriously addressed. OBTAIN DETAILED HISTORY ASSESSMENT TREATMENT TRANSPORT Obtain history of event, including duration and severity, whether patient awake or asleep at time of episode, and what resuscitative measures were done by the parent or caretaker. Obtain past medical history, including history of chronic diseases, seizure activity, current or recent infections, gastroesophageal reflux, recent trauma, medication history. Obtain history with regard to mixing of formula if applicable. Perform comprehensive exam, including general appearance, skin color, interaction with environment, or evidence of trauma Treat identifiable cause if appropriate If treatment/transport is refused by parent or guardian, contact base hospital to consult prior to leaving patient. Document refusal of care.

45 P2 PEDIATRIC COMPRESSIONS AED or MONITOR/ DEFIBRILLATOR BASIC AIRWAY MANAGEMENT and VENTILATION CARDIAC ARREST INITIAL CARE AND CPR Begin compressions at a rate of at least 100 per minute Compress chest approximately 1/3 of AP diameter of chest: o In children (age 1-8) - around 2 inches o In infants (under age 1) around 1 ½ inches Allow full chest recoil (lift heel of hand) Change compressors every 2 minutes Minimize any interruptions in compressions. If necessary to interrupt, limit to 10 seconds or less Do not stop compressions while defibrillator is charging Resume compressions immediately after any shock Priority of second rescuer is to apply pads while compressions in progress Determine rhythm (or allow AED analysis) and shock if indicated Follow specific treatment guideline based on rhythm Open airway For 2-person CPR: o Provide 2 breaths:30 compressions for children over age 8 o Provide 2 breaths:15 compressions for infants > 1 month and children to age 8 AVOID EXCESSIVE VENTILATION Ventilations should last one second each, enough to cause visible chest rise Use two-person BLS Airway management (one holding mask and one squeezing bag). MEDICATIONS AND DEFIBRILLATION Use length-based tape to determine weight if not known o If child is obese and length-based tape used to determine weight, use next highest color to determine appropriate equipment and drug dosing See Pediatric Drug Chart for medication dose and defibrillation energy levels ADVANCED AIRWAY MANAGEMENT and END-TIDAL CO2 MONITORING For patients 40 kg or greater only: Placement of advanced airway is not a priority during the first 5 minutes of resuscitation unless no ventilation is occurring with basic maneuvers. Laryngoscopy for endotracheal tube placement must occur with CPR in progress and compressions should be halted only for advancement of tube through the cords. Advanced airway placement should not interrupt compressions for a period of more than 10 seconds Continous monitoring of End-Tidal CO2 with waveform capnography is mandatory for all patients with advanced airway device in place. BLOOD GLUCOSE PREVENT HYPOTHERMIA TRANSPORT Treat if indicated. Glucose may be rapidly depleted in pediatric arrest. Move to warm environment and avoid unnecessary exposure Pediatric arrest victims are at risk for hypothermia due to their increased body surface area, exposure and rapid administration of IV/IO fluids Consider rapid transport to definitive care

46 P3 PEDIATRIC WARM PATIENT CLEAR AIRWAY DRY AND STIMULATE EVALUATE RESPIRATIONS, HEART RATE AND COLOR NEONATAL CARE AND RESUSCITATION Provide warmth move to warm environment immediately If needed, position airway or suction. Rapidly suction secretions from mouth or nares. Dry child thoroughly, stimulate, reposition if needed, place hat on infant If breathing, heart rate above 100 and pink, observational care only If breathing, heart rate above 100 and central cyanosis OXYGEN 100% by mask reassess in 30 seconds o If cyanosis resolves (skin pink) observational care only o If persistent central cyanosis after oxygen, initiate bag mask ventilation at rate of 40-60/minute If apneic, gasping, or heart rate below 100 initiate bag mask ventilation at a rate of 40-60/minute with OXYGEN 100% reassess in 30 seconds o If heart rate increases to above 100 and patient ventilating adequately, discontinue bag mask ventilation and continue close observation o If heart rate persists below 100 continue bag mask ventilation REASSESS / BEGIN CPR IF INDICATED If heart rate less than 60 despite ventilation with oxygen for 30 seconds, begin CPR (3:1 ratio 90 compressions and 30 ventilations/minute). Reassess in 30 seconds. If heart rate remains less than 60 despite adequate ventilation and chest compressions: IV/IO TKO ml NS bag (use care to avoid inadvertent fluid administration). Do not delay transport for IV or IO access. EPINEPHRINE 1:10,000, 0.01 mg/kg IV or IO. Repeat every 3-5 minutes if heart rate remains below 60. Consider FLUID BOLUS Consider NALOXONE 10 ml/kg NS IV or IO. May repeat once if needed. 0.1 mg/kg IV or IO if depressed respiratory status despite efforts. Avoid use if long term use of opioids during pregnancy known or suspected. Key Treatment Considerations For uncomplicated deliveries, treatment priorities are to warm, dry, and stimulate the infant Anticipate complex resuscitation if not term gestation, amniotic fluid not clear, if newborn is not breathing or crying or if newborn does not have good muscle tone Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose.

47 P4 PEDIATRIC VENTRICULAR FIBRILLATION PULSELESS VENTRICULAR TACHYCARDIA INITIAL CARE DEFIBRILLATION CPR BVM VENTILATION IO or IV DEFIBRILLATION EPINEPHRINE DEFIBRILLATION AMIODARONE TRANSPORT See Cardiac Arrest - Initial Care and CPR (P3) 2-4 joules/kg AED can be used if patient over 1 year and pediatric electrodes available (age 1-8) or if adult electrodes can be applied without touching each other Use infant paddles and manual defibrillator up to 1 year of age or 10 kg For 2 minutes or 5 cycles between rhythm check For patients 40 kg and over, defer advanced airway unless BLS airway inadequate TKO. Should not delay defibrillation or interrupt CPR 4 joules/kg 1:10, mg/kg IV or IO every 3-5 minutes - See Pediatric Drug Chart 4 joules/kg. Higher energy levels may be considered not to exceed 10 joules/kg or the adult maximum. 5 mg/kg IV or IO (see Pediatric Drug Chart for dosage) If Return of Spontaneous Circulation see guidelines for Shock (P8) if treatment indicated Key Treatment Considerations Uninterrupted CPR and timely defibrillations are the keys to successful resuscitation. Their performance takes precedence over advanced airway management and administration of medications. To minimize CPR interruptions, perform CPR during charging, and immediately resume CPR after shock administered (no pulse or rhythm check) Avoid excessive ventilation with BLS airway management, which may cause gastric distention and limit chest expansion. Provide breaths over one second, with movement of chest wall as guide for volume needed. If advanced airway placed (40 kg and over), perform CPR continuously without pauses for ventilation Confirm placement of advanced airway with end-tidal carbon dioxide measurement. Continuous monitoring with ETCO2 is mandatory if values less than 10 mm Hg seen, assess quality of compressions for adequate rate and depth. Rapid rise in ETCO2 may be the earliest indicator of return of circulation. Prepare drugs before rhythm check and administer during CPR Give drugs as soon as possible after rhythm check confirms VF/pulseless VT (before or after shock) Follow each drug with 5-10 ml NS flush (minimum). Increase accordingly for patient size (20 ml in adolescents). Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for medication dose and defibrillation energy levels.

48 P5 PEDIATRIC INITIAL CARE BVM VENTILATION IV or IO PULSELESS ELECTRICAL ACTIVITY / ASYSTOLE See Cardiac Arrest Initial Care and CPR (P3) Defer advanced airway (for patients 40 kg and over) unless BLS airway inadequate TKO EPINEPHRINE 1:10, mg/kg IV or IO every 3-5 minutes Consider treatable causes treat if applicable: Consider 20 ml/kg NS may repeat X 2 for hypovolemia FLUID BOLUS VENTILATION WARMING MEASURES Ensure adequate ventilation (8-10 breaths per minute) for hypoxia For hypothermia Consider NEEDLE For tension pneumothorax THORACOSTOMY To determine treatment for other identified potentially treatable causes - Hydrogen Ion (Acidosis), BASE CONTACT Hyperkalemia, Toxins Safety Warning: Unlike adult resuscitation, atropine is not used in treatment of asystole or PEA in the pediatric patient If Return of Spontaneous Circulation see guidelines for Shock (P8) if treatment indicated Key Treatment Considerations Uninterrupted CPR is key to successful resuscitation. This takes precedence over advanced airway management and administration of medications. If advanced airway placed in patients 40 kg and over, perform CPR continuously without pauses for ventilation Avoid hyperventilation. If intubated, give 8 to 10 ventilations per minute, administered over one second. Prepare drugs before rhythm check and administer during CPR Follow each drug with 5-10 ml NS flush (minimum). Increase accordingly for patient size (20 ml in adolescents). Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose.

49 P6 PEDIATRIC SYMPTOMATIC BRADYCARDIA 90% of pediatric bradycardias are related to respiratory depression and respond to support of ventilation Only unstable, severe bradycardia causing cardiorespiratory compromise will require further treatment Signs of severe cardiorespiratory compromise are poor perfusion, delayed capillary refill, hypotension, respiratory difficulty, altered level of consciousness OXYGEN IV or IO Consider CPR EPINEPHRINE High flow. Be prepared to support ventilation. TKO. Use IO only if patient unstable and requires medication. Use ml NS bag. If heart rate remains less than 60 with poor perfusion despite oxygenation and ventilation, perform CPR. 1:10, mg/kg IV or IO. Repeat every 3-5 minutes. SAFETY WARNING: Atropine should be considered only after adequate oxygenation/ventilation has been assured Consider ATROPINE 0.02 mg/kg IV, IO (0.1 mg minimum dose) Child (1-8 years): Maximum single dose 0.5 mg. Maximum total dose 1 mg Adolescent (9-14 years): Maximum single dose 1 mg. Maximum total dose 2 mg. If continued heart rate less than 60, repeat 0.02 mg/kg IV or IO Key Treatment Considerations Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose.

