Columbia Co (OR) Protocols (2009)

01/02
Columbia County Emergency Medical Services Protocols

Table of Contents
1. Signature page
2. Introduction/Orientation
3. EMS Protocols
A. Treatment Protocols
T1. Abdominal Pain
T2. Airway
T3. Altered Mental Status/Coma
T4. Amputation
T5. Anaphylaxis/Allergies
T6. Burns
T7. Cardiac Arrest
T8. Cardiac Chest Pain
T9. Cardiac Dysrhythmias
T10. Childbirth
T11. Dental Avulsions
T12. Diabetic Emergencies
T13. Head trauma
T14. Heat Illness
T15. Hypertensive Emergencies
T16. Hypothermia
T17. Musculoskeletal Injuries
T18. Near Drowning
T19. Neonatal Resuscitation
T20. Ob-Gyn Emergencies
T21. Poisons and Overdoses
T22. Psychiatric/Behavioral Emergencies
T23. Respiratory Distress
T24. Seizures
T25. Shock
T26. Suspected Spinal Injuries
T27. Syncope
T28. 12 Lead EKG and Thrombolysis
B. Medication Protocols
M1. Activated Charcoal (Actidose®)

M2. Adenosine (Adenocard®)
M3. Albuterol (Proventil®)
M4. Amiodarone (Cordarone®)
M5. Aspirin (acetylsalycilic acid or ASA)
M6. Atropine
01/02

Table of Contents
B. Medication Protocols (cont)
M7. Benadryl® (diphenhydramine)
M8. Calcium
M9. Dextrose
M10. Diltiazem (Cardiazem®)
M11. Dopamine
M13. Epinephrine
M14. Glucagon
M15. Hanks Solution®
M16. Ipatropium (Atrovent® - Combivent®)
M17. Ipecac
M18. Ketorolac (Toradol®)
M19. Lasix® (furosemide)
M20. Lidocaine (xylocaine)
M21. Magnesium
M22. Midazolam (Versed®)
M23. Morphine
M24. Naloxone (Narcan®)
M25. Nitroglycerine (Nitrostat®, Nitrolingual® pump spray)
M26. Nubain
M27. Oxygen
M28. Properacaine (Alcaine®)
M29. Retavase
M30. Sodium Bicarbonate
M31. Succinylcholine (Anectine®)
M32. Thiamine
M33. Vecuronium (Norcuron®)
C. Procedural/Operational Protocols
P1. Airway Management
P2. Control/Monitoring of IV Solutions
P3. Crime Scene Response
P4. Death in the Field
P5. Do Not Resuscitate
P6. Documentation of Care
P7. Intraosseous Infusions
P8. Ocular Exposures
P9. OLMC-Hospital Communications
01/02

Table of Contents
C. Procedural/Operational Protocols (cont)
P10. On-Scene Medical Control
P11. Patient Refusal
P12. Patient Restraint
P13. Patient Treatment Rights
P14. Radiologic Emergencies
P15. Scope of Practice
P16. Slow Down/Cancellation
P17. Staging EMS Units
P18. Time at the Scene
P19. Tension Pneumothorax Decompression
P20. Transcutaneous Pacing
P21. Trauma
P22. Transport of the Chronically Ill
4. MCI/MPS Protocol
01/02
Signature Page
EMT Basic/Intermediate/Paramedic Protocols
We recognize these protocols to be the written detailed procedures for medical
and trauma emergencies to be performed by the EMT Basic/Intermediate/Paramedic, as
issued by the supervising physician commensurate with the scope of practice and level of
certification of the EMT. This statement is applicable to all EMTs providing care for the
following agencies/districts:
Scappoose Rural Fire Protection District
St Helens Rural Fire Protection District
Rainier Rural Fire Protections District
Clatskanie Rural Fire Protection District
Mist/Birkenfeld Rural Fire Protection District
Vernonia Rural Fire Protection District
This statement is intended to be consistent with the Oregon Administrative Rules

as they pertain to EMT Basic/Intermediate/Paramedic scope of practice
________________________________ ______________________________
Michael Greisen Brian Burright
Fire Chief Division Chief/EMS Coordinator
Scappoose Rural Fire Protection District St Helens Rural Fire Protection District
________________________________ ______________________________
Vince Donner Robert Keyser
Division Chief/EMS Coordinator Medical Officer
Rainier Rural Fire Protections District Clatskanie Rural Fire Protection District
________________________________ ______________________________
Ann Berg Paul Epler
Medical Officer Fire Chief
Mist/Birkenfeld Fire Protection District Vernonia Rural Fire Protection District
Louis J Perretta MD, FACEP

Physician Supervisor
Columbia County Emergency Medical Services
01/02
Introduction/Orientation
These protocols were written for all Columbia county EMS providers that are
comprised of the following fire districts:
Scappoose Rural Fire Protection District
St Helens Rural Fire Protection District
Rainier Rural Fire Protections District
Clatskanie Rural Fire Protection District
Mist Birkenfeld Rural Fire Protection District
Vernonia Rural Fire Protection District
The protocols are written for all EMT providers and specific medications,
procedures and treatments that are limited to the EMT Intermediate level or EMT
Paramedic level will be indicated by an asterisk . The system is as follows:
No asterisk or one asterisk means that the procedure, medication, or treatment
can be provided by all EMTs
Two asterisks means that the procedure, medication, or treatment can be provided
by EMT Intermediates or EMT Paramedics only
Three asterisks means that the procedure, medication, or treatment can be
provided by EMT Paramedics only
The protocols are arranged into 3 sections, Treatment, Medications, and
Procedural/Operational. The protocols are labeled and ordered according to the
following classification:
T, M or P (indicating Treatment, Medication, or Procedural/Operational
respectively) followed by:
The Number of the Protocol. These protocols will be numbered in alphabetical
order and pages within a protocol will be labeled by a period followed by a number to
indicate the page of the protocol. For example:
The fourth page of the Trauma protocol will be labeled: P21.4… since it is the fourth
page of the 21st Procedural/ Operational protocol
01/02
Treatment
Protocols
07/01 T1.1
ABDOMINAL PAIN
HISTORY
♦ Pain
•Nature
•Duration
•Location and Radiation
•Severity
•Time of onset
•Quality
♦ Associated Symptoms
• Nausea
• Vomiting (bloody or coffee- ground)
• Diarrhea
• Constipation
• Melena (red or tarry feces)
• Urinary difficulties
• Menstrual history
• Fever
• Shortness of breath
• Chest pain
♦ Past History
• Surgery, Recent trauma
• Abnormal ingestion
• Medical Illnesses, medications
• History of similar pain in the past
PHYSICAL FINDINGS
♦ Vital signs
♦ Abdominal Exam
• Tenderness, guarding, rebound tenderness, rigidity, bowel sounds,
distention, pulsatile mass
• Emesis
• Lower extremity pulses
TREATMENT
♦ Place patient in a position of comfort
♦ Keep patient NPO
♦ Give O2*
♦ Initiate IV access, Balanced Salt Solution, large bore, SL, or as needed**
7/01 T1.2
TREATMENT (cont)
♦ If shock is present (BP<90) and there is a history of a traumatic event, enter the
patient into the trauma system
♦ If there is no history of trauma and shock is present. Proceed with the shock
(hypovolemia) protocol
♦ Obtain vital signs frequently
SPECIFIC PRECAUTIONS
♦ Abdominal pain may be the first warning of catastrophic internal bleeding
(ruptured aneurysm, ischemic/infarcted bowel, ectopic pregnancy, perforated
viscous, etc.). Since the bleeding is not apparent, you must think of volume
depletion and monitor patient closely to recognize shock
♦ In upper abdominal pain, consider myocardial ischemia as an etiology
1/02 T2.1
AIRWAY
PURPOSE
♦ The purpose of this protocol is to define for the EMT, procedures which should be
used to assure a PROTECTED airway and adequate ventilation of a patient (see
AIRWAY MANAGEMENT protocol)
♦ Use of the bag valve mask and oropharyngeal airway is not considered sufficient
to provide and maintain a protected airway, except for limited time periods prior
to intubation or during drug administration in the Altered Mental Status Protocol.
♦ Patients who are unconscious and need positive pressure ventilation should be
endotracheally intubated as soon as possible.
INDICATIONS
♦ Respiratory insufficiency or impending respiratory failure
♦ Altered mental status with airway compromise (high risk of aspiration) e.g.
overdose, poisoning
♦ Cardiac and/or Respiratory arrest
♦ Situations requiring positive pressure ventilation
PROCEDURE
1. All unconscious patients who need positive pressure ventilation should be
intubated unless they are immediately resuscitated or have a high probability of
rapidly regaining consciousness (i.e., drug overdose, hypoglycemia)
2. The intubation should take no longer than 5 minutes, with no more than 3
attempts. Intubation should occur within 10 minutes of arrival at the scene.
3. The Sellick Maneuver should be used whenever the bag valve mask is used.
4. No individual intubation attempt should take longer than 30 seconds. However, if
the oximeter is being used, the alternative endpoint is an O2 saturation of 90 or
less
5. Start by opening the airway with basic airway maneuvers and pre-oxygenate the
patient with 100% O2 via mask while maintaining cricoid pressure. This does not
always mean ventilating the patient since ideally the patient should be breathing
100% O2 on their own in this preparatory phase
6. If the patient is not in cardiac arrest or not completely relaxed for intubation,
please see the Advanced Airway Management section of this protocol
7. Intubate the patient and verify tube placement with a 5-point check and the end
tidal CO2 monitor***
8. Place an oral airway or bite block and secure the tube recording the tube depth
9. Recheck and redocument the ET tube placement after movement of the patient or
a change in the vital signs
1/02 T2.2
ADVANCED AIRWAY MANAGEMENT

(see AIRWAY MANAGEMENT protocol)
INDICATIONS
♦ Additional indications for ET tube placement are:
• A clenched jaw
• An active gag reflex
• Uncontrollable combative behavior
• Head injured patients with a GCS of 8 or less
• Clinical conditions requiring airway protection
PROCEDURE
1. Maintain opening the airway and pre-oxygenate with 100% O2 while maintaining
cricoid pressure
2. Assemble your airway equipment and place the patient on a cardiac monitor and
pulse oximeter
3. Start IV (if not already established)
4. Start the premedication phase and give:
• Lidocaine 1-1.5 mg/kg IV
• Midazolam 0.1mg/kg IV not to exceed an initial dose of 5mg
5. Continue cricoid pressure
6. Administer the paralytic agent:
• Succinylcholine 1.5 mg/kg
• If the patient doe not relax completely within 1 minute, repeat the same
dose
7. About 1 minute after the Succinylcholine is administered, paralysis should occur
and the patient should be intubated at this point
8. If the patient desaturates during the intubation attempt (SaO2 less than 90%),
abort the attempt and ventilate with a BVM and 100% oxygen until the SaO2
moves up into the mid to high 90% range
9. If all intubation attempts fail, ventilate with BVM and 100% O2 and insert a
Combi-Tube or perform a Cricothyroidotomy (see AIRWAY MANAGEMENT
PROTOCOL)
10. Intubate the patient and verify tube placement with a 5-point check and the end
tidal CO2 monitor. Place an oral airway or bite block and secure the tube,
recording the tube depth (consider c-collar for further stability)
12. If paralysis is needed during transport, give Vecuronium 0.1 mg/kg IV.
[ONLY TO BE DONE BY PARAMEDICS WHO HAVE DONE AN OR

ROTATION AND HAVE PASSED THE ADVANCED AIRWAY EXAM]
1/02 T2.3
PEDIATRIC CONSIDERATIONS
♦ Administer Atropine 0.02 mg/kg IV for children under 2 years (minimum dose is
0.1 mg not to exceed the adult dose)
♦ Administer Succinylcholine 2 mg/kg IV for children under 6 years. May repeat
once if there is inadequate relaxation
♦ A formula that is helpful to remembering tube sizes for different age children
younger than 8 years:
Tracheal tube size (mm) = (age in years/4) + 4
♦ Generally use an un-cuffed endotracheal tube until 8 years
♦ Try to utilize a length based resuscitation tape (e.g. Broselow tape) when
available
♦ DO NOT perform a Cricothyroidotomy in children under 8 years; consider a
Needle Cricothyroidotomy procedure (see AIRWAY MANAGEMENT
protocol) if unable to intubate or ventilate
1/02 T3.1
ALTERED MENTAL STATUS/COMA