50 P7 PEDIATRIC TACHYCARDIA Sinus tachycardia is by far the most common pediatric rhythm disturbance UNSTABLE SINUS TACHYCARDIA (narrow QRS less than 0.08) P waves present/normal, variable R-R interval with constant P-R interval Unstable sinus tachycardia is usually associated with shock and may be pre-arrest UNSTABLE SUPRAVENTRICULAR TACHYCARDIA (SVT) (narrow QRS less than 0.08) P waves absent/abnormal, heart rate not variable History generally vague, non-specific and/or history of abrupt heart rate changes Infants rate usually greater than 220 bpm, Children (ages 1 8) rate usually greater than 180 bpm UNSTABLE POSSIBLE VENTRICULAR TACHYCARDIA - Wide QRS (greater than 0.08 sec) In some cases, wide QRS can represent supraventricular rhythm OXYGEN CHECK PULSE AND PERFUSION CARDIAC MONITOR IV or IO INITIAL THERAPY ALL TACHYCARDIA RHYTHMS Low flow. If increased work of breathing high flow. Be prepared to support ventilation. Determine stability: Stable - Normal perfusion: Palpable pulses, normal LOC, normal capillary refill, and normal BP for age Unstable - Poor perfusion: ALOC, abnormal pulses, delayed cap. refill, difficult/unable to palpate BP. If unstable, transport early and treat as below. Run strip to evaluate QRS Duration TKO. Use ml bag NS FLUID BOLUS 20 ml/kg NS if hypovolemia suspected. May repeat X 1. UNSTABLE SUPRAVENTRICULAR TACHYCARDIA (narrow QRS less than 0.08) VAGAL MANEUVERS Consider if will not result in treatment delays. ICE PACK to face of infant/child. BASE CONTACT For all treatments listed below: ADENOSINE 0.1 mg/kg rapid IV push followed by ml NS flush (maximum dose 6 mg) If not converted, 0.2 mg/kg rapid IV push followed by ml NS flush (maximum dose 12 mg) SYNCHRONIZED CARDIOVERSION If unable to obtain IV access, prepare for Synchronized Cardioversion. Do NOT delay cardioversion to obtain IV or IO access or sedation. Consider SEDATION Consider MIDAZOLAM 0.1 mg/kg IV or IO, titrated in 1 mg maximum increments (maximum dose 5 mg) SYNCHRONIZED CARDIOVERSION joule/kg. If not effective, repeat at 2 joules/kg. UNSTABLE POSSIBLE VENTRICULAR TACHYCARDIA ( Wide QRS greater than 0.08 sec) BASE CONTACT For all treatments listed below: SYNCHRONIZED CARDIOVERION Consider SEDATION SYNCHRONIZED CARDIOVERSION Prepare for CARDIOVERSION while attempting IV/IO access, but do not unduly delay care for IV access or medications If IV/IO access has been obtained, consider MIDAZOLAM 0.1 mg/kg IV or IO, titrated in 1 mg maximum increments (maximum dose 5 mg) joule/kg. If not effective, repeat at 2 joules/kg. Early transport appropriate in unstable patients. Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose.

51 P8 PEDIATRIC SHOCK Altered level of consciousness; cool, clammy, mottled skin; capillary refill greater than 2 seconds; tachycardia; blood pressure less than 70 systolic Listless infant or child with poor skin turgor, dry mucous membranes, history of fever may indicate sepsis, meningitis OXYGEN Keep patient warm CARDIAC MONITOR EARLY TRANSPORT CODE 3 IV or IO High flow. Be prepared to support ventilations as needed. FLUID BOLUS 20 ml/kg NS may repeat X 2 BLOOD GLUCOSE PREVENT HYPOTHERMIA Check and treat if indicated Move to warm environment. Avoid unnecessary exposure. Related guidelines: Altered level of consciousness (G2), Tachycardia (P7) Key Treatment Considerations Successful pediatric resuscitation relies on early identification of the pre-arrest state Normal blood pressure, delayed capillary refill, diminished peripheral pulses and tachycardia indicates compensated shock in children Hypotension and delayed capillary refill > 4 seconds indicates impending circulatory failure Systolic blood pressure in children may not drop until the patient is 25-30% volume depleted. This may occur through dehydration, blood loss or an increase in vascular capacity (e.g. anaphylaxis). Decompensated shock (Hypotension with > 5 seconds capillary refill) may present as PEA in children Sinus tachycardia is the most common cardiac rhythm encountered Supraventricular tachycardia should be suspected if heart rate greater than 180 in children (ages 1-8) or greater than 220 in infants Hypoglycemia may be found in pediatric shock, especially in infants Pediatric shock victims are at risk for hypothermia due to their increased body surface area, exposure and rapid administration of IV/IO fluids Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose.

52 IFT1 Interfacility Transfer of STEMI Patients IFT2 Interfacility Transfer of Intubated Patients INTERFACILITY TRANSFER GUIDELINES

53 IFT 1 TRANSFER INTERFACILITY TRANSFER OF STEMI PATIENTS Patients with ST-elevation Myocardial Infarction (STEMI) needing interventional cardiac care require timely transfer. A scene time of 10 minutes or less at the sending facility is ideal. OXYGEN Monitor IV Prompt Transport Consider MORPHINE SULFATE Low flow Maintain TKO or other existing flow rate Transfer for definitive care is the priority in STEMI patients mg in 2-4 mg increments for pain relief if BP greater than 90. Patients with STEMI often do not get complete relief with morphine treatment. Do not administer Morphine Sulfate if Right Ventricular MI is suspected. Key Treatment Considerations Treatment during interfacility transfer varies from field approach to chest pain/acs: Confirmatory ECG for STEMI has been done by hospital and does not need repeat prior to transfer or en route to accepting facility. Nitroglycerin treatment is not required and generally ineffective in patients with confirmed STEMI. Aspirin or other anti-platelet treatment if indicated should be administered by sending hospital prior to patient departure. Patients generally will be directed directly to catheterization laboratory. Outcome in STEMI patients directly related to timeliness of intervention to relieve coronary artery blockage. Minimizing time delay in transfer is essential. IFT 2 TRANSFER INTERFACILITY TRANSFER OF INTUBATED PATIENTS Patients requiring specialty care (most commonly trauma or neurosurgical care) may be transferred with an established endotracheal tube. Sedation may be required if patient agitation present because of risk of inadvertent extubation. NOTE: This treatment guideline pertains to sedation of intubated patients during interfacility transport only (not for patients with field response who are intubated). OXYGEN 100% VENTILATION CARDIAC MONITOR END-TIDAL CO 2 MONITORING PULSE OXIMETRY Consider MIDAZOLAM MONITOR PATIENT As needed if patient with apnea or inadequate respiratory rate or effort Continuous monitoring with waveform capnography is required and must be established prior to departure from sending facility. Maintain end-tidal CO 2 between 35 and 45. ETCO 2 may not be reliable in patients with shock or significant lung injury. Maintain at least a minimum respiratory rate of 8-10 breaths per minute. For sedation in agitated or uncooperative patient: 2-5 mg IV in up to 2 mg increments. Repeat dosing with base contact only. Follow vital signs and ETCO 2 closely. If Midazolam administered, anticipate potential respiratory depression. Key Treatment Considerations Some patients may need paralysis and require additional nursing or physician staff to administer these medications. If inadvertent extubation occurs, manage with basic airway maneuvers unless ventilation cannot be adequately maintained.

54 12-Lead ECG and STEMI BLS Airway Management Key Paramedic Procedures Pediatric Assessment Pediatric Vital Signs and GCS Scoring SBAR Reporting Spinal Immobilization Vascular Access PROCEDURES AND PATIENT CARE REFERENCE

55 V4R Sternal 12-LEAD ACQUISITION AND LEAD PLACEMENT Limb Lead Placement: Place limb leads on distal extremities if possible Confirm correct lead placement for each limb May be moved to proximal if needed (if motion artifact) Chest Lead Placement: To begin placement of chest leads, locate sternal angle (2 nd ribs are adjacent) then count down to 4 th interspace (below 4 th rib) V1 4th intercostal space at the right sternal border V2 4th intercostal space at the left sternal border V4 5th intercostal space at left midclavicular line Note: Place V4 lead first to aid in correct placement of V3 V3 Directly between V2 and V4 V5 Level of V4 at left anterior axillary line V6 Level of V4 at left mid-axillary line V4R (to detect Right Ventricular Infarct) mirrors V4 on right side of chest move V4 lead across Do V4R if Inferior MI noted (elevation in II, III, avf) Label ECG for V4R Note: Careful skin preparation prior to lead placement (rub with gauze or abrasive, clean skin oils with alcohol) is critical to obtaining a high-quality ECG LOCALIZING SITE OF INFARCT Localization of an infarct pattern adds to the accuracy of ECG interpretation A STEMI will have 1 mm or more ST-segment elevation in two or more contiguous leads (which means findings noted in the same anatomical location of the infarct) o Contiguous leads for inferior infarction include II, III, and avf o Contiguous leads for anterior infarction include V1-V4 (V1-V2 elevation also called septal infarction) o Contiguous leads for lateral myocardial infarction include Leads I, avl, V5, and V6 o Lateral MI findings may be in addition to anterior or inferior MI patterns (anterolateral or inferolateral) In patients with an inferior infarct pattern (Leads II, III, avf), a separate ECG with V4R should be obtained A 1 mm ST-segment elevation in V4R when inferior infarction noted indicates right ventricular infarct I LATERAL avr V1 SEPTAL or ANTERIOR V4 ANTERIOR (V4R RVMI) II - INFERIOR avl LATERAL V2 SEPTAL or ANTERIOR V5 LATERAL III INFERIOR avf - INFERIOR V3 ANTERIOR V6 LATERAL

56 STEMI RECOGNITION AND DESTINATION STEMI Recognition STEMI Report Destination Policy Patients who have ECGs of acceptable quality with the following messages are candidates for transport to STEMI Receiving Centers: o ***Acute MI*** (Zoll) o ***Acute MI Suspected*** (LIFEPAK 12) o ***Meets ST-Elevation MI Criteria*** (LIFEPAK15) The 12-lead ECG should be inspected prior to initiation of a STEMI Alert a steady baseline in all 12-leads and a tracing free of artifact is critical for accurate interpretation Causes of artifact include patient motion or tremor, poor lead contact, or electrical interference Good skin preparation is essential for optimal lead contact and clear 12-lead tracings If artifact is noted the ECG should be repeated Paced rhythms may cause false readings the pacemaker spike is not always detected by the computer algorithm. Inform facility if patient has a pacemaker during report. If a STEMI is noted on 12-lead ECG, the receiving STEMI facility should be notified as soon as possible following completion of the ECG Patients with an identified STEMI shall be transported to a STEMI Receiving Center (SRC) Patients shall be transported to the closest SRC unless they request another facility A SRC that is not the closest facility is an acceptable destination if estimated additional transport time does not exceed 15 minutes Patients with cardiac arrest who have a STEMI identified by 12-lead ECG before or after arrest shall be transported to the closest SRC Patients with unmanageable airway en route shall be transported to the closest available emergency department STEMI REPORT A patient with a computer interpretation of ***Acute MI*** (Zoll) or ***Acute MI Suspected*** (LP-12) or ***Meets ST Elevation MI Criteria*** (LP-15) is a candidate for transport to a STEMI Receiving Center Verify that 12-lead tracing has good tracings and baseline in all 12-leads and does not have significant baseline artifact or other deficit before initiating a STEMI Alert SITUATION Identify the call as a STEMI Alert Estimated time of arrival (ETA) in minutes Patient age and gender Report ECG computer interpretation has a STEMI message (as listed above) Report if subsequent ECG findings are variable or if ECG quality not optimal (e.g., if no ***Acute MI*** findings noted in tracings without significant artifact) BACKGROUND ASSESSMENT Presenting chief complaint and symptoms Pertinent past cardiac history History of pacemaker (important paced rhythms may give false ECG interpretations) General assessment Pertinent vitals (especially heart rate and BP) and physical exam Cardiac rhythm Pain level RX RECAP Prehospital treatments given Patient response to prehospital treatments

57 BLS AIRWAY MANAGEMENT GOALS The goal of airway management is to ensure adequate ventilation and oxygenation. Initial airway management should always begin with BLS Maneuvers VENTILATION RATES AND DELIVERY Avoid excessive ventilation. In non-arrest patients, ventilation rates: Adults 10 / minute Children 20 / minute Infants 30 / minute Deliver ventilations over one second to produce visible chest rise and to avoid distention of the stomach (do not squeeze hard or fast). Ventilation volumes will vary based on patient size. For all patients who can be adequately ventilated (visible chest rise), bag-valve mask ventilation using twoperson technique is the preferred method. PREFERRED MANEUVERS Maneuvers Use JAWS mnemonic J Jaw thrust maneuvers to open airway A Airway - Use oral or nasal airway W Work together Ventilation using a bag-valve mask should include two rescuers one to hold mask and other to deliver ventilations S Slow and small ventilations Position the patient to optimize airway opening and facilitate ventilations (see below) Use the sniffing position with head extended (A) and neck flexed forward (B) unless suspected spinal injury. Position with head/shoulders elevated anterior ear should be at the same horizontal level as the sternal notch (C). This is especially advantageous in larger or morbidly obese patients. AIRWAY POSITIONING C

58 KEY PARAMEDIC PROCEDURES Skill Indication / Comment Contraindication 12-Lead ECG Blood Glucose Testing Continuous Positive Airway Pressure (CPAP) Chest pain or suspected Acute Coronary Syndrome (ACS) Atypical ACS or anginal equivalents: o Symptoms include shortness of breath, diaphoresis, syncope, dizziness, weakness, and altered level of consciousness o Elderly patients, females and diabetics are more likely to present atypically Arrhythmias (both pre- and post-conversion) Suspected cardiogenic shock Cardiac arrest after return of spontaneous circulation Altered level of consciousness Patients with signs and symptoms of hypoglycemia (may include diaphoresis, weakness, hunger, shakiness, anxiety) Patient has 2 or more findings: RR >25 Pulse ox <94% Use of accessory muscles and patient is awake, able to maintain airway & follow commands Uncooperative patient Any condition in which delay to obtain ECG would compromise immediately needed care (e.g. arrhythmia requiring immediate shock) Patients not meeting any indication Unconscious or unable to follow commands Respiratory arrest / apnea Pneumothorax Vomiting Major head, facial or chest trauma KEY PARAMEDIC PROCEDURES Skill Indication / Comment Contraindication Endotracheal Intubation Endotracheal Tube Introducer (Bougie) External Cardiac Pacing Patient with decreased sensorium (GCS less than or equal to 8) and apneic (adults) Patient with decreased sensorium (GCS less than or equal to 8) and ventilation unable to be maintained with BLS airway Note: In non-arrest patients, allow no more than 2 interruptions of ventilation lasting up to 30 seconds during laryngoscopy or intubation attempts Helpful in situations with limited neck mobility, short neck, or immobilized patients Note: Do not force introducer as it can perforate pharynx or trachea Symptomatic bradycardia Note: Use careful titration with midazolam or morphine if required for relief of discomfort. Pediatric patients under 40 kg Suspected hypoglycemia or narcotic overdose Maxillo-facial trauma with unrecognizable facial landmarks Seizures Patients with an active gag reflex Note: Patients with perfusing pulses should be managed with BLS airways unless unable to successfully ventilate (e.g. trauma, respiratory insufficiency) Cannot be used with endotracheal tubes smaller that 6.0 mm. Cardiac arrest Hypothermia Pediatric Patients

59 KEY PARAMEDIC PROCEDURES Skill Indication / Comment Contraindication Impedance Threshold Device (ITD) - ResQPOD (Optional Equipment) Patients 9 years of age in cardiac arrest o Remove if patient resumes spontaneous breathing or regains perfusing pulse Note: If secretions encountered, clear device by removing and shaking. Age below 9 years Perfusing pulse or spontaneously breathing History of traumatic cardiac arrest due to blunt chest trauma Flail chest Intranasal Naloxone Patient with altered mental status, respiratory rate less than 12 and suspected opiate overdose Note: May be less effective in patients with prior nasal mucosal damage Shock Copious nasal secretions or bleeding Patients with established vascular access King Airway Cardiac arrest Inability to ventilate non-arrest patient (with BLS airway maneuvers) in a setting in which endotracheal intubation is not successful or unable to be done Presence of gag reflex Caustic ingestion Known esophageal disease (e.g. cancer, varices, stricture) Laryngectomy with stoma (place ET tube in stoma) Height less than 4 feet KEY PARAMEDIC PROCEDURES Skill Indication / Comment Contraindication LUCAS Chest Compression System Adult patients 18 or older with medical cardiac arrest who properly fit device. Patient < 18 years old Traumatic arrest Pregnant Patients Improper fit of device o Too small suction cup pad does not touch chest when lowered as far as possible o Too large support legs of LUCAS cannot be locked to back plate without compressing patient Needle Thoracostomy Signs and symptoms of tension pneumothorax: Altered level of consciousness Decreased BP Increased pulse and respirations Absent breath sounds, hyperresonance to percussion on affected side Jugular venous distention Difficulty ventilating Tracheal shift Any condition without signs and symptoms of tension pneumothorax

60 Pulse Oximetry KEY PARAMEDIC PROCEDURES Skill Indication / Comment Contraindication Suspected hypoxemia Note: Accuracy may be affected by poor perfusion, hypothermia or cold extremities, excessive movement (e.g. seizures), nail polish, carbon monoxide poisoning, or anemia. None Stomal Intubation Tracheostomy Tube Replacement Waveform Capnography (ETCO 2 ) Patients requiring intubation who have mature stoma and do not have a replacement tracheostomy tube available Note: Pass tube until cuff is just past stoma. If inserted further, mainstem bronchus intubation may occur as carina is only around 10 cm from stoma. Dislodged tracheostomy tube (decannulation) Tracheostomy tube obstruction not resolved by suction All intubated patients (King or ET Tube) Can be used via nasal cannula in non-intubated patients with respiratory depression or distress Patients without mature stoma Recent tracheostomy surgery (less than 1 month) Inadequately sized tract or stoma for insertion of new tube (use endotracheal tube instead) None

61 Appearance Work of Breathing PEDIATRIC ASSESSMENT PEDIATRIC ASSESSMENT TRIANGLE - GENERAL VISUAL ASSESSMENT Assessment Assess TICLS: Tone, Interactiveness, Consolability, Look/Gaze, Speech/Cry Assess effort Any Abnormal Abnormal Increased or decreased effort or abnormal sounds Circulation Assess for skin color Abnormal skin color or external bleeding PREHOSPITAL PRIMARY ASSESSMENT Assessment Signs of Life-Threatening Condition Airway Assess patency Complete or severe airway obstruction Breathing Assess respiratory rate and effort, Apnea, slow respiratory rate, very fast respiratory rate or significant work air movement, airway and breath of breathing sounds, pulse oximetry Circulation Disability Assess heart rate, pulses, capillary refill, skin color and temperature, blood pressure Assess AVPU response, pupil size and reaction to light, blood glucose Tachycardia, bradycardia, absence of detectable pulses, poor blood flow (increased capillary refill, pallor, mottling, or cyanosis), hypotension Decreased response or abnormal motor response (posturing) to pain, unresponsiveness Hypothermia, rash (petichiae/purpura) consistent with septic shock, Exposure Assess skin for rash or trauma significant bleeding, abdominal distention BEGIN INTERVENTIONS IMMEDIATELY AND TRANSPORT PROMPTLY IF LIFE-THREATENING CONDITIONS ARE IDENTIFIED IN GENERAL VISUAL ASSESSMENT OR PRIMARY ASSESSMENT VITAL SIGNS / GLASGOW COMA SCALE IN CHILDREN Age Normal RR Normal HR Hypotension by systolic blood pressure Term Neonate Infant (<1 yr) Neonate: Less than 60 mmhg or weak pulses Toddler (1-3 yr) Infant: Less than 70 mmhg or weak pulses Preschooler (4-5 yr) yrs: Less than 70 mmhg + (age in yrs x 2) School Age (6-12yr) Over 10: Less than 90 mmhg Adolescent (13-18 yr) Pediatric GCS Infant Score Child Score Spontaneous movements 6 Obeys commands 6 Withdraws to touch 5 Localizes 5 Motor Response Withdraws to pain 4 Withdraws 4 Flexion 3 Flexion 3 Verbal Response Extension 2 Extension 2 No response 1 No response 1 Coos and babbles 5 Oriented 5 Irritable cry 4 Confused 4 Cries to pain 3 Inappropriate 3 Moans to pain 2 Incomprehensible 2 No response 1 No response 1 Eye Response Opens spontaneously 4 Opens spontaneously 4

62 SBAR REPORTING SBAR is a tool that is recommended to assure timely, effective communication during all patient-related communications between all health care providers. SBAR assures that urgent issues and immediate needs get addressed up front. SBAR is compatible with the trauma MIVT reporting. Routine use during base contact and patient handoff supports safe and effective patient care. Key Information SBAR Report Example Situation Background Assessment Identify yourself What is the situation? State urgent issues and immediate needs up front! What has happened up to this point? What past history would be important to know for further patient treatment? (e.g. high risk medications, past medical history) How is the patient now? Improved or worse since on scene? Patient stable or unstable? This is Unit 123 with a STEMI alert. Patient is a 45 yo male with 12 lead positive for ST elevation Patient started having chest pain off and on the last 2 hours. Family called 911. Patient has no history of heart problems and takes Lipitor and metformin. RR 28 labored B/P 160/98 Diaphoretic, Pain 9 out 10, 12 lead ***Acute MI*** no significant artifact seen. No significant change with treatment. Airway stable. Rx Recap What field care given? Was it effective? Concerns? ASA, Nitro x2 and 100% rebreather. STEMI alert TRAUMA BASE CALL EXAMPLE (Destination Decision Report) S B A R This is paramedic unit 123 with a trauma call, requesting destination decision. We have a 66 year old male with a fall and altered level of consciousness, and we think the patient needs trauma center activation. Our ETA is 20 minutes. The patient was working on his roof and fell approximately 10 feet, landing on his head on a cement path. He sustained an injury to the right parietal area and there is significant swelling in that area. He has a GCS of 14. He is apparently generally healthy although he does take aspirin daily. BP 180/110, pulse 52, RR 10. SpO2 95%. His airway is stable. The patient is awake and cooperative, but is confused has repetitive questioning. He is vomiting and complains of a severe headache. He also has right chest wall tenderness but no flail chest, and has deformity of his right forearm with intact CMSTP. We have him on 100% oxygen, in spinal precautions. We are going to be splinting his right forearm and will start an IV en route. We believe he needs trauma activation. TRAUMA HAND-OFF EXAMPLE (Report at Trauma Center) S MECHANISM B INJURIES This is unit 123 with a 66 year old male who fell from a roof onto a cement path. Swelling and deformity in the right parietal area. He is confused, with repetitive questioning, vomiting, and complaining of a severe headache. He also has pain in the right chest and deformity of the right forearm which we splinted. A VITAL SIGNS BP 180/110, pulse 52, RR 10. SpO2 95%. GCS is 14. R TREATMENT 100% oxygen non-rebreather, IV placed and infusing NS.