HISTORY
♦ Onset (acute vs. gradual)
♦ History of trauma
♦ Description of the scene (pills found, notes present, syringes, unusual odors at the
scene e.g. Ammonia, Natural gas))
♦ Recent emotional crisis (suicidal or homicidal ideations, abrupt or bizarre
behavioral changes)
♦ Drug or alcohol ingestion
♦ Environmental exposures (toxic, exertion or heat exposure)
♦ Psychiatric Disorders
♦ Medical history (diabetes, seizures, etc.)
♦ Medications and Allergies
PHYSICAL FINDINGS
♦ Vital Signs (including temperature)
♦ Level of Consciousness (GCS)
♦ Pupil size, reactivity, symmetry
♦ Breath odor (alcohol, ketones)
♦ Nuchal rigidity (suspect C spine injury with head trauma)
♦ Abnormal breathing patterns
♦ Presence of needle tracks
♦ Evidence of trauma
♦ Medical alert tags
TREATMENT
♦ Airway, Breathing, Circulation*
♦ Start oxygen and follow AIRWAY protocol as needed*
♦ Initiate IV access**
♦ Attempt to establish rapport
♦ Restrain if necessary (follow PATIENT RESTRAINT protocol
♦ Determine whole blood glucose level using glucometer. If blood glucose is less
than or equal to 80 mg%:
• Give D50W, orally if the patient is able to;* 50 ml of D50W in large vein
if patient is unable to take sugar orally**
• Consider Thiamine 100 mg slow IV push if there is any question of
alcoholism or malnutrition***
• Give Glucagon 1.0 mg IM or SQ when unable to give glucose IV and
blood glucose level less than or equal to 80 mg%***
1/02 T3.2
TREATMENT (cont)
♦ Consider Narcan® for suspected opiate intoxication. Titrate in 0.4-2.0 mg
increments every 3-5 minutes to reverse coma up to 8 mg total (see
POISONING/OVERDOSE protocol** The end point of administration is to
have adequate respiratory effort.
♦ For patients who are suicidal:
• Do not leave patient alone
• Remove or have someone remove dangerous objects (i.e., knives, guns,
pills, etc.)
• Inquire specifically regarding depression, helpless or hopeless feelings and
thoughts of suicide.
• Question specifically about hallucinations or delusions
• Transport in calm, quiet manner; obtain, monitor vitals
♦ Psychiatric disorders almost never cause Organic Brain Syndrome. If patient is
disoriented, think of medical causes
♦ Do not attribute the patient’s behavior to alcohol without checking for other
etiologies
♦ In cases of dangerous environment, safety of personnel on scene is paramount
♦ Be particularly attentive to airway. Aspiration of secretions, vomiting and
inadequate tidal volume are common. Transport in left lateral decubitus position
when possible
♦ When dealing with patients with an altered mental state, you should also consider
these other medical conditions:
• Seizures (see SEIZURE protocol)
• Stroke (CVA)
• Sepsis
7/01 T4.1
AMPUTATION
HISTORY
♦ Time of amputation
♦ Mechanism of amputation, care of severed part
♦ History of bleeding problems (also family history)
♦ Amputation at or proximal to wrist or ankle requires Trauma System entry
♦ Medical history, medications, and allergies
PHYSICAL FINDINGS
♦ Vital signs
♦ Excessive bleeding, blood loss at scene, arterial bleeding
♦ Note structural attachments in partial amputations
♦ Distal neurovascular exam in partial amputations
TREATMENT
♦ Maintain appropriate body substance isolation precautions
♦ For Complete Amputations:
• Cover the stump (proximal part) with sterile dressing, moistened with a
Balanced Salt Solution and cover with dry dressing (Chux, Kerlix, etc.).
• Control bleeding by direct pressure and elevation
• Retrieve the severed part and wrap it in a dry sterile dressing then place it
in a plastic bag.
• Place sealed bag into a ice cold water immersion. The ice cubes may be in
the water, however, no direct contact between injured tissue/part(s) and ice
should occur
♦ For Partial Amputations:
• Cover with sterile dressing, moistened with Balanced Salt Solution, cover
with dry dressing, splint in anatomical position, avoid torsion and
angulation. Reduce any torsion into anatomical position
♦ If the patient has severe, incapacitating pain, consider Morphine Sulfate (see
MORPHINE protocol).*** Do not use if a patient has undiagnosed abdominal
pain or head injury.
♦ If bleeding is excessive, consider starting an IV en route with a Balanced Salt
Solution.**
♦ If unable to control bleeding with direct pressure and elevation, use a pressure
point (rarely effective). If you continue to have significant bleeding, use a BP
cuff as a tourniquet and inflate to 50 mm Hg above systolic BP. Do not apply for
more than 6 minutes allowing the cuff to relax for a minute or two then re-inflate
if bleeding is still not controlled
♦ Oxygen (see AIRWAY Protocol)
7/01 T4.2
♦ Do not use dry ice.
♦ Time is of the greatest importance to assure viability. If the extrication or
transport time will be prolonged, consider sending the amputated part ahead to be
surgically prepared for re-implantation.
1/02 T5.1
ANAPHYLAXIS AND ALLERGIC REACTIONS

HISTORY
• Symptoms
• Itching
• Difficulty breathing
• Chest tightness
• Nausea, vomiting
• Abdominal cramps
• Subjective airway impairment or swelling
• Numbness and tingling
• Rash, swelling
• Syncope
• Weakness
• Anxiety
• Choking sensation
• Cough.
• Present history
Exposure (orally, IM or IV) during past few hours to allergenic substances such as
drugs (antibiotics, allergy shots), insect bites, toxic substances, unusual foods
(nuts, fish and fruit most common)
Also, with isolated angioedema, exposure to any of the group of medications
known as angiotensin converting enzyme inhibitors may be secondary to the
medication and potentially life-threatening:
• Benazepril (Lotensin®), Captopril (Capoten®), Enalapril (Vasotec®),
Fosinopril (Monopril®), Lisinopril (Zestril®), Losartan (Cozaar®), Moexipril
(Univase®), Quinapril (Accupril®), Ramipril (AltaceTM)
As well as the combination agents:
• Capozide®, Hyzaar®, Lotensin® HCT, Lotrel®, Prinzide®, Vaseretic®,
Zestoretic®
Past history
• Known allergies, prior allergic reactions, current medications
PHYSICAL FINDINGS
♦ Vital signs.
♦ HEENT
• Periorbital edema, lip edema, tongue edema, sublingual/lingual edema,
edema of posterior oropharynx, uvula, or soft palate.
♦ Respiratory
• Stridor, wheezing, hoarseness, cough.
♦ Skin
• Rash, urticaria, edema.
1/02 T5.2
PHYSICAL FINDINGS (CONT)

• Neurological
♦ Level of consciousness.
TREATMENT
♦ Protect airway
♦ Further treatment may not be indicated if only hives and itching are present. Consider
diphenhydramine 25 to 50 mg IM or IV slow push for adults
♦ O2, high flow, by non-rebreather mask; Suction as needed
♦ Advanced airway techniques (see AIRWAY protocol) may be required if unable to
intubate or ventilate by bag mask after Epinephrine has been administered.
Cricothyrotomy may be needed for larnygospasm (see AIRWAY MANAGEMENT
protocol
♦ Remove injection mechanism if still present
♦ IV: Balanced Salt Solution, large bore; Treat for shock syndrome if BP less than 90
mm Hg (see SHOCK protocol)
♦ Patient should be supine with legs elevated unless respiratory distress predominates
♦ Monitor cardiac rhythm (see CARDIAC DYSRHYTHMIAS protocol)
♦ IF THE PATIENT HAS SIGNS OF ANAPHYLAXIS
• With BP greater than 90 mm Hg systolic, administer Epinephrine 0.3 ml 1:1,000
SQ1
• With BP less than 90 mm Hg systolic, administer Epinephrine 3.0 ml 1:10,000
slow IV or 6.0ml ET in adult***
• If no improvement in the blood pressure noted after the Epinephrine and a 500cc
fluid challenge, repeat Epinephrine 3.0 cc 1:10,000 IV in 10 minutes. Maximum
dose is 1.0 mg (10 cc of 1:10,000)***
• Use Albuterol® (see RESPIRATORY DISTRESS protocol) if wheezing is
present**
SPECIFIC PRECAUTIONS:
♦ Epinephrine should only be given if there are signs or symptoms of cardiovascular
collapse or significant respiratory distress
♦ It is important to differentiate anaphylaxis from hyperventilation, since epinephrine
will aggravate anxiety in patients who are hyperventilating
♦ Epinephrine increases cardiac work and may precipitate angina or MI in susceptible
individuals
♦ Common side effects include anxiety, tremor, vomiting, palpitations, tachycardia and
headache, particularly with IV administration.
♦ Two forms of Epinephrine are available; 1) 1:1,000 dilution appropriate for SQ
administration 2) 1:10,000 dilution for IV or ET administration***. BE SURE TO
GIVE THE PROPER DILUTION TO YOUR PATIENT
1/02 T5.3
♦ Epinephrine can induce vomiting in children
♦ For itching give diphenhydramine 1.0 mg/kg IM or slow IV push
♦ If wheezing is present treat with inhaled albuterol (see RESPIRATORY DISTRESS
protocol)**
♦ For severe respiratory distress:
• Epinephrine 1:1000, 0.01 mg/kg (0.01 cc/kg) SQ*1 maximum dose is 0.3 mg (0.3
cc)**
• Epinephrine, 1:10,000, 0.01 mg/kg (0.1 cc/kg) IV or IO; maximum dose is 0.1 mg
(1.0 cc)**
• Epinephrine, 1: 1000, 0.1 mg/kg in 1-2 cc NS by ET***
1
EMT Basics need to file a copy of the PCR with the Board of Medical Examiners in
each instance
1/02 T6.1
BURNS
HISTORY
♦ Time elapsed since burn
♦ Was patient in an enclosed space with steam or smoke? How long?
♦ Loss of consciousness
♦ Accompanying explosion, trauma, toxic fumes
♦ Respiratory complaints
♦ Prior cardiac or pulmonary disease
♦ Medications/Allergies
PHYSICAL FINDINGS
♦ Vital signs.
♦ Evidence of respiratory burns:
• Soot or erythema of mouth
• Singed nasal hairs
• Cough, hoarseness
• Respiratory distress
• Carbonaceous sputum
♦ Extent of burns:
• Description of areas involved
• Use the “Rule of Nines” to estimate % total body surface area (TBSA)
♦ Depth of burns:
• Superficial - erythema only
• Significant - blistered, denuded, or charred areas.
• Associated trauma.
♦ Level of consciousness - orientation to name, place, and date. Short-term memory.
TREATMENT
♦ Remove clothing which is smoldering or which is non-adherent to the patient.
♦ Remove rings, bracelets and other constricting items.
♦ O2, high flow, by non-rebreathing mask (see AIRWAY protocol)*
♦ If burn is moderate-to-severe, cool the area with saline saturated dressings; cover the burns with
dry, clean dressings.
♦ Consider Morphine for pain control (see MORPHINE protocol) in combination with midazolam
per protocol (see MIDAZAOLAM protocol)***
♦ Leave unbroken blisters intact
♦ Types of Burns:
1/02 T6.2
TREATMENT (cont)
• Thermal Burns
If more than about 20% significant burn or if respiratory distress or hypotension
exist:
• Monitor airway and start oxygen (see AIRWAY protocol)
• Start IV: Balanced Salt Solution, large bore, at 10 cc/kg for adults and 20
cc/kg for children(see SHOCK protocol)**
• Monitor cardiac rhythm**
• Electrical Burns
These burns usually have an exit and entry burn and the patient has a greater risk
of cardiac dysrhythmias and internal organ damage; their treatment includes:
• Apply sterile dressings to entry and exit burns
• Monitor cardiac rhythm and treat dysrhythmias (see CARDIAC
DYSRHYTMHIAS protocol)**
• Start IV: Balanced Salt Solution, large bore, TKO or as % burn (see
SHOCK protocol)**
• Chemical Burns
With these burns there may be a chance of contamination to the rescuers and a
HAZMAT response should be considered if this is the case; remember to protect
yourself from contamination first; their treatment includes:
• Flush contaminated skin and eyes with copious amounts of water
• If the chemical is dry, brush it off the skin and flush with water
• During the washing process, wear rubber or latex gloves and control the
wash to avoid splashing
BURN CENTER CRITERIA

♦ The following patients should be transported to the Burn center directly; the exception would be
for Clatskanie and Rainier, where the patient should be transported to the closest facility for
stabilization:
• Total significant (second degree) burn which is 20% or more of body surface in an adult;
10% in a child under 10 years or an adult over 50 years
• Full thickness (third degree) burn which is greater than 5% TBSA
• Electrical burns
• Burns with Inhalation injuries
• Significant Chemical burns
• Burns to the face, hands, feet, genitalia, and circumferential
• Significant burns in patients with chronic medical problems
• Trauma system patients with burns meeting the criteria above
1/02 T6.3
♦ Suspect airway burns in any facial burns or burns received in an enclosed space
♦ Consider Carbon Monoxide and Cyanide poisoning in all closed space burns. If suspected, give
O2, high flow, through non- rebreather mask
♦ Consider Morphine Sulfate for pain***
Deaths in the first 24 hours after burn injury are due to either airway burns or fluid loss.
♦ In a few instances, caution should be used with water flushing of chemical contaminants. In the
case of lime (CaCO3), brush off excess, and then flush with copious amounts of water. Do not
use water for phosphorus contamination
♦ Consider child abuse in pediatric burns
♦ Morphine dose for children under 30 kg (66 pounds) is 0.1 mg/kg IV for the first dose and titrate
once with a repeated dose if needed***
1/02 T6.4
Rule of Nines
RULE OF NINES
♦ In adults, most areas of the body can be divided into portions of 9% or multiples of 9. This is a
useful technique for estimating the total body surface area (TBSA) of a burn. In a small child,
the head takes more surface area and the rule of nines is modified. See diagram above.
7/01 T7.1
CARDIAC ARREST
HISTORY
♦ Preceding symptoms
♦ Onset
♦ Downtime (no CPR)
♦ Duration of CPR
♦ Witnessed arrest?
♦ Past history: cardiac disease, hypertension
♦ Medications/allergies
♦ Evidence of drug ingestion
♦ Evidence of penetrating or blunt injury
♦ Appropriateness of resuscitative efforts; DNR orders or advanced directives (see
DEATH IN THE FIELD protocol
PHYSICAL FINDINGS
♦ Determine presence of arrest
• Unresponsive
• Absent or terminal respirations
• Absent pulses over major arteries
• Pupil size
♦ Document:
• Dependent lividity
• Decomposition
• Rigor Mortis
TREATMENT
♦ Initiate CPR: Follow American Heart Association Basic Life Support Standards*
♦ Initiate airway management and intubate (either Combitube** or Endotracheal***)
♦ Check cardiac rhythm and follow appropriate arrest algorithm**
♦ Do not diagnose Cardiac Arrest solely on the basis of a monitor reading. Consider
also the absence of respirations and pulse.
7/01 T7.2
TREATMENT (cont)
♦ These following algorithms were developed to treat a broad range of patients with
Ventricular Fibrillation (VF), Pulseless Ventricular Tachycardia (VT), Ventricular
Asystole, and Pulseless Electrical Activity (PEA). Some patients may require care
not specified herein. These algorithms should not be construed as prohibiting such
flexibility. Flow of algorithms presumes that the dysrhythmia is continuing. If the
rhythm changes, move to the appropriate algorithm
CARDIAC ARREST ALGORITHM

FIRST RESPONDERS-EMT Basics
♦ For patients in cardiac arrest secondary to ventricular fibrillation or pulseless
ventricular tachycardia. In all cardiac arrest cases, ALS backup must be requested, if
not already responding.
Start ABC’s and set up/attach AED

Press “Analyze” and Defibrillate if recommended
If no pulse, repeat the process
Do CPR for one minute, if still no pulse
Do CPR for one minute, and if no pulse continue with 3 stacked shocks after pressing
“Analyze” the defibrillate each time
7/01 T7.3
EMT INTERMEDIATES**
♦ For patients in cardiac arrest secondary to ventricular fibrillation or pulseless
ventricular tachycardia. In all cardiac arrest cases, ALS backup must be requested, if
not already responding.
ABC’s
Perform CPR until the defibrillator is attached
Defibrillate 200 Joules if needed
Check pulse and rhythm
Ventricular Fibrillation Pulse Asystole
Ventricular Tachycardia PEA
(pulseless)
Place Combi-tube High flow O2 Place Combi-tube
Initiate IV Initiate IV Initiate IV
1:10000 Epinephrine Lidocaine 1:10000 Epinephrine