63 Penetrating Injury (Trauma to head, neck or torso) Blunt Injury (Regardless of mechanism) Blunt Injury (When mechanism of injury is concerning) INDICATIONS FOR SPINAL IMMOBILIZATION Presence of neurologic complaint or deficit paralysis, weakness, numbness, tingling, priapism or neurogenic shock, loss of consciousness Anatomic deformity of spine Altered level of consciousness (GCS < 15) Presence of spinal pain or tenderness Anatomic deformity of spine Presence of neurologic complaint or deficit paralysis, weakness, numbness, tingling, priapism or neurogenic shock Presence of alcohol or drugs or acute stress reaction / anxiety Distracting injury (e.g. long bone fracture, large laceration, crush or degloving injury, large burns) Inability to communicate (e.g. speech or hearing impaired, language gap, small children, developmental or psychiatric conditions) Concerning mechanisms of injury include but are not limited to: Violent impact to head, neck, torso, or pelvis (e.g. assault, entrapment in structural collapse) Sudden acceleration, deceleration or lateral bending forces to neck or torso (e.g., moderate- to high-speed MVC, pedestrian struck, explosion) Falls (especially in elderly patients) Ejection from motorized or other transportation device (e.g. scooter, skateboard, bicycle, motor vehicle, motorcycle, recreational vehicle, or horse) Victims of shallow-water diving incident *** USE CLINICAL JUDGMENT IF IN DOUBT, IMMOBILIZE *** VASCULAR ACCESS Skill Indication / Comment Contraindication Saline Lock Upper Extremity IV Antecubital IV Intraosseous Access (IO) When medication alone is being given or a potential for medication is anticipated When fluids or medications needed and patient not in shock or arrest Shock Adenosine (rapid IV bolus) Cardiac arrest if IO cannot be obtained Other peripheral sites not available and medications or fluids indicated Cardiac arrest In cases of profound shock or unstable dysrhythmia when rapid IV access or suitable vein cannot be rapidly located o Use lidocaine for pain control in nonarrest patients PRIOR to giving fluid or medication (Infusion is painful!) No anticipated need for prehospital medication or fluid. No anticipated need for prehospital medication or fluid. No anticipated need for prehospital medication or fluid. If no medication or fluid is being administered (do not use for prophylactic vascular access) If patient stable When other routes for medications available (IM, IN) External Jugular IV Unstable patient needs emergent IV medication or fluids AND no peripheral site is available AND IO not appropriate (e.g. very alert patient). Contraindicated in cardiac arrest unless IO and antecubital IV cannot be started (interrupts CPR) When other routes for medications available (IM, IN) e.g. naloxone or use of glucagon instead of dextrose

64 Base Hospital and Receiving Facilities Burn Centers Burn Patient Destination Burn Surface Area - Rule of Nines Declining Medical Care or Transport (AMA) Destination Determination Destination and Obstetric Considerations Determination of Death Hazardous Materials Exposure Management Principles Helicopter Transport Criteria MCI Tiers Reporting Requirements - Abuse Restraints Trauma Base Call-In Criteria Trauma Triage Criteria POLICY SUMMARIES and HOSPITAL REFERENCES

65 Contra Costa County Base Hospital Hospital Base Phone ED Phone XCC EMS 2 Alert Code Receiving Facility John Muir Medical Center Taped: Notification: Walnut Creek Campus (925) (925) Ygnacio Valley Road Walnut Creek CA ED: Contra Costa County Hospitals (Receiving Facilities) Hospital Services ED Phone XCC EMS 2 Alert Code Contra Costa Regional Medical Center 2500 Alhambra Avenue Martinez CA Basic ED OB/Neonatal (925) Doctor s Medical Center San Pablo 2000 Vale Road San Pablo CA John Muir Medical Center Concord Campus 2540 East Street Concord CA John Muir Medical Center Walnut Creek Campus 1601 Ygnacio Valley Road Walnut Creek CA Basic ED STEMI Center Basic ED STEMI Center Basic ED OB/Neonatal Trauma Center STEMI Center (510) (925) Receiving Facility Notification: (925) ED: (925) Kaiser Medical Center Antioch 5001 Deer Valley Road Antioch CA Basic ED OB/Neonatal (925) (switchboard) Kaiser Medical Center Richmond 901 Nevin Avenue Richmond CA Basic ED (510) Kaiser Medical Center Walnut Creek 1425 South Main Street Walnut Creek CA San Ramon Regional Medical Center 6001 Norris Canyon Road San Ramon CA Sutter/Delta Medical Center 3901 Lone Tree Way Antioch CA Basic ED OB/Neonatal STEMI Center Basic ED OB/Neonatal STEMI Center Basic ED OB/Neonatal STEMI Center (925) (925) (925)

66 BURN CENTERS Hospital Services Phone Santa Clara Valley Medical Center 751 S. Bascom Avenue San Jose CA Adult and Pediatric Burn Center UC Davis Medical Center Regional Burn Center 2315 Stockton Blvd. Sacramento CA Adult and Pediatric Burn Center St. Francis Burn Center 900 Hyde Street San Francisco CA Adult and Pediatric Burn Center (No Helipad available) BURN PATIENT DESTINATION General Destination Principles Burned patients with unmanageable airways should be transported to the closest basic ED Patients with minor burns and moderate burns can be cared for at any acute care hospital Adult and pediatric patients with burns and significant trauma should be transported to the closest appropriate trauma center Patient Selection for Initial Transport to Burn Center The following patients may be appropriate for initial transport to a Burn Center: Partial thickness (2nd degree) greater than 20% TBSA Full thickness (3rd degree) greater than 10% Chemical or high voltage electrical burns Smoke inhalation with external burns Procedure for Burn Center Destination Contact Burn Center prior to transport to confirm bed availability Consult base hospital if any questions regarding destination decision

67 RULE OF NINES BURN SURFACE AREA DECLINING MEDICAL CARE OR TRANSPORT (AMA) All qualified persons are permitted to make decisions affecting care, including the ability to decline care Patient Competency Qualified Person Base Contact Requirements Any person encountered by EMS personnel who demonstrates any known or suspected illness or injury OR is involved in an event with significant mechanism that could cause illness or injury OR who requests care or evaluation The ability to understand and to demonstrate an understanding of the nature of the illness/injury and the consequence of declining medical care A competent person making decision for him/herself or another qualified by: An adult patient defined as a person who is at least 18 years old; A minor (under 18 years old) who qualifies based on one of the following conditions: o A legally married minor; o A minor on active duty with the armed forces; o A minor seeking prevention / treatment of pregnancy or treatment related to sexual assault; o A minor, 12 years of age or older, seeking treatment of contact with an infectious, contagious or communicable disease or sexually transmitted disease; o A self-sufficient minor at least 15 years of age, living apart from parents and managing his/her own financial affairs; o An emancipated minor (must show proof); OR The parent of a minor child or a legal representative of the patient (of any age). Spouses or relatives cannot consent to or decline care for the patient unless they are legally designated representatives. When, in the field personnel s opinion, patient s decision to decline care poses a threat to his/her well being If the patient s competency status is unclear (neither competent nor clearly incompetent) and treatment or transport is felt to be appropriate Any other situation in which, in the field personnel s opinion, that base contact would be beneficial in resolving treatment or transport issues

68 DESTINATION DETERMINATION BASIC PROCEDURE Field personnel shall assess a patient to determine if the patient is unstable or stable Patient stability must be considered along with a number of additional factors in making destination and transport code decisions FACTORS TO CONSIDER Patient or family s choice of receiving hospital and ETA to that facility Recommendations from a physician familiar with the patient s current condition Patient s regular source of hospitalization or health care Ability of field personnel to provide field stabilization or emergency intervention ETA to the closest basic emergency department Traffic conditions Hospitals with special resources Hospital diversion status UNSTABLE PATIENTS STABLE PATIENTS Usually transported to the closest appropriate acute care hospital emergency department or specialized care centers if indicated If the patient or family requests, or if other factors exist which indicate that another facility be considered, field personnel are to contact the base hospital and present their findings, including ETAs to both facilities. Base personnel will assess the benefits of each destination and may direct field personnel to a facility other than the closest. Stable patients are transported to appropriate acute care hospitals within reasonable transport times based on patient s/family preference If a patient does not express a preference, the hospital where the patient normally receives health care or the closest ED is to be considered Patients on 5150 Holds Obstetric Patients DESTINATION 5150 and OBSTETRIC PATIENTS A patient placed on a 5150 hold in the field shall be assessed for the presence of a medical emergency. Based upon the history and physical examination of the patient, field personnel shall determine whether the patient is stable or unstable. Stable patients on 5150 holds shall be transported to Contra Costa Regional Medical Center Unstable patients on 5150 holds shall be transported to the closest acute care hospital: A patient with a current history of overdose of medications is to be considered unstable A patient with history of ingestion of alcohol / illicit street drugs is considered unstable if: o Significant alteration in mental status (e.g., decreased LOC or extremely agitated); or o Significantly abnormal vital signs; or o Any other history or physical findings that suggest instability (e.g. chest pain, shortness of breath, hypotension, diaphoresis A patient is considered Obstetric if pregnancy is estimated to be of 20 weeks duration or more. Obstetric patients should be transported to hospitals with in-patient OB services in the following circumstances: Patients in labor Patients whose chief complaint appears to be related to the pregnancy, or who potentially have complications related to the pregnancy Injured patients who do not meet trauma criteria or guidelines Obstetric patients with impending delivery or unstable conditions where imminent treatment appears necessary to preserve the mother s life should be transported to the nearest basic emergency department Stable obstetric patients should be transported to the emergency department of choice if their complaints are clearly unrelated to pregnancy

69 Obvious Death Medical Arrest Traumatic Arrest DETERMINATION OF DEATH Pulseless, non-breathing patients with any of the following: Decapitation, Total incineration, Decomposition Total destruction of the heart, lungs, or brain, or separation of these organs from the body Rigor mortis or post-mortem lividity without evidence of hypothermia, drug ingestion, or poisoning. In patients with rigor mortis or post-mortem lividity: o Attempt to open airway, assess for breathing for at least 30 seconds; assess pulse for 15 seconds o Rigor, if present, should be noted in jaw and/or upper extremities o If any doubt exists, place cardiac monitor to document asystole in two leads for one minute Mass casualty situations Definition: Cardiac arrest with total absence of observers or witness information; or cardiac arrest in which witness information states arrest occurred greater than 15 minutes prior to arrival of prehospital personnel and no resuscitative measures have been done Procedure: BLS personnel Follow Public Safety defibrillation guideline ALS personnel - Do not initiate CPR; Assess for presence of apnea, pulselessness (no heart tones/no carotid or femoral pulses), document asystole in two leads for one minute Definition: Blunt or penetrating traumatic arrest Procedure: BLS personnel Follow Public Safety defibrillation guideline ALS personnel - Do not initiate CPR; Assess for presence of apnea, pulselessness (no heart tones/no carotid or femoral pulses), document asystole or wide-complex pulseless electrical activity (PEA) at rate of 40 or less

70 HAZMAT RECOGNITION WHILE RESPONDING HAZMAT RECOGNITION WHILE ON SCENE HAZARDOUS MATERIALS EXPOSURE MANAGEMENT PRINCIPLES If alerted to a known or suspected hazmat exposure prior to scene arrival: Request from dispatch the location and safe route to staging area or IC If no staging area, determine location and safe route to report to IC Do not enter contaminated areas or approach contaminated patients until cleared to do so by Incident Commander or designee. Decontaminate patient - Appropriately trained personnel shall perform decontamination in a designated area. Obtain clearance from IC prior to transport Obtain MSDS for chemical if available After patient decontamination, provide care as indicated per treatment guidelines. Provide early alert to hospital repeat decontamination may be needed. If EMS personnel become aware that a patient in their care may have been contaminated by a unknown or suspected hazardous material: EMS personnel should consider themselves contaminated Minimize exposure by evacuating to an uphill/upwind safe location. If in cloud, travel crosswind until out of cloud. Notify fire/medical dispatch and IC of exposure Request Hazardous Materials response team through Sheriff s Dispatch Request backup Fire / Transport as needed for affected EMS personnel and patients HAZMAT RECOGNITION WHILE ON SCENE (continued) HAZMAT RECOGNITION WHILE TRANSPORTING GENERAL GUIDELINES FOR ALL SITUATIONS Remain in safe area until Incident Commander arrives and provides further instructions. Prepare to be decontaminated Decontaminate EMS personnel and patient(s) - Appropriately trained personnel shall perform decontamination in a designated area. If EMS personnel become aware while transporting that a patient may have been contaminated by a known or suspected hazardous material: EMS personnel should consider themselves contaminated Determine if safe to drive (e.g. rescuers with or without symptoms) If not safe to drive, immediate decontamination is needed. Stop transport, notify Fire/Medical Dispatch and request CCHS HazMat response. Request Fire/Transport backup as needed. Protect from further exposure and prepare to be decontaminated. If safe to drive (decontamination is not immediately indicated), proceed to hospital decontamination staging area. Alert hospital early of the HazMat situation. Request staging site if not known. Prepare to be decontaminated. Provide prehospital medical care as soon as it is safe All precautions should be taken to prevent contamination of hospital emergency department and personnel.

71 HELICOPTER TRANSPORT CRITERIA USE HELICOPTER ONLY WHEN BOTH TIME AND CLINICAL CRITERIA MET Time Criteria Helicopter transport generally should be used only when it provides a time advantage. Helicopter field care and transport time (which includes on-scene time, flight time, and transport from helipad to the emergency department) is optimally minutes in most cases Also consider: Time to ground transport to a rendezvous site, or a time delay in helicopter arrival Exception: Patients with potential need for advanced airway intervention (GCS 8 or less, trauma to neck or airway, rapidly decreasing mental status) may be appropriate even when time criteria not met Clinical Criteria Use and Cancellation Trauma patients who meet high-risk criteria according to EMS trauma triage policy, except for: o Stable patients with isolated extremity trauma o Patients with mechanism but no significant physical exam findings Trauma patients who do not meet high-risk criteria but by evaluation of mechanism and physical exam findings, appear to have potential significant injuries that merit rapid transport Patients with specialized needs available only at a remote facility such as burn victims/critical pediatric Critically ill or injured patients whose conditions may be aggravated or endangered by ground transport (e.g. limited access via ground ambulance or unsafe roadway) The decision to use or cancel a helicopter rests with the Incident Commander (IC). If criteria not met, helicopter should be cancelled. Considerations for IC: Patient need Estimated ground transport time versus air response and transport Proximity of a helispot or need for a helicopter/ambulance rendezvous site ETA of the helicopter TIER ZERO TIER ONE TIER TWO TIER THREE MULTICASUALTY INCIDENTS TIER DEFINITIONS and EXAMPLES Official notification of an incident that has the potential to result in activation of the MCI plan at a higher tier, even when the number of known victims is zero. Activation at this tier is required for a Community Warning System Level II incident or any receiving hospital Emergency Department closure or evacuation (not diversion or trauma bypass). Other examples of this might include active shooter where number of victims unknown or cannot be confirmed, emergency landing at airport, actual or potential significant hazmat incident, including transportation incidents. An incident involving 6-10 patients when the scene is contained and the number of patients is not expected to rise significantly. Examples include a multi-vehicle traffic collision, multiple known shooting victims and no ongoing active shooter threat. An incident involving more than 10 patients OR an incident involving less than 10 patients when there is a substantial chance that the number of patients may rise. EMS Transportation Resource Ordering will be processed by EMS Operational Area Communications Center (Sheriff s Dispatch). Examples include a petrochemical incident with a dispersal cloud moving over a populated area, passenger train derailment, or an active shooter with an uncontained scene. Any incident involving more than 50 patients, mass casualties, or a reasonable expectation of mass casualties. EMS Transportation Resource Ordering will be processed by EMS Operational Area Communications Center (Sheriff s Dispatch). Examples include a significant explosion around occupied commercial or multi-resident structure, or in a heavily populated area, or a large-scale evacuation of a hospital or skilled nursing facility.

72 ABUSE REPORTING RESPONSIBILITIES EMS personnel are mandated reporters. Report when there is reason to suspect abuse, which may be of a physical, sexual, or financial nature, or may involve neglect or domestic violence toward a child, elder, or dependent adult. BASIC ACTIONS Notify the appropriate law enforcement agency immediately if the scene is unsafe or it is suspected that a crime has been committed. Make reasonable efforts to transport the patient to a receiving hospital for evaluation, and advise the receiving hospital staff of abuse/neglect suspicions. Document observations and findings on the patient care report. Contact the appropriate reporting agency by telephoning immediately or as soon as reasonably possible to provide a verbal report. CHILD ABUSE REPORTING Call Children & Family Services Screening Unit: (all numbers are 24 hours/day) at Complete a Suspected Child Abuse Report Form within 2 working days (SS 8572) (available online at ) ELDER ABUSE REPORTING (LONG-TERM CARE FACILITY) If the alleged abuse has occurred in a long-term care facility: Call Ombudsman Services of Contra Costa (925) to make a verbal report 24-Hour Crisis Line: Complete a Suspected Dependent Adult/Elder Abuse Form within 2 working days (SOC 341). Available at: ABUSE REPORTING RESPONSIBILITIES (Continued) ELDER ABUSE REPORTING (ALL OTHER SITES) If the alleged abuse has occurred anywhere else (not at a long-term care facility): Call Adult Protective Services (925) or to make a verbal report Complete a Suspected Dependent Adult/Elder Abuse Form within 2 working days (SOC 341). Available at: SEXUAL ASSAULT Sexual assault shall be reported as above in situations involving elder, dependent adult, child, or domestic violence. It is recommended to transport patients who have been sexually assaulted to Contra Costa Regional Medical Center for evaluation and evidentiary exam; however, the patient may be transported to the receiving hospital of choice or if medically unstable to the most appropriate facility for medical care. Discourage any activity that would compromise evidence collection prior to transport such as bathing, brushing teeth, brushing hair, urinating, defecating or changing clothes. DOMESTIC VIOLENCE Reporting responsibilities are fulfilled by notifying the local law enforcement agency, and by reporting suspicions and patient findings to receiving hospital staff (if transported)

73 Restraint Types Restraint Issues Law Enforcement Role Transport Issues RESTRAINTS Leather or soft restraints may be used during transport Handcuffs may only be used during transport if law enforcement accompanies the patient in the ambulance. Patients may not be handcuffed to the gurney. Chemical restraint requires a base hospital order Patients shall be placed in Fowler s or Semi-Fowler s position Patients shall not be restrained in hogtied or prone position Method of restraint should allow for monitoring of vital signs and respiratory effort and should not restrict the patient or rescuer s ability to protect the airway should vomiting occur Restrained extremities should be monitored for circulation, motor and sensory function every 15 minutes Law enforcement agencies are responsible for capture and/or restraint of assaultive or potentially assaultive patients Law enforcement agencies retain responsibility for safe transport of patients under arrest or on 5150 holds Patients under arrest or 5150 hold should undergo a weapons search by law enforcement personnel Patients under arrest must be accompanied by law enforcement personnel If an unrestrained patient becomes assaultive during transport, ambulance personnel shall request law enforcement assistance, and make reasonable efforts to calm and reassure the patient If the crew believes their personal safety is at risk, they should not inhibit a patient's attempt to leave the ambulance. Every effort should be made to release the patient into a safe environment. Ambulance personnel are to remain on scene until law enforcement arrives to take control of the situation.