1.0 mg IV; repeat every 1.5 mg/kg IV 1.0 mg IV; repeat every
3-5 minutes while 3-5 minutes while
patient is in arrest TRANSPORT patient is in arrest
Defibrillate 360 J Check Pulse & rhythm

within 30-60 seconds
Asystole PEA
Lidocaine 1.5 mg/kg if
Persistent VF/VT Atropine 1mg IV, repeat 500 cc Fluid
q 3-5 minutes up to challenge
0.04 mg/kg maximum
If heart rate is
less than 60 BPM
Atropine 1mg
IV q 3-5 min
7/01 T7.4

EMT PARAMEDIC***
♦ These following algorithms were developed to treat a broad range of patients with
Ventricular Fibrillation (VF), Pulseless Ventricular Tachycardia (VT), Ventricular
Asystole, and Pulseless Electrical Activity (PEA). Some patients may require care
not specified herein. These algorithms should not be construed as prohibiting such
flexibility. Flow of algorithms presumes that the dysrhythmia is continuing. If the
rhythm changes, move to the appropriate algorithm. Continue CPR between drug
doses and defibrillate within 30-60 seconds of the drug dose.
Ventricular Fibrillation and

Pulseless Ventricular Tachycardia
ABC’s
CPR until a defibrillator is available
Check monitor for rhythm
Defibrillate 200 J
Defibrillate 300 J
Defibrillate 360 J
CPR
Check pulse and rhythm
Intubate
Initiate IV access
1:10,000 Epinephrine 1.0 mg IV every 3-5 minutes
Defibrillate 360 J
Magnesium 2 gms IV
Defibrillate 360 J
Amiodarone 300 mg IV or Lidocaine 1.5 mg/kg IV (3 mg/kg ET)1
3
Defibrillate 360 J
Amiodarone 150 mg IV or Lidocaine 1.5 mg/kg IV (3 mg/kg ET)1
3
Defibrillate 360 J
Consider Sodium Bicarbonate 1 mEq/kg IV2
Defibrillate 360J
1
If successful in converting to a rhythm with a pulse with lidocaine, start a drip at 2 mg/min.
Be cautious with lidocaine if: a) systolic BP<90, b) pulse <50, c) periods of sinus arrest, d)
the presence of AV block
2
Bicarbonate should be used early in cardiac arrest of known cyclic antidepressant overdose
or renal failure patients with hyperkalemia. If used, half the dose may be repeated every 10
minutes
3
Amiodarone has a tendency to foam if it is withdrawn too rapidly from the vial into the
syringe. If successful conversion, start a drip at 1 mg/min.
7/01 T7.5
EMT PARAMEDIC
Asystole
ABC’s
CPR
Intubate
Confirm asystole in 2 leads
Initiate IV access
Atropine 1 mg IV every 3-5 minutes up to 0.04 mg/kg maximum
Consider and treat the possible causes:
Hypoxia-oxygenate and ventilate

Hyperkalemia (renal failure)- give sodium bicarbonate 1mEq/kg IV and
calcium chloride 10mg/kg IV
Acidosis- give sodium bicarbonate 1mEq/kg IV
Cyclic antidepressant OD- give sodium bicarbonate 1mEq/kg IV
Pulseless Electrical Activity

ABC’s
CPR
Intubate
Initiate IV access
If the heart rate is less than 60/min give Atropine 1 mg IV
every 3-5 minutes up to 0.04 mg/kg maximum
Consider and treat the possible causes:

Hypoxia-oxygenate and ventilate
Hyperkalemia (renal failure)- give sodium bicarbonate 1mEq/kg IV and
calcium chloride 10mg/kg IV
Acidosis- give sodium bicarbonate 1mEq/kg IV
Cyclic antidepressant OD- give bicarbonate 1mEq/kg IV
Tension pneumothorax- needle decompression
Cardiac tamponade-immediate transport
Massive pulmonary embolism- immediate transport
SPECIAL CONSIDERATIONS
♦ Intubation is preferable and should be performed as soon as possible. ***
♦ Endotracheal Epinephrine, Atropine, and Lidocaine may be used. Double the
recommended dose when given endotracheally.***
7/01 T7.6
♦ Cardiac arrest in children is often secondary to respiratory failure. Aggressive airway support
with oxygenation and ventilation can lead to spontaneous return of the pulse and cardiac
rhythm
♦ In all the arrest algorithms, High Dose Epinephrine (0.1 mg/kg) is given after an initial
standard dose in children under the age of 18. ***
Quick Reference to Pediatric Drugs
NEONATES
DRUG INDICATION DOSE
Atropine** Bradycardia, asystole 0.1 mg
Dextrose 25%** Hypoglycemia 0.5 gms/kg

(dilute D50 by ½ in NS) 2cc/kg
Epinephrine** Bradycardia, Cardiac 0.01 mg/kg

1:10,000 Arrest Don’t use
high dose
Sodium Bicarbonate*** Metabolic acidosis 1 mEq/kg

(dilute by ½ in NS)
INFANTS AND CHILDREN
DRUG INDICATION DOSE
Adenosine*** SVT 0.05 mg/kg
Atropine** Bradycardia, asystole 0.02 mg/kg

Min dose 0.1 mg
Don’t exceed adult dose
Dextrose 25%** Hypoglycemia 0.5 gm/kg(dilute

D50 by ½ in NS) (2cc/kg)
Dopamine*** Low cardiac output 5-20 mcg/kg/min
Epinephrine** V fib, low cardiac output 0.01 mg/kg

Cardiac arrest then 0.1 mg/kg
Lidocaine** V tach, V fib 1.5 mg/kg bolus

10-50 mcg/kg drip
Naloxone** Respiratory depression 0.1 mg/kg

20 to narcotics
Sodium Bicarbonate*** Metabolic acidosis 1 mEq/kg/dose

(dilute by ½ in NS) Cyclic antidepressant OD
Hyperkalemia
Midazolam (Versed)*** Sedation for Pacing, IV or IO 0.1 mg/kg

Cardioversion, Seizures to max of 2.5 mg
IM: 0.2 mg/kg to max 5mg
1/02 T8.1
CARDIAC CHEST PAIN

HISTORY
♦ Pain (may be heaviness, squeezing, indigestion or discomfort)
• Onset
• Duration
• Location and Radiation
• Aggravating and Alleviating Factors
♦ Associated Symptoms
• Nausea and/or Vomiting
• Diaphoresis
• Shortness of Breath
• Neck, jaw, shoulder or arm pain
• Generalized Weakness (in the elderly)
♦ Past History
• Prior Myocardial Infarction
• Prior history of Angina
• History of PTCA or CABG
• Hypertension
• High Cholesterol
• Diabetes
• Cocaine/Methamphetamine use
• Smoking
• Family History of Coronary Artery Disease
PHYSICAL FINDINGS
♦ General Appearance
♦ Vital Signs
• Upon arrival and after every intervention, as well as before any intervention
which may alter the blood pressure.
♦ Cardiac
• Neck vein distension, irregular pulse
♦ Respiratory
• Rales, wheezing, rhonchi, Chest wall tenderness
♦ Skin
• Diaphoresis, cyanosis, peripheral edema
TREATMENT
♦ Place the patient in a position of comfort
♦ Administer O2: 6 liters per minute via nasal cannula or to maintain oxygen saturation
above 95% (see AIRWAY PROTOCOL)*
1/02 T8.2
♦ Place cardiac monitor and pulse oximeter (see CARDIAC DYSRHYTHMIA

protocol)**
♦ Initiate IV access, single large bore IV with Lactated Ringers in a microdrip at TKO**
♦ Administer nitroglycerin spray, one dose SL Q 5 minutes until pain relieved, you give a
total of 3 doses, or systolic BP < 90 mmHg***
♦ Be cautious with administering nitroglycerin to patients who have taken Viagra < 24
hours prior to encounter as these patients are more likely to have hypotensive episodes
♦ Administer 81 mg baby ASA X 4, chew and swallow*
♦ You may administer Morphine Sulfate for relief of continued pain, as long as systolic
blood pressure > 90 mmHg.***
♦ Complete the Thrombolytic Checklist*** and transport
♦ For St Helens Fire District (see 12 LEAD EKG AND THROMBOLYSIS
PROTOCOL)***
1/02 T9.1
CARDIAC DYSRHYTHMIAS
HISTORY
♦ Chief Complaint: sudden or gradual
♦ Related symptoms:
• Dizziness
• Weakness
• Chest pain (angina)
• Syncope
• Shortness of breath
• Palpitations
♦ Past medical/cardiac history
PHYSICAL FINDINGS
♦ Vital signs
♦ Level of consciousness
♦ Distended neck veins
♦ Peripheral edema
♦ Presence of rales or pulmonary congestion
♦ Irregular heart sounds; thready, irregular pulse
TREATMENT
♦ Start high flow O2 and apply the pulse oximeter (see AIRWAY protocol)*
♦ Monitor the cardiac rhythm**
♦ Dysrhythmias may not require treatment in the field if the patient is asymptomatic
♦ If the patient has a BRADYDYSRHYTHMIA:
1. Determine if the patient is SYMPTOMATIC
Hypotension (heart rate <60/min)
Shortness of Breath (pulmonary edema) (heart rate <60/min)
Ventricular Ectopy (heart rate <60/min)
Chest Discomfort (heart rate <40/min)
2. The patient is ASYMPTOMATIC if:
There is NO hypotension, shortness of breath, ventricular ectopy, and chest

discomfort and the patients systolic blood pressure is greater than 90 mmHg.
1/02 T9.2
TREATMENT (cont)
For SYMPTOMATIC BRADYDYSRHYTHMIAS:
3. Apply the transcutaneous pacemaker and concurrently establish an IV if not already
established (see TRANSCUTANEOUS PACING protocol). Do not delay pacing in the
symptomatic patient while vascular access is being established.***
4. If no IV is established, begin pacing***
5. If IV is established, administer 0.5 mg** mg or 1.0mg ***of Atropine IV. If there is no
response to the Atropine, begin pacing***
6. If mechanical capture is achieved (see TRANSCUTANEOUS PACING protocol)
consider administering midazolam (Versed®) 2.5 mg-5 mg IVP*** and transport. You
may repeat the dose of midazolam if the patient is still uncomfortable.
7. IF mechanical capture is not achieved, repeat the Atropine 1.0 mg IV**, repeating every
5 minutes, up to a maximum of 3.0 mg, as needed to maintain heart rate above 60/min
and systolic BP >90 mmHg.***
♦ For patients with SUPRAVENTRICULAR TACHYCARDIA:

• This includes Atrial fibrillation, Atrial flutter, and Paroxysmal Supraventricular
Tachycardia (PSVT) or any narrow complex heart rate greater than 150/min. These can
be difficult to differentiate.
• If the heart rate is above 150/min, regardless of the cause and in the setting of a suspected
ischemic cardiac event, treatment of the tachycardia early in the course may prevent
impending cardiovascular collapse
• If the patient is perfusing well (no chest pain, BP > 90 mmHG, no shortness of breath):
Administer O2 (see AIRWAY protocol)*
Initiate IV access**
Cardiac monitoring**
Transport
1/02 T9.3
TREATMENT (cont)
♦ If the patient is unstable (chest pain, pulmonary edema, hypotension, altered mental status)
treat according to the following:
_______UNCONSCIOUS***_________________________CONSCIOUS***_____
Synchronous Cardioversion Consider sedation with
100 Joules midazolam 2.5mg-5 mg IV***
Synchronous Cardioversion Synchronous Cardioversion

200 Joules 100 Joules


Synchronous Cardioversion
360 Joules
♦ If the patient is stable (no chest pain, no respiratory distress, blood pressure > 90mmHG)
treat according to the following:
_______CONSCIOUS***_____________________________UNCONSCIOUS**_
Consider early transport Consider Altered Mental
Consider Valsalva Status/Coma protocol
Adenosine 6 mg IVP***
Diltiazem 0.25 mg/kg IV***
over 2 minutes
1/02 T9.4
TREATMENT (cont)
♦ For patients with WIDE COMPLEX TACHYCARDIA or VENTRICULAR
TACHYCARDIA, it will be important to determine if the patients have a pulse or not. If
VENTRICULAR TACHYCARDIA or WIDE COMPLEX TACHYCARDIA is
pulseless, treat it the same as VENTRICULAR FIBRILLATION (see CARDIAC
ARREST protocol)
• For any patient with a cardiac dysrhythmia, if the patient is unconscious with a blood
pressure > 90 mmHG, the ALTERED MENTAL STATUS/COMA protocol should
also be considered.
• The following treatment is for patients with stable (no chest pain, no respiratory distress,
blood pressure > 90mmHG) WIDE COMPLEX TACHYCARDIA or
VENTRICULAR TACHYCARDIA:
WIDE COMPLEX TACHYCARDIA***

Adenosine 6 mg IVP
Adenosine 12 mg IVP VENTRICULAR TACHYCARDIA***
Magnesium Sulfate 2.0 gms slowly over 2 minutes

Lidocaine 1.0-1.5 mg/kg IV push
Lidocaine 0.5-0.75 mg/kg IV push up to 3.0 mg/kg
Contact OLMC to discuss current therapy
• The following treatment is for patients with unstable (chest pain, pulmonary edema,
hypotension, altered mental status) WIDE COMPLEX TACHYCARDIA or
VENTRICULAR TACHYCARDIA***:
Consider sedation with midazolam 2.5-5 mg

Synchronized cardioversion 100 Joules
Synchronized cardioversion 300Joules
If V TACH reoccurs, give Lidocaine 1.5 mg/kg
and cardiovert again at previously successful setting
1/02 T9.5
TREATMENT (cont)
♦ For patients with Premature Ventricular Complexes (PVC’s):