74 TRAUMA BASE CALL-IN CRITERIA (IF NOT HIGH-RISK CRITERIA) Base Hospital Destination Decision Required Prior to Transport Evidence of high-energy dissipation or rapid deceleration which may include: o vehicle rollover with unrestrained occupant o intrusion of passenger space by 1 foot or greater o impact of 40 mph or greater (restrained) o persons requiring disentanglement from a vehicle Adult hit by vehicle traveling faster than 15 mph Child (under 15) or elderly patient (65 years and over) struck by a vehicle Persons ejected from a moving object (motorcycle, horse, etc.) Significant blunt force to the head, neck, thorax (chest/back), abdomen or pelvis Penetrating injury to extremities (above knee or elbow) without apparent fracture Precaution with Elderly Patients Additional Considerations: Patients 65 years of age and older may sustain significant injuries with less forceful mechanisms, and may merit call-in for less significant mechanisms (e.g. ground level fall with new alteration of mental status) Base contact should be made if a patient meets call-in criteria and it is believed trauma center services may be needed, even in the event that the trauma has occurred several hours prior to EMS response If no significant symptoms or physical findings noted despite above mechanism(s), call-in not required and patient may be transported to hospital of choice or to closest facility TRAUMA TRIAGE CRITERIA Unmanageable airway or arrest not meeting field Closest receiving facility determination of death The following meet high-risk criteria and merit direct transport to the trauma center: Physiologic Criteria Anatomic Criteria Mechanism Criteria Combined Criteria (combined mechanism and physical findings) BP < 90 in adults GCS 13 or below if not pre-existing Penetrating injury to head, neck, torso, groin, pelvis or buttocks Fracture of femur Fracture of long bone(s) resulting from penetrating trauma Traumatic Paralysis Amputation above wrist or ankle Major burns associated with trauma Motor vehicle crash with: o Extrication > 20 minutes Note: In the absence of o Fatalities in the same vehicle significant symptoms o Ejection or physical findings Unrestrained motor vehicle crash with: with these mechanisms, o Head on mechanism > 40 mph call base hospital for o Extrication required destination Fall 15 feet or greater determination Motorcycle crash with: o Abdominal or chest tenderness o Observed loss of consciousness Unrestrained motor vehicle crash with abdominal tenderness

75 Adult Drug Reference Dopamine Drip Chart Pediatric Drug Reference Pediatric Drug Dosage Charts DRUG REFERENCES

76 ADULT DRUG REFERENCE Drug Indication Adult Dosage Precautions / Comments ADENOSINE Paroxysmal SVT 1 st Dose 6 mg rapid IV 2 nd & 3 rd Doses 12 mg rapid IV push Follow each dose with rapid bolus of 20 ml NS May cause transient heart block or asystole. Side effects include chest pressure/pain, palpitations, hypotension, dyspnea, or feeling of impending doom. Use caution when patient is taking carmbamazepine, dipyramidole, or methylxanthines. Do not administer if drugs or poisons are suspected cause of tachycardia. ALBUTEROL Bronchospasm Crush Injury Hyperkalemia 5 mg in 6 ml NS nebulized 5 mg in 6 ml NS nebulized continuously Repeat as needed for bronchospasm. Use with caution in patients taking MAO inhibitors (antidepressants Nardil and Parnate) AMIODARONE Ventricular Fibrillation or Pulseless VT Stable Ventricular Tachycardia 300 mg IV or IO bolus, repeat 150 mg bolus if rhythm persists 150 mg IV infusion or slow IV push over 10 minutes (15 mg/minute) In patient with pulses, may cause hypotension. Do not administer if patient hypotensive. When creating infusion, careful mixing needed to avoid foaming of medication (do not use filter needle). ASPIRIN ADULT DRUG REFERENCE Drug Indication Adult Dosage Precautions / Comments Chest Pain Suspected ACS 4 81 mg tabs chewed Contraindicated in aspirin or salicylate allergy. Coumadin or Plavix use is not a contraindication. ATROPINE Asystole PEA rate under 60 Symptomatic Bradycardia 1 mg IV or IO every 3-5 minutes up to max. 3 mg 0.5 mg IV or IO every 3-5 minutes up to max. 3 mg Atropine can dilate pupils, aggravate glaucoma, cause urinary retention, confusion, and dysrhythmias, including V-tach and Vfib. Doses less than 0.5 mg can cause paradoxical bradycardia. Increases myocardial oxygen consumption. CALCIUM CHLORIDE Organophosphat e poisoning Hyperkalemia Arrest Hyperkalemia Crush Injury Hydrofluoric Acid Toxicity 1-2 mg IV or IO repeat every 3-5 min. as needed to decrease symptoms 500 mg IV or IO slowly May repeat in 5-10 minutes 1 gm IV or IO slowly over 60 seconds 500 mg IV or IO slowly Remove clothing of victim of organophosphate poisonings, and flush skin to remove traces of poison. Use cautiously or not at all in patients on digitalis. Avoid extravasation Rapid administration can cause dysrhythmias or arrest DEXTROSE 50% Hypoglycemia 25 g IV repeat if needed Recheck glucose after administration

77 ADULT DRUG REFERENCE Drug Indication Adult Dosage Precautions / Comments DIPHENHYDRAMINE DOPAMINE Allergy Hives / Itching Dystonic Reaction Shock Symptomatic Bradycardia Cardiac Arrest EPINEPHRINE 1:10,000 Anaphylactic Shock EPINEPHRINE 1:1000 Allergy/ Anaphylactic Shock Asthma mg IV or IM Starting dose (see chart) 5 mcg/kg/min IV or IO Maximum dose 20 mcg/kg/min IV or IO 1 mg IV or IO every 3-5 minutes 0.1 mg increments IV or IO up to 0.5 mg IV total dose Use only if IM treatment ineffective mg IM Use lower dose in smaller, older patients 0.3 mg subcutaneously 0.3 mg IM if respiratory arrest from asthma or bronchospasm For allergy, consider lower dose if patient has already taken po dose in past two hours for symptoms Alpha & beta sympathomimetic. May cause serious dysrhythmias and exacerbate angina. Avoid extravasation. Avoid exposure to light. Alpha & beta sympathomimetic. May cause serious dysrhythmias and exacerbate angina. Never administer intravenously! Do not use in asthma patients with a history of hypertension or coronary artery disease. May cause serious dysrhythmias and exacerbate angina. ADULT DRUG REFERENCE Drug Indication Adult Dosage Precautions / Comments GLUCAGON Hypoglycemia 1 mg IM Effect may be delayed 5 20 min. LIDOCAINE IO Pain mg IO Not needed in arrest situations MIDAZOLAM MORPHINE Seizure Sedation for pacing or cardioversion Sedation transfer of intubated patient Behavioral Emergency Pain Control Trauma, Burn or Non-Traumatic Pain Sedation Pacing Pulmonary Edema Titrate 1-5 mg IV in 1-2 mg increments 0.2 mg/kg IM (max. dose 10 mg IM) Titrate 1-5 mg IV in 1-2 mg increments Titrate 2-5 mg IV in up to 2 mg increments 5 mg IM 1-5 mg IV in 1 mg increments if IV available 2-20 mg IV (2-5 mg increments) 5-20 mg IM (max single dose 10 mg) 1-5 mg IV in 1 mg increments 2-5 mg IV in 1-2 mg increments With IV dosing, begin with 1 mg dose. IV increments should not exceed 2 mg Observe respiratory status Use with caution in patients over age 60 Base order required for behavioral emergency indication Can cause hypotension and respiratory depression. Recheck VS between each dose. Hypotension more common in patients with low cardiac output or volume depletion. Nausea is a frequent side effect. Respiratory depression reversible with naloxone.

78 NALOXONE ADULT DRUG REFERENCE Drug Indication Adult Dosage Precautions / Comments Respiratory Depression or Apnea (Respiratory rate less than 12) 2 mg intranasally (IN) 1-2 mg IV or IM For careful titration in chronic pain or terminal patients, dilute 1:10 and give 0.1 mg increments Intranasal administration preferred unless patient in shock or has copious secretion/blood in nares. Shorter duration of action than that of most narcotics. Abrupt withdrawal symptoms and combative behavior may occur. NITROGLYCERIN ONDANSETRON SODIUM BICARBONATE Chest Pain Suspected ACS Pulmonary Edema Vomiting and Severe Nausea Cardiac arrest Tricyclic Antidepressant OD Crush injury 0.4 mg sl or spray up to 6 doses 0.4 mg sl or spray if systolic BP mg sl or spray if systolic BP 150 or over Max.dose 4.8 mg 4 mg IV, IM or po (ODT) May repeat q 10 min X 2 1 meq/kg IV or IO For crush injury, consider additional 1 meq/kg added to 1L NS using second IV line Can cause hypotension and headache. Do not give if BP less than 90 systolic. Do not give if right ventricular MI detected. Do not give if Viagra or Levitra taken within 24 hours or if Cialis taken within 36 hours Give IV over 1 minute may cause syncope if administered too rapidly. Assure adequate ventilation. Can precipitate or inactivate other drugs. In cardiac arrest, indicated for treatment of suspected hyperkalemia (history of renal failure or diabetes). Patient Weight (kg) DOPAMINE DRIP RATES Dopamine concentration = 1600 mcg/ml solution = 400 mg in 250 ml D5W or NS Drops per minute based on microdrip tubing (60 gtt/ml) 5 mcg / kg / min 10 mcg / kg / min 15 mcg / kg / min 20 mcg / kg / min

79 PEDIATRIC DRUG REFERENCE Drug Indication Pediatric Dosage Precautions / Comments ADENOSINE Paroxysmal SVT 1 st Dose 0.1 mg/kg rapid IV (max. 6 mg) 2 nd Dose 0.2 mg/kg rapid IV (max 12 mg) Follow each dose with rapid ml NS bolus Base Order Required: May cause transient heart block or asystole. Side effects include chest pressure/pain, palpitations, hypotension, dyspnea, or feeling of impending doom. Do not administer if drugs or poisons are suspected cause of tachycardia. ALBUTEROL Bronchospasm 5 mg in 6 ml NS nebulized Repeat as needed AMIODARONE Ventricular Fibrillation or Pulseless VT 5 mg/kg IV or IO bolus Maximum dose 300 mg ATROPINE Symptomatic Bradycardia 0.02 mg/kg IV or IO Minimum dose 0.1 mg Child (1-8 years): Single dose max 0.5 mg Total dose 1 mg Adolescent (9-14 years): Single Dose max 1 mg Total Dose 2 mg Bradycardia in pediatric patients primarily related to respiratory issue assure adequate ventilation first Atropine is not used in asystole in pediatric patients PEDIATRIC DRUG REFERENCE Drug Indication Pediatric Dosage Precautions / Comments DEXTROSE 10% Hypoglycemia 0.5 g/kg IV (5 ml/kg) Maximum 250 ml Recheck glucose after administration DIPHENHYDRAMINE EPINEPHRINE 1:10,000 Allergy - Hives / Itching Cardiac Arrest Anaphylactic Shock 1 mg/kg IV or IM Maximum dose 50 mg 0.01 mg/kg IV or IO every 3-5 minutes Max. dose 1 mg Titrate in up to 0.1 mg increments slow IV or IO to a max. of 0.01 mg/kg Consider lower dose (0.5 mg/kg) if patient has already taken po dose in the past two hours for symptoms In anaphylactic shock, IM epinephrine 1:1000 should be administered first and epinephrine 1:10,000 IV should only be used if IM is ineffective EPINEPHRINE 1:1000 GLUCAGON Allergy/ Anaphylactic Shock Asthma Hypoglycemia 0.01 mg/kg IM Max single dose 0.3 mg 0.01 mg/kg subcutaneously Maximum dose 0.3 mg Weight less than 24 kg: 0.5 mg IM Weight 24 kg or more: 1 mg IM Never administer intravenously! If respiratory arrest from asthma or bronchospasm, administer IM Effect may be delayed 5 20 minutes - if patient responds, give po sugar

80 PEDIATRIC DRUG REFERENCE Drug Indication Pediatric Dosage Precautions / Comments LIDOCAINE IO Pain 0.5 mg/kg IO. Maximum dose 20 mg Not needed in arrest situations MIDAZOLAM MORPHINE NALOXONE ONDANSETRON Seizure Sedation for Cardioversion Pain Control Trauma, Burn or Non-Traumatic Pain Respiratory Depression or Apnea Vomiting and Severe Nausea Titrate in up to 1 mg increments IV up to 0.1 mg/kg 0.2 mg/kg IM Maximum dose 10 mg IM 0.1 mg/kg IV or IO titrated in 1 mg increments Maximum dose 5 mg See pain management drug chart for dosage. Use IV increments of up to 2 mg 0.1 mg/kg IM 0.1 mg/kg IM or IV Maximum dose 2 mg May repeat as needed 4 mg IV, IM, or po (ODT) In patients 40 kg and over, may repeat q 10 min X 2. Observe respiratory status carefully Sedation and cardioversion only with base hospital order Can cause hypotension and respiratory depression. Hypotension is more common in patients with volume depletion. Nausea is a frequent side effect. Use IM route initially unless shock present. Shorter duration of action than that of most narcotics. For use in patients 4 years and up. Administer IV over 1 minute. Rapid administration may cause syncope.

81 GRAY 3-5 kg LENGTH-BASED TAPE COLOR GRAY Weight Range: 3-5 kg (6-11 lbs) Defibrillation Doses: 8-16 J (1 st ) / 16 J (2 nd ) Max 40 J ADMINISTER MEDICATION CONCENTRATION DOSE 0.13 ml IV Adenosine 1 st dose 3 mg / ml 0.4 mg 0.27 ml IV Adenosine 2 nd dose 3 mg / ml 0.8 mg 1 ml IV Atropine 0.1 mg / ml 0.1 mg 20 ml IV Dextrose 10% 0.1 gm / ml 2 g 0.08 ml IV or IM Diphenhydramine 50 mg / ml 4 mg 0.04 ml SC or IM Epinephrine 1: mg / ml 0.04 mg 0.4 ml IV Epinephrine 1:10, mg / ml 0.04 mg 0.5 ml IM Glucagon 1 mg / ml 0.5 mg 0.16 ml IM Midazolam IM 5 mg / ml 0.8 mg 0.08 ml IV Midazolam IV 5 mg / ml 0.4 mg 0.4 ml IM or IV Naloxone 1 mg / ml 0.4 mg 80 ml IV Normal Saline Bolus Standard Some volumes rounded for ease of administration. To assure accuracy, be sure the designated concentration of medication is used. Effective 4/1/2011 Contra Costa EMS

82 PINK 6-7 kg LENGTH-BASED TAPE COLOR PINK Weight Range: 6-7 kg (13-15 lbs) Defibrillation Doses: 13 J (1 st ) / 26 J (2 nd ) Max 65 J ADMINISTER MEDICATION CONCENTRATION DOSE 0.22 ml IV Adenosine 1 st dose 3 mg / ml 0.65 mg 0.43 ml IV Adenosine 2 nd dose 3 mg / ml 1.3 mg 0.64 ml IV Amiodarone 50 mg / ml 32 mg 1.3 ml IV Atropine 0.1 mg / ml 0.13 mg 33 ml IV Dextrose 10% 0.1 gm / ml 3.25 g 0.13 ml IM or IV Diphenhydramine 50 mg / ml 6.5 mg 0.06 ml SC or IM Epinephrine 1: mg / ml mg 0.65 ml IV Epinephrine 1:10, mg / ml mg 0.5 ml IM Glucagon 1 mg / ml 0.5 mg 0.16 ml IO Lidocaine 2% (IO pain) 100 mg / 5 ml 3.3 mg 0.25 ml IM Midazolam IM 5 mg / ml 1.25 mg 0.1 ml IV initial 0.13 ml - max Midazolam IV 5 mg / ml 0.65 mg (max.) 0.65 ml IM or IV Naloxone 1 mg / ml 0.65 mg 130 ml IV Normal Saline Bolus Standard Some volumes rounded for ease of administration. To assure accuracy, be sure the designated concentration of medication is used. Effective 4/1/2011 Contra Costa EMS

83 RED 8-9 kg LENGTH-BASED TAPE COLOR RED Weight Range: 8-9 kg (17-19 lbs) Defibrillation Doses: 17 J (1 st ) / 34 J (2 nd ) Max 85 J ADMINISTER MEDICATION CONCENTRATION DOSE 0.28 ml IV Adenosine 1 st dose 3 mg / ml 0.85 mg 0.56 ml IV Adenosine 2 nd dose 3 mg / ml 1.7 mg 0.84 ml IV Amiodarone 50 mg / ml 42 mg 1.7 ml IV Atropine 0.1 mg / ml 0.17 mg 43 ml IV Dextrose 10% 0.1 gm / ml 4.25 g 0.16 ml IM or IV Diphenhydramine 50 mg / ml 8.5 mg 0.08 ml SC or IM Epinephrine 1: mg / ml mg 0.85 ml IV Epinephrine 1:10, mg / ml mg 0.5 ml IM Glucagon 1 mg / ml 0.5 mg 0.21 ml IO Lidocaine 2% (IO pain) 100 mg / 5 ml 4.25 mg 0.34 ml IM Midazolam IM 5 mg / ml 1.7 mg 0.1 ml IV initial 0.17 ml - max Midazolam IV 5 mg / ml 0.85 mg (max.) 0.85 ml IM or IV Naloxone 1 mg / ml 0.85 mg 170 ml IV Normal Saline Bolus Standard Some volumes rounded for ease of administration. To assure accuracy, be sure the designated concentration of medication is used. Effective 4/1/2011 Contra Costa EMS

84 PURPLE kg LENGTH-BASED TAPE COLOR PURPLE Weight Range: kg (22-25 lbs) Defibrillation Doses: 20 J (1 st ) / 40 J (2 nd ) Max 100 J ADMINISTER MEDICATION CONCENTRATION DOSE 0.33 ml IV Adenosine 1 st dose 3 mg / ml 1 mg 0.7 ml IV Adenosine 2 nd dose 3 mg / ml 2.1 mg 1 ml IV Amiodarone 50 mg / ml 52 mg 2.1 ml IV Atropine 0.1 mg / ml 0.21 mg 53 ml IV Dextrose 10% 0.1 gm / ml 5.25 g 0.2 ml IM or IV Diphenhydramine 50 mg / ml 10 mg 0.1 ml SC or IM Epinephrine 1: mg / ml 0.1 mg 1 ml IV Epinephrine 1:10, mg / ml 0.1 mg 0.5 ml IM Glucagon 1 mg / ml 0.5 mg 0.26 ml IO Lidocaine 2% (IO pain) 100 mg / 5 ml 5.25 mg 0.4 ml IM Midazolam IM 5 mg / ml 2 mg 0.1 ml IV initial 0.2 ml IV max Midazolam IV 5 mg / ml 1 mg (max.) 1 ml IM or IV Naloxone 1 mg / ml 1 mg 210 ml IV Normal Saline Bolus Standard Some volumes rounded for ease of administration. To assure accuracy, be sure the designated concentration of medication is used. Effective 4/1/2011 Contra Costa EMS

85 YELLOW kg LENGTH-BASED TAPE COLOR YELLOW Weight Range: kg (27-32 lbs) Defibrillation Doses: 26 J (1 st ) / 52 J (2 nd ) Max 130 J ADMINISTER MEDICATION CONCENTRATION DOSE 0.43 ml IV Adenosine 1 st dose 3 mg / ml 1.3 mg 0.9 ml IV Adenosine 2 nd dose 3 mg / ml 2.6 mg 1.3 ml IV Amiodarone 50 mg / ml 65 mg 2.6 ml IV Atropine 0.1 mg / ml 0.26 mg 65 ml IV Dextrose 10% 0.1 gm / ml 6.5 g 0.3 ml IM or IV Diphenhydramine 50 mg / ml 13 mg 0.13 ml SC or IM Epinephrine 1: mg / ml 0.13 mg 1.3 ml IV Epinephrine 1:10, mg / ml 0.13 mg 0.5 ml IM Glucagon 1 mg / ml 0.5 mg 0.33 ml IO Lidocaine 2% (IO pain) 100 mg / 5 ml 6.5 mg 0.5 ml IM Midazolam IM 5 mg / ml 2.6 mg 0.2 ml IV - initial 0.26 ml IV max Midazolam IV 5 mg / ml 1.3 mg (max.) 1.3 ml IM or IV Naloxone 1 mg / ml 1.3 mg 260 ml IV Normal Saline Bolus Standard Some volumes rounded for ease of administration. To assure accuracy, be sure the designated concentration of medication is used. Effective 4/1/2011 Contra Costa EMS

86 WHITE kg LENGTH-BASED TAPE COLOR WHITE Weight Range: kg (34-41 lbs) Defibrillation Doses: 33 J (1 st ) / 66 J (2 nd ) Max 165 J ADMINISTER MEDICATION CONCENTRATION DOSE 0.6 ml IV Adenosine 1 st dose 3 mg / ml 1.7 mg 1.1 ml IV Adenosine 2 nd dose 3 mg / ml 3.3 mg 1.6 ml IV Amiodarone 50 mg / ml 80 mg 3.3 ml IV Atropine 0.1 mg / ml 0.33 mg 83 ml IV Dextrose 10% 0.1 gm / ml 8.25 g 0.34 ml IM or IV Diphenhydramine 50 mg / ml 17 mg 0.17 ml SC or IM Epinephrine 1: mg / ml 0.17 mg 1.7 ml IV Epinephrine 1:10, mg / ml 0.17 mg 0.5 ml IM Glucagon 1 mg / ml 0.5 mg 0.43 ml IO Lidocaine 2% (IO pain) 100 mg / 5 ml 8.5 mg 0.7 ml IM Midazolam IM 5 mg / ml 3.4 mg 0.2 ml IV - initial 0.34 ml IV max Midazolam IV 5 mg / ml 1.7 mg (max.) 1.6 ml IM or IV Naloxone 1 mg / ml 1.6 mg 325 ml IV Normal Saline Bolus Standard 2 ml IV or IM or Ondansetron ( 4 y.o.) 2 mg / ml 4 mg one oral tablet Some volumes rounded for ease of administration. To assure accuracy, be sure the designated concentration of medication is used. Effective 4/1/2011 Contra Costa EMS