• Treat with Lidocaine 1.5 mg/kg IV only if in the setting of an ischemic event
• Avoid Lidocaine if PVC’s are associated with a BRADYDYSRHYTHMIA
•
♦ For patients with ATRIAL FIBRILLATION or ATRIAL FLUTTER***:
• If the patients are unstable (chest pain, pulmonary edema, hypotension, altered mental
status):
1. Consider midazolam 2.5-5.0 mg IV
2. Synchronized cardioversion 75-100 Joules
3. Synchronized cardioversion 200 Joules
• If the patients are stable (no chest pain, no respiratory distress, blood pressure >
90mmHG) with a heart rate of 150 or greater:
1. Dilitiazem 0.25 mg/kg IVP over 2 minutes for rate control***
BRADYDYSRHYTHMIAS
♦ Most bradycardia in children is due to hypoxia and can be treated with oxygenation and/or
ventilation. Aggressive airway support with oxygenation and ventilation can lead to spontaneous
return of the pulse and cardiac rhythm
♦ The ATROPINE dose in children is 0.02 mg/kg, IV or IO**. The minimal single dose is 0.1
mg and the maximal single dose for up to 10 years is 0.5 mg with 1.0 mg for over 10 years.
♦ The midazolam dose in children is 0.1 mg/kg IV in 1 mg increments up to 2.5 mg***
♦ Narrow complex tachycardia-QRS<0.08 sec
• Sinus tachycardia (less than 220/ min for under 2; less than 180/min for 2-10 years)
Consider fluid bolus (20cc/kg)**
Consider underlying causes (fever, dehydration, occult injury)
• Supraventricular Tachycardia (greater than 220/min for under 2; greater than 180/min
for 2-10 years)
If unstable (poor mentation, poor perfusion) synchronized cardioversion is at 0.5
joules/kg, repeating at 1.0 Joules/kg, 2.0 Joules/kg and 4 Joules/kg***
If stable, the Adenosine dose is 0.05 mg/kg, repeating up to two doses at 0.1 to
0.15 mg/kg***
1/02 T9.6
PEDIATRIC CONSIDERATIONS (cont)
♦ Wide Complex tachycardia-QRS>0.08 sec

• Ventricular Tachycardia
If stable treat as adults adjusting the dose of lidocaine for the child’s weight
If unstable, cardioversion starting with 1 Joule/kg followed by 2 Joules/kg and 4
Joules/kg***
♦ Use pediatric paddles for children less than 10 kg
♦ Place paddles on chest in sternal apical position
If pediatric paddles are not available, use adult paddles placed anterior-posterior on the chest wall
with firm contact
7/01 T10.1
CHILDBIRTH
HISTORY
♦ Last menstrual period or due date
♦ Bleeding (recent, within 1 week)
♦ Single or Multiple pregnancy
♦ Past medical history and past OB-GYN history (G?/P?)
♦ Hypertension
♦ Protein in the urine
♦ Edema
♦ Seizures
♦ Ruptured membranes (clear or meconium stained)
♦ Abdominal Pain/Contractions (timing and duration)
PHYSICAL FINDINGS
♦ Vital signs including fetal heart rate if possible
♦ Abdominal exam
♦ Presence of vaginal bleeding
♦ Swelling in the face or extremities
♦ If the possibility of delivery exists, observe the perineum for blood, fluid, crowning, or an
abnormal presentation (foot, arm, cord or breech)
TREATMENT
♦ If not pushing or bleeding, transport, left lateral decubitus
position.
♦ If bleeding is moderate to heavy:
• O2, high flow*
• Start IV, Balanced Salt Solution, large bore, TKO, or as indicated if shock
syndrome is present. Start IV enroute unless shock syndrome present**
♦ Transport immediately: Previous cesarean section, multiple births, abnormal presenting
parts, excessive bleeding, premature birth.
♦ If question of imminent delivery, observe briefly for frequency and quality of
contractions, then transport as indicated.
7/01 T10.2
TREATMENT (CONT)
♦ For normal delivery:
• Use clean or sterile technique
• Guide and control, but do not retard or hurry delivery. Control delivery of head
• Feel for the umbilical cord around the baby’s neck and gently remove. If it is
tightly wrapped, clamp the cord in two places and cut the cord between the
clamps
• Suction mouth, then nose (NOT throat) with bulb syringe after head delivered,
and before chest is delivered. Keep infant level with perineum
• Assess the infant for color, breathing, pulse, and appearance and follow
NEONATAL RESUSCITATION protocol if necessary
• Clamp cord in two places approximately 8”-10” from infant. Cut cord between
clamps, give infant to mother, allow to nurse (this aids in contracting uterus).
• Start IV: Balanced Salt Solution, large bore, TKO, or as necessary in mother.**
• If excessive bleeding occurs post-partum, treat for Hypovolemic Shock, massage
uterus gently.
• Transport. Do not wait for or attempt delivery of placenta. If placenta delivers
spontaneously, bring to hospital
• Obtain maternal vital signs and complete Apgar score at 1 and 5 minutes after
birth. Observe infant during transport
♦ For abnormal delivery:
• Contact OLMC (see OLMC-HOSPITAL COMMUNICATIONS). Transport to
the closest hospital.
• Place mother in Trendelenburg Position or knee chest and instruct the mother to
pant with contractions and avoid pushing
• For Prolapsed Cord:
Place mother in trendelenburg position
Insert a gloved hand into the vagina and gently push the presenting part
off the cord. Do not attempt to re-position the cord. Do not remove your
hand. Cover the exposed cord with saline soaked gauze. Transport
• For Breech Presentation:
Allow delivery to proceed passively until the baby’s waist appears.
Gently rotate the baby to a face down position and continue with the
delivery
If the head is not delivered spontaneously within 3 minutes, insert a sterile
gloved hand into vagina and elevate the head and nose from the vaginal
wall. Leave hand in place and avoid touching cord
7/01 T10.3
SPECIAL PRECAUTIONS
♦ Placental Abruption can occur in the third trimester of pregnancy when the placenta
prematurely separates from the uterine wall causing intrauterine bleeding. Shock can
develop without significant vaginal bleeding
♦ Consider an ectopic pregnancy in any woman of child bearing age (15-55) with
abdominal pain or vaginal bleeding
♦ Do not pull on the umbilical cord
♦ Bundle and keep infant near mother. Keep infant’s head covered.
♦ Remain cool and calm. The laboring mother may need your reassurance that all is well
until hospital arrival.
♦ Avoid performing digital exams except in cases of breech presentation delivery of cord
prolapse
APGAR SCORE
SIGN 0 1 2
HEART RATE Absent Less than 100 Greater than 100
RESP. EFFORT Absent Slow, Irregular Good, Crying
MUSCLE TONE Limp Some ext. flexion Active Motion
REFLEX No Response Grimace Cough or Sneeze
COLOR Blue, Pale Body Pink Completely Pink
7/01 T11.1
DENTAL AVULSIONS
HISTORY
♦ Recent trauma to the face
♦ Other injuries?
PHYSICAL FINDINGS
♦ HEENT exam
♦ Complete Oropharyngeal exam
♦ Neck exam
♦ Vital signs
TREATMENT
♦ To aid in the successful re-implantation of avulsed adult teeth when they can be placed in
solution within 1 hour of the time when they are avulsed. This increases probability of
successful re-implantation by following this procedure:
• Open “Save-A-Tooth” container
• Peel off seal from container and basket
• Drop in tooth (teeth)
• Close lid tightly
• Label with patient’s name
• Transport in upright position
♦ The following are precautions to using the “Save-A-Tooth” container:
• Not to be used for teeth that has been broken off. The root needs to be intact.
• Not for use with baby teeth
• Do not place more than one person’s teeth in one container
• Do not attempt to rinse or clean teeth before placing them in solution
♦ If there are no other indications for transport, patient may seek out their own dentist for
reimplantation. Avulsed teeth can be stored up to 24 hours in this solution.
1/02 T12.1
DIABETIC EMERGENCIES
Formerly Hypoglycemia
HISTORY
♦ Onset:
• Sudden or gradual? When was patient last well?
♦ Recent stress, either emotional or physical
♦ Last meal
♦ Presence/absence of hunger or thirst
♦ Change in diet; missed meals
♦ Presence of a medical alert tag
♦ Past History:
• Diabetes mellitus
Last insulin (time/amount)
Oral hypoglycemic
♦ Symptoms of Hypoglycemia:
• Diminished level of consciousness
• Headache
• Visual disturbances
• Dizziness
• Hunger
♦ Symptoms of Hyperglycemia:
• Frequent urination
• Thirst
• Fatigue
• Weakness
• Anorexia
• Abdominal pain
PHYSICAL FINDINGS
♦ Vital signs
♦ For Hypoglycemia:
• Skin:
Cool, clammy, diaphoretic
• Respirations
Tachypnea
• Neurological
Confusion, tremors, seizure, coma
1/02 T12.2
PHYSICAL FINDINGS (cont)

♦ For Hyperglycemia:
• Skin:
Warm, dry, flushed
• Respiratory:
Kussmaul, tachypnea, acetone or fruity breath odor
• Neurological:
Drowsiness, stupor, coma
TREATMENT
♦ Assess and support airway/breathing/circulation (see AIRWAY and/or SHOCK
protocols)
♦ Determine whole blood glucose level using glucometer*
♦ If whole blood glucose reading is less than or equal to 80 mg%:
• Administer D50 as an oral solution or equivalent if the patient is able to handle
an oral solution*
• Administer 50 ml of D50W IV if patient is comatose or unable to take oral sugar.
Repeated doses of D50W may be necessary**
• Administer Glucagon 1.0 mg IM for hypoglycemia if unable to establish IV and
patient unable to take oral glucose***
• Administer Thiamine 100 mg IV/IM if there is question of alcoholism or chronic
malnutrition***
• If patient able to maintain airway and take orally, administer oral glucose
solution, fruit juice, or candy
♦ If whole blood glucose reading is greater than or equal to 300mg%:
• Administer 100% O2 via NRBM or BVM (see AIRWAY protocol)
• Administer 500 cc fluid bolus NS**
• Check blood glucose Q 30 minutes during transport
♦ Transport all patients who are hyperglycemic; transport all hypoglycemic patients in
whom the mental status does not return to normal or baseline for them.
♦ The diabetic will frequently know what is needed. Listen to the patient.
♦ Hypoglycemia can present as seizures, coma, behavior problems, intoxication, confusion
or stroke-like picture with focal deficits (particularly in elderly patients)
♦ Patients who are elderly or who have been hypoglycemic for prolonged periods of time
may be slower to awaken.
♦ If the diabetic is unconscious, if it is difficult to decide between Diabetic Coma
(Hyperglycemia) and Insulin Shock (Hypoglycemia). If the precise nature of the
patient’s condition is in question, SUGAR SHOULD BE GIVEN TO ANY DIABETIC
WHO IS UNCONSCIOUS OR HAS AN ALTERED MENTAL STATUS.
1/02 T12.3
SPECIFIC PRECAUTIONS (cont)
♦ Administration of D50W in the alcoholic with depleted thiamine stores may

precipitate Wernicke’s or Korsakoff’s syndrome. Still administer dextrose first
before Thiamine.
♦ Glucagon may cause nausea and/or vomiting
♦ Glucagon will not be efficacious in alcoholics or chronically malnourished
patients
♦ A patient with “borderline” hypoglycemia who is asymptomatic does not require
treatment
♦ Administer 0.5-1 gm/kg of D25 solution in children (D50 diluted 1:1 with NS or
sterile water**
♦ If unable to achieve IV access, administer glucagon 0.5-1.0 mg in children mg IM
or SQ***
7/01 T13.1
HEAD TRAUMA
HISTORY
♦ Mechanism of injury (blunt vs. penetrating)
♦ Time of injury
♦ Loss of or change in consciousness
♦ Protective devices: Helmet, seat belts
♦ Nausea, vomiting
♦ Headache, neck pain
♦ Medical illnesses
♦ Current medications/allergies
♦ Drug or alcohol use
♦ Attempt to obtain pertinent medical history from patient or family member, if
available.
PHYSICAL FINDINGS
♦ Evaluate airway patency, breathing capability, and gross injuries to extremities
and trunk
♦ Evaluate level of consciousness, check for restlessness, pupil size and response to
light
♦ Document with Glasgow Coma Scale, orientation to person, place, time and
purpose
♦ External evidence of head trauma, (e.g., blood/fluid from ears/nose, scalp
lacerations, deformities)
♦ Abnormal breath odor (especially ETOH), bleeding or CSF from nose and ears
TREATMENT
♦ Assure airway protection. Aggressive ventilatory support including high flow O2
and early use of ET tube is indicated. Endotracheally intubate patients with a
GCS of 8 or less (see AIRWAY-ADVANCED AIRWAY protocol)***
♦ Maintain cervical spine alignment
♦ Use direct pressure to diminish or stop bleeding of scalp wounds. No direct
pressure over skull fractures or brain tissue
♦ Start IV, Balanced Salt Solution, TKO. If shock syndrome is present proceed per
Shock Protocol**
♦ Continue to observe vital signs and changes in LOC.
7/01 T13.2
♦ Changes in the patient’s Glasgow Coma Score in relation to time intervals, is
most important for the treating physician.
♦ Always assume cervical spine injury in all patients with head trauma.
♦ Shock syndrome findings do not occur in head injury in adults. Look elsewhere
for the cause of shock. However, head injury in infants may cause hemorrhagic
shock.
♦ Hypoventilation can cause cerebral edema.
♦ Mandatory transport for all patients with a head injury and altered level of
consciousness. If necessary, the patients may need chemical restraint (see
PATIENT RESTRAINT protocol)***.
♦ Avoid all medications which may alter mental status unless absolutely necessary,
e.g. Midazolam® in a seizing head trauma patient.***
♦ It is essential to realize that in a seriously head injured patient, the most effective
pre-hospital care that can be provided is:
1. Aggressive airway management with adequate ventilation and
oxygenation
2. Avoidance of hypotension by aggressively resuscitating any BP less than
100 or any signs of poor perfusion
An injured brain needs oxygenation and adequate cerebral perfusion to have any
chance of long-term recovery
♦ Children generally recover better than adults. However, children less than three
years of age have worse outcomes from severe head injuries than older children.
Secondary brain injury from hypoxemia and hypovolemia must be avoided
♦ Seizures occurring shortly after injury are more common in children. They are
usually self-limiting. Seizures will require investigation by CT scanning at
appropriate facility
♦ The young child with an open fontanelle and mobile features is more tolerant of
an expanding intracranial mass. Other signs of expanding mass may be hidden
until rapid decompensation occurs
♦ Glasgow Coma Scale is useful but must be modified for the pediatric age group.
The verbal response scores are as follows:
Score 5 social smile, fixes and follows

Score 4 cries but consolable
Score 3 persistently irritable
Score 2 breathless and agitated
Score l no response
7/01 T13.3
GLASGOW COMA SCALE

Scale Points
EYE OPENING:
Spontaneous 4
To Speech 3
To Pain 2
None 1
BEST VERBAL RESPONSE:

Oriented 5
Confused Conversation 4
Inappropriate Words 3
Incomprehensible Sounds 2
None 1
BEST MOTOR RESPONSE:

Obeys Commands 6
Localizes Pain 5
Withdraws From Pain 4
Flexion To Pain 3
Extension To Pain 2
None 1
1/02 T14.1
HEAT ILLNESS
HISTORY
♦ Onset and duration
♦ Patient age
♦ Patient attire
♦ Activity level (exercise induced?)
♦ Air temperature, humidity
♦ Drug or alcohol use
♦ Trauma
♦ Past history
♦ Current medications
♦ Obesity,
♦ Medical illnesses (cardiovascular disease, febrile illness, debility.
PHYSICAL FINDINGS
♦ Symptoms
• Chills
• Weakness
• Loss of consciousness, behavior changes, delirium (heat stroke)
• Sweats
• Muscle cramps
• Headache
• Thirst
• Visual disturbances
♦ Signs
• Vital signs: Temperature (usually >40°C or 104°F), BP, pulse
• Skin: Warm or cool, pallor or flushing, moist or dry
• Neck: Meningismus
• Respiratory: Rales, wheezing
• Neurological: Restlessness, level of consciousness (confusion, delirium,
coma), psychosis, seizures
1/02 T14.2
TREATMENT
♦ Secure airway (see AIRWAY protocol); administer100% O2 via NRBM*
♦ Cooling techniques:
• Remove clothing, wet sheet if available
• Use the air conditioning in the ambulance
• Ensure adequate air flow over patient for evaporative loss; use a fan if
possible
• A mist bottle is effective in exposed patient. A charged 1 ¾” line,
carefully used can rapidly cool a patient
♦ Monitor vital signs*
♦ Monitor cardiac rhythm**
♦ Initiate IV access. Administer fluid bolus of 250-500 cc NS (20 cc/kg in
children). Titrate additional fluids to maintain systolic blood pressure >100
mmHg**
♦ Check a glucose level. Administer 50 ml of D50W IV if < 80mg%***
♦ If the patient is seizing, administer midazolam 2.5 to 5.0 mg IV for seizures or 5.0
mg IM if there is no IV access***
♦ Heat stroke, a true emergency, is characterized by altered level of consciousness.
Heat stroke must be differentiated from heat exhaustion (although this may lead to
heat stroke) and heat cramps.
♦ Do not delay transport for cooling in the field.
• For children administer 20 cc/kg of NS for the fluid bolus, and re-bolus at
10cc/kg**
• For hypoglycemia (blood glucose<60) give 1.0 cc/kg of 25% solution**
• For seizures, administer midazolam 0.1 mg/kg IV or 0.2 mg/kg if IM or IO***
1/02 T15.1
HYPERTENSIVE EMERGENCIES
HISTORY
♦ Onset and duration
♦ History of hypertension
♦ Recent head trauma (within last 7 days)
♦ Is patient pregnant? (Pre-eclampsia)
♦ Past medical history (DM, CVA, Cardiac disease)
♦ Medication history (Antihypertensives?)
♦ Symptoms:
• Headache
• Nose bleed
• Dizziness
• Chest Pain
• Difficulty Breathing
PHYSICAL FINDINGS
♦ Vital signs
♦ Neurological Findings:
• Coma
• Focal neurological deficits
• Nuchal rigidity
• Cheyne-Stokes respirations
• Confusion
• Hemiparesis
• Unequal pupils
♦ Pulmonary edema
TREATMENT
♦ Assess severity of hypertension by assessing the patient for symptoms. It is
important to remember that it is more important to treat the patient if they are
having symptoms instead of treating the blood pressure
♦ If patient asymptomatic or mildly symptomatic (headache, dizziness, etc.):
• Administer O2 (see AIRWAY protocol)*
• Monitor the cardiac rhythm**
• Initiate IV access and saline lock**
• Transport with frequent monitoring of vital signs and patient’s mental
status
1/02 T15.2
TREATMENT (cont)
♦ If the patient is exhibiting signs or symptoms of hypertensive emergency, such as

chest pain (see CARDIAC CHEST PAIN protocol) or pulmonary edema (see
RESPIRATORY DISTRESS protocol):
• Administer O2 (see AIRWAY protocol)*
• Monitor the cardiac rhythm**
• Initiate IV access and saline lock**
• For systolic blood pressure greater than 200 mm Hg and/or diastolic blood
pressure greater than 120 mmHg, administer Nitroglycerine 0.4 mg SL or
one dose of nitroglycerine spray, q 5 minutes until blood pressure is less
than 200 mm Hg systolic, 100 mmHg diastolic, or symptoms resolve***
Be cautious with administering nitroglycerin to patients who have taken
Viagra® < 24 hours prior to encounter as these patients are more likely to
have hypotensive episodes
♦ Transport the patients expeditiously to the hospital
♦ Hypertensive encephalopathy often takes a few hours or even a day or two to
develop. There is no nuchal rigidity, and focal neurological deficits, if present,
are often transient and migratory.
♦ Nuchal rigidity should cause one to suspect intracerebral or sub-arachnoid
hemorrhage
♦ Rapid onset of symptoms (coma, hemiparesis) often indicates intracranial
hemorrhage or cerebral infarction
♦ Toxemia of pregnancy is best treated by emptying the uterus. Transport the
patient to a hospital with OB facilities
♦ Remember to treat the symptoms and not the blood pressure and recognize the
symptoms that need to be treated
7/01 T.17.3
HYPOTHERMIA
HISTORY
♦ Length of exposure
♦ Wet or dry
♦ Air/water temperature
♦ Wind
♦ Drug/alcohol use
♦ Extremity pain, paresthesia (frostbite), shivering
♦ History and timing of changes in mental status
♦ Past History:
• Cold injuries
• Medications
• Medical illness
PHYSICAL FINDINGS
♦ Define categories of accidental hypothermia by physical findings (patient will be
categorized by lowest physiological variable):
• APNEA - put metal or glass slide under nostrils for 60 seconds
• PULSE - palpate carotid pulse for 60 seconds
• EKG - attach EKG leads and interpret rhythm**
• LOC - determine LOC by verbal and motor responsiveness.
♦ Categorize the hypothermic patient according to the following:
• MODERATE HYPOTHERMIA
• Respirations >12/min, palpable pulses, organized EKG rhythm, and
responds to commands
• COLD ALIVE
• Respirations < or = 12/min, no palpable pulse, organized EKG rhythm,
responsive to verbal or motor stimuli
• COLD LIFELESS (see DEATH IN THE FIELD protocol)
• Apneic, pulseless, disorganized EKG rhythm, no response
• FROZEN LIFELESS (see DEATH IN THE FIELD protocol)
• Apneic, pulseless, major trauma, head or trunk frozen
7/01 T.17.4
TREATMENT
♦ Determine temperature of patient as possible
♦ Allow patient to breathe humidified 100% O2 NRB
♦ Remove wet, cold, or constricting clothing; wrap patient in blankets. Protect from further
exposure
♦ Handle patient gently; the hypothermic heart is irritable, and roughness may result in
ventricular arrhythmias
♦ Treat according to the category of hypothermia:
• MODERATE HYPOTHERMIA
Supportive care, warm O2, EKG monitoring, IV if feasible**, transport as
soon as possible
• COLD ALIVE
Warm O2, EKG monitoring, IV if feasible**, transport as soon as possible
• COLD LIFELESS (see DEATH IN THE FIELD protocol)
ACLS protocols, warm O2, start peripheral IV **
• FROZEN LIFELESS (see DEATH IN THE FIELD protocol)
Transport only if the risk to rescue personnel is acceptable
♦ Use warmed IV fluids if possible; 10 cc/kg bolus and 5 cc/kg per hour**
♦ If hypothermia injury is local (frostbite):
• Handle injured part gently; leave uncovered
• Do not allow injured part to thaw if chance exists for refreezing before arrival at
definitive care facility
• Maintain core temperature of patient with blankets
♦ Do not force oral intubation
♦ Consider other protocols as appropriate (i.e.ALTERED MENTAL STATUS/COMA)
♦ Severely hypothermic patients may appear dead. When in doubt begin CPR. Field
determination of death should not be considered until the patient is evaluated by a
physician
♦ Patients who are profoundly hypothermic (COLD LIFELESS) may require pump
rewarming and should be transported to hospitals with that capability (cardiac bypass)
♦ Do not consider the patient dead unless they are warmed first!
7/01 T1.5
MUSCULOSKELETAL INJURIES
HISTORY
♦ Mechanism of injury
o Location
o Time
♦ Past medical history
PHYSICAL FINDINGS
♦ Vital signs
♦ Level of consciousness (GCS score)
♦ Cervical exam for tenderness
♦ Localized pain, tenderness
♦ Swelling, discoloration, angulation, crepitus
♦ Deep lacerations, exposed bone fragments
♦ Loss of function, limitation of motion, guarding
♦ Quality of distal pulses, capillary refill
♦ Paralysis, numbness, incontinence
TREATMENT
♦ Assure airway, breathing, circulation, control hemorrhage

♦ Immobilize cervical spine if appropriate:
o Major or consistent mechanism of injury
o Potential C spine injury and:
Altered LOC or intoxication
Neck Pain
New neurologic deficits
♦ Examine for additional injuries, evaluate, and treat, if necessary, those with higher
priority
♦ For highly suspected pelvic or femur fractures, consider large bore IV with Balanced Salt
Solution (see SHOCK protocol)**
♦ For open fractures:
o Control bleeding with direct pressure and/or elevation
o Apply sterile dressing saturated with Normal saline
♦ Splint all fractures in the normal anatomic position, applying axial traction as needed
♦ Elevate simple fractures. Apply ice or cold packs if time and extent of other injuries
allow
♦ If the patient has severe pain, consider Morphine Sulfate 2-5 mg IV slowly (see
MORPHINE protocol)***. Do not use if a patient has undiagnosed abdominal pain or
head injury
7/01 T1.6
TREATMENT (cont)
♦ Transport as necessary, monitor circulation (pulse and skin temperature), sensation, and
motor function distal to site of injury
♦ Fractures do not necessarily lead to loss of functions, e.g., impacted fractures may cause
pain but little or no loss of function
♦ Extremity injuries benefit from appropriate care, but are of low priority in a multiple-
injured patient
♦ Small children require extra padding under the shoulders when immobilizing the C-spine
♦ The dose of morphine for children <30kg is 0.1 mg/kg***. This dose may be repeated in
5 minutes if there continues to be severe pain
7/01 T18.1
NEAR DROWNING
HISTORY
♦ How long patient was submerged

♦ Approximate temperature of water
♦ Fresh or salt water
♦ Contamination of water
♦ Depth of recovery
♦ Trauma
• MVA
• Scuba
• Diving
• Child abuse
♦ Drug/alcohol use
♦ Symptoms:
• Cough, dyspnea, vomiting, pleuritic chest pain
PHYSICAL FINDINGS
♦ Vital signs; especially temperature, respiratory rate

♦ Neurologic status:
o Mental status, pupillary exam, Seizures
♦ Respiratory
o Rales, wheezing, frothy sputum
♦ HEENT
o Signs of head and/or neck trauma, neck tenderness
TREATMENT
♦ Clear upper airway

♦ Assist ventilation as needed; if unsuccessful, patient may need intubation and positive
pressure or suction
♦ Stabilize neck prior to removing from water if any suggestion of neck injury
♦ O2, 15 LPM via non-rebreather mask*
♦ Monitor cardiac rhythm (see CARDIAC ARREST and CARDIAC DYSRHYTHMIAS
protocols**
7/01 T18.2
♦ Be prepared for vomiting

♦ ALL NEAR-DROWNINGS SHOULD BE TRANSPORTED. Even if patients initially
appear fine, they can deteriorate. Monitor closely. Pulmonary edema is likely, and can
occur after a long normal interval
♦ Hypothermia may be a problem (see HYPOTHERMIA protocol)
♦ Be aware of other injuries in near drowning associated with trauma (MVA’s, jumping or
diving)
♦ Do not resuscitate patients in cardiac arrest if submerged for more than 30 minutes
EXCEPT:
• Resuscitate if the patient is recovered after being submerged for 60 minutes if:
1. The patient may have been trapped in an underwater air pocket
2. The water is less than 40o F at recovery depth
7/01 T19.1
NEONATAL RESUSCITATION
HISTORY
♦ The following are considered high risk pregnancies and deliveries in which neonatal
resuscitation may be necessary:
• Painful bleeding in mother (Placentia Abruptio)
• Premature rupture of membranes
• Maternal fever
• Maternal signs of pre-eclampsia which include hypertension, hypotension, edema,
and seizures
PHYSICAL FINDINGS
♦ Neonatal vital signs

♦ APGAR Criteria (Absent heart rate, absent or slow respiratory response, blue or cyanotic
skin color)
♦ Meconium staining of the fluid
♦ Prolapsed cord
TREATMENT
♦ If respiratory effort inadequate:

• Assist ventilations with 100% O2 via BVM for 60 seconds and reassess
• Assess heart rate and respiratory status frequently. If spontaneous respirations
return, and heart rate is greater than 100 beats per minute, continue to provide
100% O2 to patient via face mask and assist ventilations until spontaneous
respirations are adequate and color is good
• If the infant remains apneic or bradycardic, with a pulse less than 80 beats per
minute, perform endotracheal intubation and continue to provide 100% O2 and
perform chest compressions at 120/min rate
♦ If the heart rate remains below 80 beats per minute:
• Secure intravenous access; start IV NS to run wide open (Umbilical vein
(preferred), Peripheral site, Intraosseous site, Endotracheal tube (for NAVEL
drugs)**
• Administer epinephrine 1:10,000 0.01-0.03 mg/kg IVP q 5 minutes (double the
dose for endotracheal administration)
• Check dextrostix. If < 40 mg/dl, consider dextrose in D25 solution, 0.25-0.50
mg/kg IVP; max dose is 2 cc/kg
• Administer a fluid challenge of 10 cc/kg NS IV bolus over 5-10 minutes; may
repeat onceif no response
• Consider 2 mEq/kg 4.2% solution sodium bicarbonate if the bradycardia is
prolonged
7/01 T19.2
SPECIAL PRECAUTIONS
♦ Meconium Aspiration
• Because meconium aspiration is a major cause of neonatal morbidity and
mortality, preventing this is very important and could save an infants life.
• Close to 60% of all neonates with meconium staining of the amniotic fluid
aspirate. In order to prevent aspiration the hypopharynx must be thoroughly
suctioned before initiation of respirations
• This is done by using a 10 F or larger catheter to suction the mouth, nose, and
pharynx of a meconium stained neonate as soon as the head is delivered
• After delivery, endotracheally intubate and suction the neonate if there is thick
meconium with particulates in it or they continue to have depressed respirations
• In a neonate with severe asphyxia, the full clearance of meconium need to be
weighed against the need to start resuscitation
7/01 T20.1
OB/GYN EMERGENCIES
HISTORY
♦ Last normal menstrual period

♦ Contraception
♦ Vaginal bleeding
• Onset
• Duration
• Cramping
• Passage of clots or tissue
• Dizziness
• Weakness
• Number of pads used
♦ Pregnancy
• Due date
• Contractions
• Ruptured membranes
• Signs of pre-eclampsia
Edema
Hypertension
Seizures
♦ Postpartum
• Time and place of delivery
♦ Abdominal pain
♦ Past medical history (include OB/GYN history G? P?)
♦ Contraceptive history
PHYSICAL FINDINGS
♦ Vital signs, (orthostasis, tachycardia, hypotension)

♦ Note vaginal blood loss, clots or tissue fragments (bring tissue to hospital). Note color of
blood.
♦ Abdominal tenderness, guarding
♦ If delivery is imminent, inspect the perineum for bleeding, fluid, and presentation
(crowning or abnormal) see CHILDBIRTH protocol
♦ Do not perform a digital exam
7/01 T20.2
TREATMENT
♦ O2, moderate flow (see AIRWAY protocol)*

♦ Consider IV: Balanced Salt Solution as needed (see SHOCK protocol)**
♦ In the third trimester, transport on the left side unless delivery is imminent
♦ If patient is post-partum:
1. Massage uterus, have mother nurse infant to aid in uterine contraction to stop or
slow down bleeding
♦ If the patient is near term and has signs of Preeclampsia (blood pressure greater than
160/110 mmHG, peripheral edema, headaches, seizures):
1. If seizures, see SEIZURES protocol
2. Transport immediately
3. Magnesium Sulfate can be used as a preventative agent in women with
preeclampsia for seizures. Contact OLMC to consider using Magnesium.***
♦ Obtain vital signs during transportation.
SPECIAL PRECAUTIONS
♦ Always consider pregnancy, or ectopic pregnancy particularly as a cause of vaginal
bleeding or abdominal pain in any female of child bearing age
♦ Patients in shock from vaginal bleeding should be treated the same as any patient with
hypovolemic shock (see SHOCK protocol)
7/01 T21.3
POISONS AND OVERDOSES
HISTORY
♦ Type of ingestion: What, when, and how much was ingested? Bring the poison, the
container, sample of emesis, and everything questionable in the area with the patient to
the Emergency Department.
♦ Look for multiple patients with same signs and symptoms.
♦ Reason for ingestion: Screen for child neglect, suicidal problems.
♦ Past history: medications/allergies
♦ Action taken by bystanders: Induced emesis: "antidote" given?
♦ History of drug/alcohol abuse
♦ Depression or suicidal
♦ Previous overdoses/poisonings
PHYSICAL FINDINGS
♦ Vital signs
♦ Level of consciousness, coma, seizures
♦ Breath odor, abnormal breathing patterns
♦ Vomiting
♦ Needle marks or tracks
TREATMENT
♦ External Contamination:
1. Assess and support ABC's
2. Protect medical personnel
3. Remove contaminated clothing
4. Flush contaminated skin and eyes with copious amounts of water
♦ Internal Ingestion (IV or PO):
1. Assess the airway and initiate O2 (see AIRWAY protocol)*

2. Initiate IV as indicated**
3. Consider administration of activated charcoal (1 gm/kg) in conscious, alert
patients, if the ingestion occurred within the past 6 hours.* Note Specific
Precautions. Contact Poison Control before administering Activated Charcoal or
Ipecac
4. Do not induce vomiting in patients who:
A. Have ingested strong acid, strong base, iodides, silver nitrate, strychnine,
or phenothiazines, hydrocarbons, camphor, tricyclics, INH, or short acting
sedatives
B. Are unconscious, obtunded, seizing, or have no gag reflex
C. Are in the third trimester of pregnancy
7/01 T21.4
TREATMENT (cont)
5. If patient has depressed respirations and decreased mental status (see ALTERED
MENTAL STATUS/COMA protocol):
A. Administer naloxone 2.0 mg, slowly injected IV, IM, SQ, SL, or ET, and
observe for improved ventilations (may be repeated every 3 to 5 minutes
up to 8.0 mg). Titrate to respiratory rate of 12.**
B. Determine whole blood glucose level using glucometer. If the blood
glucose reading is less than or equal to 60 mg %:
a. Administer D50 orally* or IV, 50 ml**
b. Thiamine, 100 mg IV if alcoholism or malnutrition is possible***
c. Administer glucagon 1.0 mg IM if unable to administer
dextrose.***
6. Monitor cardiac rhythm** (see CARDIAC DYSRHYTHMIAS protocol)
♦ If overdose includes a Cyclic Antidepressant:

1. Hyperventilate if possible, place Combitube** or endotracheally intubate*** if
comatose or no gag reflex
2. Treat hypotension with a fluid challenge** (see SHOCK protocol)
3. If life-threatening arrhythmias, PVC's, coma, hypotension, or sinus tachycardia
greater than or equal to 120 exist, administer 1.0 mEq/kg NaHCO3 slow IV
push.*** If QRS complex is greater than 100 ms, administer NaHCO3 1.0
mEq/kg slow IV push.***
♦ If Cholinergic poisoning (e.g. organophosphate poisoning) has occurred and patient is

critical with "SLUDGE" symptoms:
1. Administer 1.0 - 2.0 mg Atropine, slow IV push and repeat dosage every 5
minutes until secretions have substantially decreased**
2. Consider the need for HazMat response. Toxicity to prehospital crew may result
from inhalational or topical exposure
♦ If there is Carbon Monoxide poisoning (without burns):

1. Administer 100% O2 nonrebreather (see AIRWAY protocol)*
2. If there is decreased LOC, hyperventilate with 100%O2, place Combitube** or
endotracheally intubate***
3. Initiate IV (see SHOCK protocol)**
4. Transport to Providence Medical Center. Alert them as soon as possible of a
possible hyperbaric chamber patient.
♦ Consider the following additional therapy in patients with Beta Blocker overdose who
have bradycardia and hypotension:
1. Dopamine: in doses needed to maintain blood pressure above 100 systolic (see
SHOCK protocol)***
2. Glucagon: give IV glucagon 3-5 mg (50-75 µg/kg) over 1 minute***
7/01 T21.5
TREATMENT (cont)
♦ For Chlorine Gas Inhalation:
3. Nebulize Normal Saline via face mask or hand held nebulizer for duration of
transport**
4. Inhalation poisoning is particularly dangerous to rescuers. Recognize an
environment with continuing contamination and extricate rapidly by properly
trained and equipped personnel
♦ Obtain and document vital signs during transport.
♦ Some hydrocarbon ingestions may benefit from emesis. Contact Poison Control on all
hydrocarbon ingestions
♦ Do not try to neutralize acids with strong alkalis. Do not try to neutralize alkalis with
acids
♦ Activated Charcoal may be ineffective in ingestions such as mineral acids, alkalies,
petroleum products, Iron, and Lithium
♦ SLUDGE syndrome consists of Salivation, Lacrimation, Urination, Defecation,
Gastrointestinal distress (cramping, abdominal pain), Emesis.
♦ Intubate patient with compromised airway and/or ineffective respiratory effort who is
unresponsive to Narcan®.**
♦ IV glucagon dose is 50-75 µg/kg over 1 minute for ß Blocker OD***
♦ Naloxone dose is 0.1 mg/kg IV, IM, SL or SQ**
♦ The atropine dose may be very high in children with organophosphate poisoning***
♦ Consider the possibility of abuse or neglect
7/01 T22.1
PSYCHIATRIC/BEHAVIORAL EMERGENCIES
HISTORY
♦ Recent crisis
♦ Emotional trauma
♦ Bizarre or abrupt changes in behavior
♦ Suicidal/homicidal ideation
♦ Visual/auditory/tactile hallucinations
♦ Alcohol/drug ingestion
♦ Past medical/psychiatric history
PHYSICAL FINDINGS
♦ Vital signs
♦ Pupillary exam, focal neurologic deficits
♦ Mental status/orientation
TREATMENT
♦ If there is immediate danger to medical personnel and/or the patient:

a. Protect yourself and others
b. Summon law enforcement
c. Enter the scene after law enforcement clears the area and deems it safe
♦ If there is no evidence of immediate danger to medical personnel and/or the patient:

a. Assess ABC’s (see AIRWAY protocol)*
b. Assess their orientation and level of consciousness (see ALTERED MENTAL
STATUS/COMA protocol)
c. Convey concern for the patient at the same time establishing rapport
d. Do not stay alone with the patient; have help available if there is a need to restrain the
patient (see PATIENT RESTRAINT protocol)
♦ If there is no evidence of immediate danger to medical personnel and/or the patient and the
patient is suicidal:
a. Do not leave patient alone
b. Remove or have someone remove dangerous objects (i.e., knives, guns, pills, etc.)
c. Inquire specifically regarding depression, helpless or hopeless feelings and thoughts of
suicide
d. Question specifically about hallucinations or delusions
♦ Transport in calm, quiet manner; obtain, monitor vitals

7/01 T22.2
♦ Psychiatric disorders almost never cause Organic Brain Syndrome. If patient is disoriented, think
of medical causes
♦ Alcohol withdrawal can sometimes mimic a psychiatric disorder. It is manifested in the first
stage by:
• Weakness and tremulousness possibly accompanied by anxiety, headache, nausea, and
cramps
•Disturbance in gait, speech, mentation, drowsiness, erratic behavior
•Restless and agitated, craves alcohol or sedative drugs
•Patient may begin to "see" and "hear" things
♦ The second stage of withdrawal is manifested by:
• Same symptoms as first stage with the addition of convulsive seizures. The seizures may
begin as early as 12 hours after beginning of abstinence, but more often during the second
or third day
♦ The third Stage or Delirium Tremens is manifested by:
• Symptoms may include vivid and frequently terrifying auditory, visual and tactile
hallucinations, profound confusion, insomnia, disorientation, hypertension, severe
agitation, restlessness, fever, and an abnormally rapid heartbeat
• Withdrawal is a medical emergency and the patient should be hospitalized
♦ Prolonged abuse of alcohol makes the alcoholic more prone to certain illnesses, i.e. subdural
hematoma, pneumonia, cirrhosis, upper gastrointestinal hemorrhage, hypoglycemia, pancreatitis,
central nervous system disorders and heart problems.
♦ In attempting to obtain a history on the alcoholic patient there will be difficulty, because of
patient denial and family reluctance, to discuss the problem. Make the patient and/or family
aware of the seriousness of the medical situation and the possible outcome of their denial.
♦ POLICE ASSISTANCE: If the patient is in a public place and because of his/her intoxication
and/or withdrawal symptoms presents a danger to him/herself or to others, the police are
authorized by ORS to transport or arrange transport of the individual to a place of treatment.
♦ If the patient has a history of alcohol or drug abuse, consider the possibility of intervention with
the attending physician.
♦ Pediatric patients who are intoxicated may be hypoglycemic. Remember; always check a glucose
in any patient with altered mental status (see ALTERED MENTAL STATUS/COMA protocol)
1/02 T23.1
RESPIRATORY DISTRESS
HISTORY
♦ Onset (acute or gradual)
♦ Fevers/Chills
♦ Cough (sputum production)
♦ Recent illness
♦ Past medical history:
• Asthma
• CHF
• COPD
• Pneumonia
• Heart disease
• Diabetes
• Recent surgery
♦ Medications/allergies (include home O2)
♦ Chest pain
♦ Paresthesias (mouth, hands)
PHYSICAL FINDINGS
♦ Vital signs (include pulse oximetry)

♦ Cyanosis, rashes, hives
♦ Evidence of upper airway obstruction:
o Hoarseness, bucking, drooling, coughing, inspiratory stridor, irrational behavior, poor
cooperation
♦ Breath sounds: clear, rales, wheezing, symmetrical, labored. Abnormality on inspiration or
expiration?
♦ Signs of congestive failure; Distended neck veins when upright, rales, peripheral edema
♦ Evidence of trauma
BREATH SOUNDS IN RESPIRATORY DISTRESS

CHARACTERISTICS POSSIBLE DIAGNOSIS
Clear, symmetric Hyperventilation, M.I., metabolic, Pulmonary Embolus.
Rales, symmetric Pulmonary Edema, Extensive Pneumonia
Wheezing, symmetric Asthma, Pulmonary Edema, COPD
Clear, asymmetric or absent Pneumothorax, Pulmonary Embolus, COPD
Rales, asymmetric Pneumonia, Pulmonary Edema
Wheezing, asymmetric Foreign Body, Pulmonary Embolus, COPD
1/02 T23.2
TREATMENT
♦ Put patient in position of comfort

♦ Start O2 and be prepared to assist ventilation (see AIRWAY protocol)*
♦ Monitor cardiac rhythm (see CARDIAC DYSRHYTHMIAS protocol)**
♦ Use O2, low flow if patient history of COPD obtained and condition not emergent. CAUTION:
In these patients, higher O2 flows may precipitate respiratory arrest. Low flow O2 is adequate in
most clinical situations but can be safely increased in the absence of chronic lung disease.*
♦ Identify and treat UPPER AIRWAY OBSTRUCTION, if present:

• Partial or complete foreign body
2. If patient is coughing or shows evidence of air exchange, encourage patient in
these efforts*
3. If patient exhibits inadequate air exchange, perform abdominal thrusts (taking the
fist, place it thumb side toward the patient in the epigastrium; wrapping the fist
with the other hand, squeeze forcibly in and upwards) until obstruction clears or
patient loses consciousness*
4. If patient loses consciousness (or is found unconscious), position the head and
attempt to ventilate. If unable to ventilate, reposition the head and try again. If
still unable to ventilate, start CPR.*
5. If still unable to ventilate patient, perform direct laryngoscopy***. Remove any
foreign material noted with Magill forceps***. Again attempt to ventilate
patient. If unsuccessful, place Combitube** or endotracheally intubate***
6. If unable to perform endotracheal intubation and still unable to ventilate patient
by any means, perform cricothyrotomy*** and ventilate with 100% oxygen
• Infectious/inflammatory (croup, epiglottitis, anaphylaxis):