87 BLUE kg LENGTH-BASED TAPE COLOR BLUE Weight Range: kg (42-49 lbs) Defibrillation Doses: 40 J (1 st ) / 80 J (2 nd ) Max 200 J ADMINISTER MEDICATION CONCENTRATION DOSE 0.7 ml IV Adenosine 1 st dose 3 mg / ml 2.1 mg 1.4 ml IV Adenosine 2 nd dose 3 mg / ml 4.2 mg 2.1 ml IV Amiodarone 50 mg / ml 105 mg 4.2 ml IV Atropine 0.1 mg / ml 0.42 mg 105 ml IV Dextrose 10% 0.1 gm / ml 10.5 g 0.4 ml IM or IV Diphenhydramine 50 mg / ml 21 mg 0.21 ml SC or IM Epinephrine 1: mg / ml 0.21 mg 2.1 ml IV Epinephrine 1:10, mg / ml 0.21 mg 1 ml IM Glucagon 1 mg / ml 1 mg 0.5 ml IO Lidocaine 2% (IO pain) 100 mg / 5 ml 10.5 mg 0.8 ml IM Midazolam IM 5 mg / ml 4 mg 0.2 ml IV - initial 0.4 ml IV max Midazolam IV - Titrate in 0.2 ml (1 mg) increments 5 mg / ml 2 mg (max.) 2 ml IM or IV Naloxone 1 mg / ml 2 mg 420 ml IV Normal Saline Bolus Standard 2 ml IV or IM or one oral tablet Ondansetron ( 4 y.o.) 2 mg / ml 4 mg Some volumes rounded for ease of administration. To assure accuracy, be sure the designated concentration of medication is used. Effective 4/1/2011 Contra Costa EMS

88 ORANGE kg LENGTH-BASED TAPE COLOR ORANGE Weight Range: kg (54-64 lbs) Defibrillation Doses: 53 J (1 st ) / 106 J (2 nd ) Max 200 J ADMINISTER MEDICATION CONCENTRATION DOSE 0.9 ml IV Adenosine 1 st dose 3 mg / ml 2.7 mg 1.8 ml IV Adenosine 2 nd dose 3 mg / ml 5.4 mg 2.6 ml IV Amiodarone 50 mg / ml 130 mg 5 ml IV Atropine 0.1 mg / ml 0.5 mg 135 ml IV Dextrose 10% 0.1 gm / ml 13.5 g 0.5 ml IM or IV Diphenhydramine 50 mg / ml 27 mg 0.27 ml SC or IM Epinephrine 1: mg / ml 0.27 mg 2.7 ml IV Epinephrine 1:10, mg / ml 0.27 mg 1 ml IM Glucagon 1 mg / ml 1 mg 0.7 ml IO Lidocaine 2% (IO pain) 100 mg / 5 ml 13.5 mg 1 ml IM Midazolam IM 5 mg / ml 5.4 mg 0.2 ml IV - initial 0.5 ml IV max Midazolam IV - Titrate in 0.2 ml (1 mg) increments 5 mg / ml 2.7 mg (max.) 2 ml IM or IV Naloxone 1 mg / ml 2 mg 500 ml IV Normal Saline Bolus Standard 2 ml IV or IM or one oral tablet Ondansetron ( 4 y.o.) 2 mg / ml 4 mg Some volumes rounded for ease of administration. To assure accuracy, be sure the designated concentration of medication is used. Effective 4/1/2011 Contra Costa EMS

89 GREEN kg LENGTH-BASED TAPE COLOR GREEN Weight Range: kg (65-80 lbs) Defibrillation Doses: 66 J (1 st ) / 132 J (2 nd ) Max 200 J ADMINISTER MEDICATION CONCENTRATION DOSE 1.1 ml IV Adenosine 1 st dose 3 mg / ml 3.3 mg 2.2 ml IV Adenosine 2 nd dose 3 mg / ml 6.6 mg 3.3 ml IV Amiodarone 50 mg / ml 165 mg 5 ml IV Atropine 0.1 mg / ml 0.5 mg 165 ml IV Dextrose 10% 0.1 gm / ml 16.5 g 0.7 ml IM or IV Diphenhydramine 50 mg / ml 33 mg 0.3 ml SC or IM Epinephrine 1: mg / ml 0.3 mg 3.3 ml IV Epinephrine 1:10, mg / ml 0.33 mg 1 ml IM Glucagon 1 mg / ml 1 mg 0.8 ml IO Lidocaine 2% (IO pain) 100 mg / 5 ml 16.5 mg 1.3 ml IM Midazolam IM 5 mg / ml 6.6 mg 0.2 ml IV - initial 0.7 ml IV max Midazolam IV - Titrate in 0.2 ml (1 mg) increments 5 mg / ml 3.3 mg (max.) 2 ml IM or IV Naloxone 1 mg / ml 2 mg 500 ml IV Normal Saline Bolus Standard 2 ml IV, IM or Ondansetron ( 4 y.o.) 2 mg / ml 4 mg one oral tablet Some volumes rounded for ease of administration. To assure accuracy, be sure the designated concentration of medication is used. Effective 4/1/2011 Contra Costa EMS

90 40 kg For Pediatric Patients Beyond Length-Based Tape PEDIATRIC DOSAGE 40 kg (90 lbs) ADMINISTER MEDICATION CONCENTRATION DOSE 1.3 ml IV Adenosine 1 st dose 3 mg / ml 4 mg 2.7 ml IV Adenosine 2 nd dose 3 mg / ml 8 mg 4 ml IV Amiodarone 50 mg / ml 200 mg 5 ml IV Atropine 0.1 mg / ml 0.5 mg 200 ml IV Dextrose 10% 0.1 gm / ml 20 g 0.8 ml IM or IV Diphenhydramine 50 mg / ml 40 mg 0.3 ml SC or IM Epinephrine 1: mg / ml 0.3 mg 4 ml IV Epinephrine 1:10, mg / ml 0.4 mg 1 ml IM Glucagon 1 mg / ml 1 mg 1 ml IO Lidocaine 2% (IO pain) 100 mg / 5 ml 20 mg 1.6 ml IM Midazolam IM 5 mg / ml 8 mg 0.2 ml IV - initial 0.8 ml IV max Midazolam IV - Titrate in 0.2 ml (1 mg) increments 5 mg / ml 4 mg (max.) 2 ml IM or IV Naloxone 1 mg / ml 2 mg 500 ml IV Normal Saline Bolus Standard 2 ml IV, IM or one oral tablet Ondansetron 2 mg / ml 4 mg Some volumes rounded for ease of administration. To assure accuracy, be sure the designated concentration of medication is used. Effective 4/1/2011 Contra Costa EMS

91 45 kg For Pediatric Patients Beyond Length-Based Tape PEDIATRIC DOSAGE 45 kg (101 lbs.) ADMINISTER MEDICATION CONCENTRATION DOSE 1.5 ml IV Adenosine 1 st dose 3 mg / ml 4.5 mg 3 ml IV Adenosine 2 nd dose 3 mg / ml 9 mg 4.5 ml IV Amiodarone 50 mg / ml 225 mg 5 ml IV Atropine 0.1 mg / ml 0.5 mg 225 ml IV Dextrose 10% 0.1 gm / ml 22.5 g 0.9 ml IM or IV Diphenhydramine 50 mg / ml 45 mg 0.3 ml SC or IM Epinephrine 1: mg / ml 0.3 mg 4.5 ml IV Epinephrine 1:10, mg / ml 0.45 mg 1 ml IM Glucagon 1 mg / ml 1 mg 1 ml IO Lidocaine 2% (IO pain) 100 mg / 5 ml 20 mg 1.8 ml IM Midazolam IM 5 mg / ml 9 mg 0.2 ml IV - initial 0.9 ml IV max Midazolam IV - Titrate in 0.2 ml (1 mg) increments 5 mg / ml 4.5 mg (max.) 2 ml IM or IV Naloxone 1 mg / ml 2 mg 500 ml IV Normal Saline Bolus 2 ml IV, IM or one oral tablet Ondansetron 2 mg / ml 4 mg Some volumes rounded for ease of administration. To assure accuracy, be sure the designated concentration of medication is used. Effective 4/1/2011 Contra Costa EMS

92 MORPHINE IM Pain Evaluation and Treatment IM MORPHINE 10 mg / ml concentration COLOR / WEIGHT GRAY (3-5 kg) IM DOSE (0.1 mg/kg) Not Given PINK (6-7 kg) 0.06 ml IM (0.6 mg) RED (8-9 kg) 0.08 ml IM (0.8 mg) PURPLE (10-11 kg) 0.1 ml IM (1 mg) YELLOW (12-14 kg) 0.13 ml IM (1.3 mg) WHITE (15-18 kg) 0.17 ml IM (1.7 mg) BLUE (19-22 kg) 0.2 ml IM (2 mg) ORANGE (24-28 kg) 0.25 ml IM (2.5 mg) GREEN (30-36 kg) 0.35 ml IM (3.5 mg) 40 kg 0.4 ml IM (4 mg) 45 kg 0.45 ml IM (4.5 mg) To assure accuracy, be sure the designated concentration is used. Effective 4/1/2011 Contra Costa EMS

93 MORPHINE IV Pain Evaluation and Treatment IV MORPHINE 10 mg / ml concentration mg / kg is used in children up to 18 kg. Titrate up to 10 mg as needed in patients > 18 kg. COLOR / WEIGHT FIRST DOSE IV GRAY (3-5 kg) Not Given Not Given MAXIMUM TOTAL IV DOSE * PINK (6-7 kg) 0.03 ml IV (0.3 mg) 0.06 ml IV (0.6 mg) RED (8-9 kg) 0.04 ml IV (0.4 mg) 0.08 ml IV (0.8 mg) PURPLE (10-11 kg) 0.05 ml IV (0.5 mg) 0.1 ml IV (1 mg) YELLOW (12-14 kg) 0.07 ml IV (0.7 mg) 0.13 ml IV (1.3 mg) WHITE (15-18 kg) 0.08 ml IV (0.8 mg) 0.17 ml IV (1.7 mg) BLUE (19-22 kg) 0.1 ml IV (1 mg) 1 ml (10 mg) ORANGE (24-28 kg) ml IV (1-2 mg) 1 ml (10 mg) GREEN (30-36 kg) ml IV (1-2 mg) 1 ml (10 mg) 40 kg ml IV (1-2 mg) 1 ml (10 mg) 45 kg ml IV (1-2 mg) 1 ml (10 mg) * Base contact required for higher doses than maximum listed. Careful titration should be done with repeat dosages. To assure accuracy, be sure the designated concentration is used. Effective 4/1/2011 Contra Costa EMS

94 Contra Costa County Emergency Medical Services Agency 1340 Arnold Drive, Ste. 126 Martinez CA phone fax Replacement Cost: $10

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