1. O2,highflow, blow-by for pediatrics (see PEDIATRIC CONSIDERATIONS)*
2. Allow patient to sit in position of comfort. Parent may be allowed to hold the
pediatric patient
3. Croup with stridor at rest: 0.5ml/kg of Epinephrine 1:1,000 (1mg/ml), in 3.0 cc
NS nebulized via hand held nebulizer. For child < 20 kg; may repeat X 1; for
child > 20 kg; may give continuously for child in danger of respiratory
collapse.***
4. Croup without stridor at rest: Nebulized Normal Saline***
5. Consider anaphylaxis and treat if appropriate (see
ANAPHYLAXIS/ALLERGIES protocol).
♦ Consider treatment for specific problem if field assessment can be made by history and physical
findings
♦ If wheezing or bronchospasm is present (Asthma, COPD):
1. Administer oxygen by most appropriate means to maintain oxyhemoglobin

saturation >92%. Measure and document initial room air oxyhemoglobin
saturation if possible prior to use of oxygen therapy***
1/02 T23.3
TREATMENT (cont)
2. Inhalation therapy with nebulized albuterol (2.5-5.0 mg); may repeat as

needed.** Stop treatment if:
• The heart rate increases by 20 beats/minute
• Ventricular ectopy occurs
3. If a second treatment is needed or if the patient is normally on a combination
of Albuterol and Atrovent® for COPD, administer Ipatropium*** along with
the Albuterol. Administer 1 unit dose (0.5 mg) of Ipatropium.***
4. Consider early use of SQ Epinephrine in children (see PEDIATRIC
CONSIDERSATIONS)*
5. If the patient with bronchospasm is unresponsive to treatment and is
deteriorating, who is less than 40 years old, not diabetic and has no history of
cardiac disease, consider epinephrine 1:1,000 O.3 cc SQ***
6. Initiate IV access, Balanced Salt Solution if respiratory distress is severe**
7. Monitor cardiac rhythm**
♦ IF symmetrical rales present (Pulmonary Edema):

1. Administer O2, high flow (see AIRWAY protocol)*
2. Sit patient upright, dangle legs if possible
3. Initiate IV access, Balanced Salt Solution**
4. Monitor cardiac rhythm (see CARDIAC DYSRHYTHMIAS protocol)**
5. If BP is less than 100 mmHG, consider cardiogenic shock (see SHOCK
protocol)
6. Nitroglycerin 0.4 mg SL q 5 minutes, if systolic BP greater than 100 mg
Hg**; Be cautious with administering nitroglycerin to patients who have
taken Viagra® < 24 hours prior to encounter as these patients are more likely
to have hypotensive episodes
7. Furosemide (Lasix®) according to the following dosage schedule***:
• If the patient is not currently taking, give 40 mg IV
• Give the patient the same dosage that they are currently taking IV (e.g. if
the patient takes 40 mg/day, give 40 mg IV)
• Do not give more than 80 mg
8. Consider Morphine Sulfate, 2.0 mg increments to a maximum of 8.0 mg***
9. Consider nebulized Albuterol treatment, 2.5 mg for severe respiratory
distress with bronchospasm**
♦ Consider a Combitube** or endotracheal intubation*** in a rapidly deteriorating patient (see

AIRWAY protocol)
♦ If pneumothorax is present, watch for signs of tension. Consider decompression.*** (see
TENSION PNEUMOTHORAX DECOMPRESSION protocol)
1/02 T23.4
♦ If you are unable to differentiate the cause of the respiratory distress, the proper course is to
administer Oxygen and transport.
♦ Wheezing in older persons is frequently due to pulmonary edema, not asthma. Your patient may
make the wrong diagnosis. Consider also pulmonary embolus.
♦ Do not over-diagnose "hyperventilation" in the field. Your patient could have a pulmonary
embolus or other serious problem, give him/her the benefit of the doubt. Treatment with oxygen
will not harm the hyperventilator, and it will protect you from underestimating the problem
♦ Children with croup, epiglottitis or laryngeal edema usually have respiratory arrest due to
exhaustion or spasm. You will still be able to ventilate with mouth-to-mouth, pocket mask or
bag/valve/mask technique. Do not attempt intubation, even after several attempts at
repositioning, unless you are unable to ventilate the patient with non-invasive methods.
♦ Transport in a parents arms if the child is conscious
♦ Do not dilute or reduce the dose of albuterol
♦ Use "blow-by" technique with mask or nebulizer in children unable to properly use nebulizer
♦ Dose of epinephrine for children with asthma:
• Epinephrine 1:1000, 0.01 mg/kg (0.01 cc/kg) SQ***
7/01 T24.1
SEIZURES
HISTORY
♦ Onset
♦ Time interval
♦ Type of seizure (focal, febrile, grand mal, petit mal)
♦ Previous history of seizures
♦ Medical history
• Medications and compliance
• Head trauma
• Diabetes
• Headaches
♦ Drugs or alcohol withdrawal
♦ Pregnancy (eclampsia)
PHYSICAL FINDINGS
♦ Vital signs
♦ Seizure activity
♦ Head and oral trauma
♦ Incontinence. (Urinary or fecal)
♦ Focal neurologic signs
♦ Headache.
TREATMENT
♦ Airway: Ensure patency and start O2 (see AIRWAY protocol)*

♦ Monitor cardiac rhythm (see CARDIAC DYSRHYTHMIAS protocol)**
♦ Continue assessing and document level of consciousness every 5 minutes
♦ Obtain and document vitals.
♦ Transport on the left side
♦ Medical personnel are often called to assist epileptics who seize in public. If patient
clears completely, is taking his medications, has his own physician and is experiencing
his usual frequency of seizures, transport may be unnecessary. Document patient's
mental status and have patient sign a refusal form. If under the age 18, have a parent or
guardian sign.
7/01 T24.2
TREATMENT (cont)
♦ If patient is in status seizures upon arrival, (status seizures are defined as: a continuous
seizure lasting more than 5 minutes, or repetitive seizures without regaining
consciousness):
1. Do not FORCE anything between the teeth; suction as needed

2. Initiate IV access**
3. Determine whole blood glucose level using glucometer. If the blood glucose
level is less than or equal to 60 mg %:
D50W, 50 ml IV into secure vein.** Give Thiamine 100 ml IV after
giving glucose if alcoholism or malnutrition is suspected.*** Administer
Glucagon 1.0 mg IM if unable to administer dextrose***
4. Administer midazolam 2.5 mg IV and may repeat once for continued seizure. If
no IV access, give midazolam 5mg IM and repeat once for continued seizure***
SPECIAL PRECAUTIONS
♦ Don't forget to check for a pulse. Seizure activity may be the first sign of cerebral
hypoxia from cardiac arrest
♦ Seizures in patients over the age of 50 are frequently caused by dysrhythmias
♦ Move hazardous material away from patient. Restrain the patient only if needed to
prevent injury. Protect patient's head.
♦ Focal motor seizures are generally not treated in the pre- hospital setting
♦ New onset seizure in any patient needs medical evaluation
♦ New onset seizures in a pregnant woman, in the third trimester may be indicative of
eclampsia (see OB-GYN EMERGENCIES protocol)
♦ Febrile seizures are found in children between the ages of 1 and 6; there is usually a
history of recent fever or illness and the seizures are usually short in duration
♦ The midazolam dose for children is:
o 0.1mg/kg IV for a continuous or repetitive seizure up to a maximum of 2.5 mg;
may repeat once***
o If there is no IV access, give 0.2 mg/kg IM or IO to a maximum of 5 mg; may
repeat once***
7/01 T25.1
SHOCK
PHYSICAL FINDINGS
♦ Shock is defined as inadequate organ perfusion

♦ Signs and Symptoms may include, but are not limited to:
• Tachycardia (Pulse over 120)
• Hypotension (systolic BP <90 mm Hg)
• Skin cold and clammy. (May be absent in early septic shock).
• Mental status: Confusion, restlessness, apathy.
• Other: Marked thirst, syncope
CLASSIFICATION OF SHOCK
♦ Hypovolemic Shock: Shock characterized by the loss of circulating blood volume. This
may be due to direct hemorrhage or through loss of fluids from severe vomiting, diarrhea,
burns, or peritonitis.
♦ Cardiogenic Shock: Pump failure.
♦ Distributive Shock: Characterized by abnormal vascular tone. Includes anaphylaxis,
early sepsis, neurogenic shock.
♦ Obstructive Shock: Mechanical obstruction to blood flow to or from the heart. Includes
cardiac tamponade, tension pneumothorax, dissecting aneurysm, massive pulmonary
embolism.
TREATMENT
♦ HYPOVOLEMIC SHOCK
1. Stop exsanguinating hemorrhage, if present.
2. Place patient on stretcher, in Trendelenburg or shock position as tolerated.
3. O2, high flow with ventilatory assistance as required.* Consider early
intubation*** (see AIRWAY protocol)
4. IV, Balanced Salt Solution, large bore, x 2 if time and sites permit**
5. If no signs of fluid overload are present, give 500 ml Balanced Salt Solution IV as
rapidly as possible (10 ml/kg); monitor and document changes in patient status**
6. Repeat fluid bolus can be given if improvement is transient; without
improvement, may be repeated if the EMT believes it is in the patient’s best
interest and the patient shows no signs of pulmonary edema
7. Monitor and document cardiac rhythm**, if possible and vital signs as well as
level of consciousness during transport.
8. DO NOT DELAY TRANSPORT. PATIENTS IN PROFOUND SHOCK MUST
BE TRANSPORTED IMMEDIATELY WITH AS MANY OF THE ABOVE
STEPS AS POSSIBLE ACCOMPLISHED ENROUTE.
7/01 T25.2
TREATMENT (CONT)
♦ CARDIOGENIC SHOCK
1. O2, high flow; assist ventilation as necessary. Consider placing a Combitube** or
endotracheal intubation***
2. Monitor cardiac rhythm**. Evaluate and treat (see CARDIAC
DYSRHYTHMIAS protocol. Remember that shock itself can be a cause of
dysrhythmias
3. IV, balanced salt solution, large bore**
• Administer fluid challenge of 250 ml. ** If the systolic blood pressure
does not increase to 90 mm Hg or greater:
Administer Dopamine (see DOPAMINE INFUSION)***
4. Consider Tension Pneumothorax as a cause and treat accordingly
5. Obtain vital signs frequently, watch level of consciousness and transport
WITHOUT DELAY.
♦ DISTRIBUTIVE SHOCK
1. Give a 500 cc fluid challenge IV and repeat once if no response (BP systolic > 90
mmHg)**
2. If shock persists, consider Dopamine (see DOPAMINE INFUSION)***
3. If anaphylaxis is suspected, see ANAPHYLAXIS/ALLERGIES protocol
♦ OBSTRUCTIVE SHOCK
1. Apply the cardiac monitor (see CARDIAC DYSRHYTHMIAS protocol)**
2. Consider a fluid challenge of 500cc Balanced salt solution**
3. Treat underlying causes:
• Tension Pneumothorax- needle thoracentesis***
• Cardiac Tamponade- pericardiocentesis in the hospital
• Massive Pulmonary Embolus- Hospital surgery
• Dissecting Aneurysm- Hospital surgery
DOPAMINE INFUSION***
♦ Mix Dopamine in a Volutrol® type device (60 gtts/cc)

♦ For Adults:
1. Mix 400 mg in 250 cc of BSS or 800 mg in 500 cc BSS giving a concentration of
1600 mcg/cc
2. Take the patients weight in POUNDS, round to the nearest ten, drop the zero, and
that number is the number of drops/minute that equals 5 mcg/kg/min
3. An example of this is:
Patient weight 174 pounds, round to 170
Drop the zero and you get 17
17 gtts/min=5 mcg/kg/min
7/01 T25.3
• Initial pediatric fluid bolus is 20 cc/kg IV or IO**

• Additional fluid boluses of 20 cc/kg can be given up to 60 cc/kg total**
• Determine the blood glucose level for shock in children and treat (see DIABETIC
EMERGENCIES protocol)**
• For CARDIOGENIC SHOCK and DISTRIBUTIVE SHOCK, consider Dopamine if no
improvement in BP or perfusion after 60 cc/kg fluid challenge***
• The Dopamine formula for Pediatrics is***:
o Mix 80 mg in 250 cc BSS or 160 mg in 500 cc BSS giving a concentration of 320
mcg/cc
o 1 gtt/kg/min of this solution equals 5 mcg/kg/min
o If the patient weighs 10 kg, run the infusion at 10 gtts/min to get 5 mcg/kg/min
7/01 T26.1
SUSPECTED SPINAL INJURY

HISTORY
♦ Violent mechanism of injury (witness, scene, situation)

♦ High-energy transfer (ejection, helmet damage, starred windshield, etc.)
♦ Spinal cord injury may be the result of direct blunt and/or penetrating trauma, compression forces
(axial loading), abnormal motion (hyper flexion, hyperextension, hyper rotation, lateral bending
and distraction, i.e., hanging)
PHYSICAL FINDINGS
♦ Significant injury above the clavicles and around the head

♦ Significant multiple trauma
♦ Prior or present altered mental status
♦ Paralysis, weakness, numbness, or tingling with violent mechanism of injury or high energy
transfer
♦ Pain of the spine with or without movement
♦ Point tenderness, deformity, or guarding of the spine.
TREATMENT
♦ The following treatment will be used when any or all of the above PHYSICAL FINDINGS are
present, or when in the EMTs best judgment, the patient needs spinal support:
1. Temporarily immobilize cervical spine with rigid extrication collar, and continuous
manual in-line support. Immobilize thoracic and lumbosacral spine to long spine board
when possible, and/or other appropriate device as patient condition allows (KED,
orthopedic, etc.).
2. Place 1 - 2" of soft material behind head to cushion head and preserve neutral position of
head on backboard. Secure head and cervical spine to long spine board using dense, soft,
support material on both sides of the head, and tape. Straps affixed directly to the long
board will securely immobilize patient’s entire body. During this procedure the patient
should be moved as little as possible, and always as a unit.
3. Administer O2 as indicated (see AIRWAY protocol)*
4. Initiate IV if appropriate (see SHOCK protocol)**
♦ Vomiting should be expected in head injury patients. Therefore, patient should be securely
strapped to long board to enable board and patient to be turned as a unit. EMT should be aware
that additional help may be necessary during transport to turn patient and manage airway while
maintaining C-spine integrity.
♦ Chin straps that could compromise the airway should be removed as the patient is immobilized to
the long board.
♦ Most patients require 1 to 1 1/2 inches of firm padding behind the head to assume standard
neutral anatomic position.
7/01 T26.2
SPECIFIC PRECAUTIONS (CONT)
♦ In the severely traumatized patient requiring immediate life saving intervention and rapid
transport, rigid C-collar, continuous manual in-line support during rapid extrication onto a long
spine board and transport should be substituted for more time consuming methods.
♦ Airway problems, respiratory difficulty, and Shock are common in the traumatized patient.
Alternative techniques for performing airway procedures should be used in spinal injury patients.
To maintain proper control of the C-spine, 2 EMTs must perform a Combitube** or endotracheal
intubation*** with in-line stabilization.
♦ If any immobilization techniques cause an increase in pain or neurologic deficit, the patient
should be immobilized in position found or position of greatest comfort.
♦ Geriatric patients (over 55) should cause a higher index of suspicion for the EMT due to
physiologic aging changes. The EMTs awareness of the need to provide for C-spine
immobilization should be more acute in these patients.
7/01 T27.1
SYNCOPE
HISTORY
♦ Onset
♦ Duration
♦ Seizure activity
♦ Precipitating factors; was the patient sitting, standing or lying
♦ Patient pregnant?
♦ Recent trauma
♦ Past medical history:
o Prior syncope
o Cardiac disease
o CVA
♦ Medications (newly prescribed)/allergies
♦ Symptoms: Vertigo, nausea, palpitations, chest or abdominal pain.
PHYSICAL FINDINGS
♦ Vital signs: Orthostasis (significant if pulse change > 30 bpm or systolic BP change > 15
mmHg from lying to sitting or standing)
♦ Neurologic exam: decreased level of consciousness, coma (see ALTERED MENTAL
STATUS/COMA protocol)
♦ Cardiovascular: presence of dysrhythmias (see CARDIAC DYSRHYTHMIAS
protocol)
♦ HEENT: Signs of head trauma
♦ Incontinence
TREATMENT
♦ Assess the airway and administer O2 (see AIRWAY protocol)*

♦ Initiate IV access (see SHOCK protocol)**
♦ Determine whole blood glucose level using glucometer. If blood glucose is less than or
equal to 60 mg%:
• Give D50W orally if possible* or 50 ml in large vein if patient is unable to take
sugar orally**
♦ Cardiac monitor (see CARDIAC DYSRHYTHMIAS protocol)**
♦ Obtain and document vital signs during transport
7/01 T27.2
♦ Most syncope is vasovagal, not cardiac. Recumbent position should be sufficient to

restore vital signs and level of consciousness to normal.
♦ Syncope in a recumbent position is almost always cardiac in etiology.
♦ Syncope of recent onset in middle-aged or elderly patients is often cardiac and deserves
special concern. Occult GI bleeds, dissecting aneurysms, and ectopic pregnancy may
also present with syncope.
♦ Syncope by definition is a transient state of unconsciousness from which the patient has
recovered. If the patient is still unconscious, follow the ALTERED MENTAL
STATUS/COMA Protocol or SHOCK protocol.
7/01 T28.1
12 LEAD EKG AND THROMBOLYSIS***

St Helens Only
♦ Follow CARDIAC CHEST PAIN protocol
♦ Obtain 12-lead EKG, transmit to Good Samaritan Emergency Department.

Telephone/radio link with Emergency physician for confirm/deny "Acute Myocardial
Infarction" as EKG diagnosis. Emergency physician will not order thrombolytic therapy;
that is a paramedic decision. Notify Emergency Physician of your destination so that the
12-lead EKG can be faxed to the receiving hospital.
♦ If confirmed, review the checklist to insure there are no YES or questionable responses.
♦ Mix and administer Retavase® using sterile technique:

1. Inject 10 ml of Sterile Water for Injection into the vial of Retavase®.
2. Swirl gently to dissolve. DO NOT SHAKE.
3. Withdraw 10 ml of the solution from the vial, and inject into a patent, running IV
over a 2 minute period.
4. Repeat steps 1-3, timing the administration of the second bolus to begin thirty
(30) minutes after the start of the first bolus.
♦ Initiate Code 3 transport to the receiving hospital

7/01
Medication
Protocols
7/01 M1.1
ACTIVATED CHARCOAL
CLASS
♦ Absorbent
PHARMACOLOGY AND ACTIONS:
♦ Activated charcoal is a fine black powder that binds and absorbs ingested toxins
that may still be present in the GI tract
♦ Once bound to the activated charcoal, the combined poison-charcoal in excreted
from the body
INDICATIONS
♦ Effective in the management of poisoning or overdose of many substances.
PRECAUTIONS/CONTRAINDICATIONS
♦ Poison Control must be contacted before administering Activated Charcoal.
♦ Activated Charcoal should NOT be given to patients who are unconscious or who
may have a rapidly diminishing level of consciousness.
♦ Activated Charcoal may be ineffective in ingestions such as mineral acids,

alkalies, petroleum products, Lithium, or Iron.
♦ Administration of Activated Charcoal can result in aspiration.
♦ Activated charcoal may cause constipation
ADMINISTRATION
♦ Poison Control must be contacted.
♦ 1.0 gm/kg of Activated Charcoal in an aqueous- based solution. Dosage may be

higher as directed.
7/01 M2.1
ADENOSINE (ADENOCARD®)***
CLASS
♦ Endogenous nucleoside
PHARMACOLOGY AND ACTIONS
♦ Adenosine is a naturally occurring nucleoside that has the ability to slow conduction
through the AV node.
♦ Since most cases of PSVT involve AV nodal re-entry, Adenosine is capable of
interrupting the AV nodal circuit and stopping the tachycardia, restoring normal sinus
rhythm. It is not associated with hypotension and can be used safely in both wide and
narrow complex tachycardias.
♦ It is eliminated from the circulation rapidly, having a half life in the blood of less than 10
seconds. This allows for the use of repeated doses in rapid succession if needed.
INDICATIONS
♦ To convert PSVT to normal sinus rhythm, including PSVT that is associated with
accessory bypass tracts (e.g. WPW).
PRECAUTIONS /CONTRAINDICATIONS
♦ When doses larger than 12 mg are given by infusion, there may be a decrease in blood
pressure secondary to a decrease in the peripheral vascular resistance.
♦ The effects of Adenosine are antagonized by the methylxanthines, such as Caffeine or

Theophylline. This would mean that larger doses of Adenosine may be required in the
presence of methylxanthines.
♦ Adenosine effects are potentiated by dipyridamole, thus requiring smaller doses of

Adenosine in the presence of dipyridamole.
♦ In the presence of Carbamazepine (Tegretol®), higher degrees of heart block may be

produced.
♦ Inhaled Adenosine has been shown to produce bronchospasm in asthmatic patients but IV
Adenosine has not. One should be aware of the possibility that Adenosine may produce
bronchoconstriction in patients with asthma
♦ Adenosine is not effective in converting Atrial Fibrillation, Atrial Flutter, or Ventricular

Tachycardia.
♦ Adenosine may “expose” atrial flutter in a patient who is being treated for presumed
PSVT in that the flutter waves become apparent during the administration of Adenosine.
7/01 M2.2
PRECAUTIONS /CONTRAINDICATIONS (CONT)
♦ Contraindicated in :
1. 2nd or 3rd degree AV block, sick sinus syndrome.
2. Known hypersensitivity.
3. Pregnancy is a relative contraindication.
ADMINISTRATION
♦ Adenosine is administered in less than 5 seconds via a rapid IV bolus, preferable through
a large bore IV in an antecubital vein.
♦ The medication should be administered through as IV port as close to the patient as

possible so it is not diluted in the tubing.
♦ ADULT DOSE:
6 mg should be administered as an initial bolus followed by a 20 ml saline
flush.
A second bolus of 12 mg should be administered in 1 - 2 minutes if the first
bolus did not convert the patient to a normal sinus rhythm. A third 12 mg
bolus may be administered in 1 - 2 minutes if the two previous boluses were
unsuccessful.
♦ PEDIATRIC DOSE:
0.1 mg/kg IV push; increase to 0.2 mg/kg if necessary. May repeat X 1
SIDE EFFECTS/SPECIAL CONSIDERATIONS
♦ The most common side effects include facial flushing, dyspnea, chest pressure, nausea,
headache, and lightheadedness. These side effects are transient and usually last for only
5 - 10 seconds.
♦ Transient 3rd degree heart block is common.
♦ If the patient becomes hemodynamically unstable at any point in time, cardioversion

should occur.
7/01 M3.1
ALBUTEROL SULFATE (PROVENTIL®)**
CLASS
♦ Sympathomimetic, bronchodilator
♦ Albuterol Sulfate is a potent, relatively selective ß2 adrenergic agonist and bronchodilator.
♦ The onset of improvement in pulmonary function is within 2 - 15 minutes after the initiation of
treatment and the duration of action is from 4 - 6 hours.
♦ As a ß2 agonist, Albuterol induces bronchial dilatation, but has occasional ß1 overlap with
clinically significant cardiac effects. Clinically significant arrhythmias may occur especially in
patients with underlying cardiovascular disorders such as Coronary Insufficiency and
Hypertension.
INDICATIONS
♦ Bronchial Asthma
♦ Reversible bronchial spasms that occur with Chronic Pulmonary Disease
♦ Wheezing secondary to allergic reactions.
♦ The patient's rhythm should be observed for arrhythmias. Stop treatment if:
1. Pulse increases by 20 BPM.
2. Frequent PVC's develop.
3. Any tachyarrhythmias other than Sinus Tachycardia appear.
♦ Paradoxical brochospasm may occur with excessive administration.
ADMINISTRATION
♦ The usual dosage for adults and children is 2.5 mg of Albuterol administered 3 - 4 times daily by
nebulization.
♦ Albuterol Sulfate solution for inhalation comes premixed in 3.0 ml unit dose containing total 2.5
mg at a concentration of 0.83 mg/ml. Refrigeration is not necessary with this medication.
7/01 M3.2
ADMINISTRATION (CONT)
♦ Patients in significant respiratory distress after the first treatment may require another treatment
immediately. If necessary, continue with sequential treatments.
♦ THE TECHNIQUE FOR ADMINISTERING ALBUTEROL IS AS FOLLOWS:
1. Nebulization should be accomplished using the supplied kit.
2. Oxygen flow should be set at 6 LPM. Patients with COPD should be monitored carefully for
CO2 retention.
3. Patients should be instructed to breathe as follows:
4. Inhale slowly.
5. Hold breath.
6. Exhale passively through nose.
♦ Albuterol may precipitate angina pectoris and dysrhythmias
♦ Albuterol should only be administered via inhalation
♦ Should be used with caution in patients with diabetes mellitus, hyperthyroidism, prostatic
hypertrophy or seizure disorders
♦ Safe to use in Pregnancy
♦ May be used with Ipatropium*** in selected patients with COPD. (see RESPIRATORY
DISTRESS protocol)
1. Skeletal muscle tremors are a common side effect

7/01 M4.1
AMIODARONE (CORDARONE®)***
optional
CLASS
♦ Amiodarone is a class IV antiarryhmic drug
♦ It has a negative chronotropic effect in nodal tissues similar to class IV drugs and blocks
sodium potassium and calcium channels. It also has alpha and beta blocking properties.
♦ Amiodarone is metabolized by the cytochrome P450 system in the liver to N-
desethylamiodarone (DEA), the major active metabolic in humans.
INDICATIONS
♦ Amiodarone IV is indicated for the treatment of ventricular fibrillation and pulseless

ventricular tachycardia (see CARDIAC ARREST protocol)
CONTRAINDICATIONS
♦ In patients with cardiogenic shock

♦ Marked sinus bradycardia
♦ 2nd or 3rd degree heart block
♦ Known hypersensitivity
PRECAUTIONS
♦ Hypotension is the most common side effect seen with infusions of amiodarone as well as
bradycardia and AV block both of which are treated by slowing the infusion rate.
♦ When used in patients taking beta blockers, there is an increased risk of hypotension and
bradycardia. When used in patients taking calcium channel blockers, there is an increased
risk of AV block in patients on verapamil or dilitiazem, and hypotension in all other calcium
channel blockers.
ADMINISTRATION
♦ Amiodarone is administered as a bolus of 300 mg IV for VF and unstable VT.

♦ If the patient converts to a sinus rhythm with amiodarone, an infusion should be started at
60mg/hr or 1 mg/min.
♦ The liquid has a tendency to foam if withdrawn too rapidly, rendering it useless. Consider
drawing it slowly and through a specialized filter needle.
7/01 M5.1
ASPIRIN*1
CLASS
♦ Anti-inflammatory agent, platelet aggregation inhibitor.
PHARMACOLOGY/ACTIONS
♦ Aspirin has a plethora of actions through its inhibition of the production of

prostaglandins, leukotrienes, and thromboxane. Aspirin acts as a potent anti-
inflammatory, analgesic, antipyretic, and inhibitor of platelet function.
INDICATIONS
♦ As an antiplatelet agent in patients with chest pain of suspected ischemic cardiac

etiology.
♦ Contraindicated in patients with a known hypersensitivity to aspirin.
♦ Contraindicated in patients with active GI bleeds. Long term use can lead to GI bleeds in
patients without other risk factors for ulcers. Overdose can be fatal.
♦ A history of asthma and nasal polyps may indicate an unknown hypersensitivity to

aspirin.
♦ Patients who have taken aspirin within the past twenty-four (24) hours do not need repeat
aspirin administration. When in doubt, treat.
♦ Multiple products and OTC preparations contain aspirin. When in doubt, read the label.
♦ Aspirin administration decreases mortality an equivalent amount as thrombolytics in

acute myocardial infarction, with substantially less risk.
ADMINISTRATION
♦ Chew and swallow four 81 mg aspirin tablets.

1
Basics may administer after completing a board approved course
7/01 M6.1
ATROPINE SULFATE
CLASS
♦ Anticholinergic
♦ Atropine is a muscarinic-cholinergic blocking agent. As such, it has the following effects:

a. Increases heart rate (by blocking vagal influences).
b. Increases conduction through A-V node (i.e., increases ventricular sensitivity to atrial
impulses).
c. Reduces motility and tone of GI tract.
d. Reduces action and tone of the urinary bladder (may cause urinary retention).
e. Dilates pupils.
f. This drug blocks cholinergic (vagal) influences already present. If there is little
cholinergic stimulation, effects will be minimal.
INDICATIONS
♦ To increase the heart rate in Bradycardias or pacemaker failure.
♦ To improve conduction in 2nd and 3rd Degree Heart Block.
♦ As an antidote for some insecticide exposures (anti- cholinesterases, e.g. organophosphates and
carbamates and nerve gases.
♦ To counteract excessive vagal influence responsible for some bradysystolic and asystolic arrests.
PRECAUTIONS
♦ Contraindicated in Atrial Fibrillation and Atrial Flutter because increased conduction may speed
ventricular rate excessively
♦ Bradycardias in the setting of an acute MI are common and probably beneficial Don't treat them
unless there are signs of poor perfusion (low blood pressure, mental confusion). Chest pain could
be due to an MI or to poor perfusion caused by the Bradycardia itself. When in doubt, watch
your patient.
7/01 M6.2
ADMINISTRATION
♦ Adult: 1.0 mg IV, repeated in 0.5 mg increments if needed at 3 - 5 minute intervals to a total dose
of 0.04 mg/kg (usually 3.0 mg and titrated to a ventricular rate of about 60/min.). 1.0 to 2.0 mg
IV or 1.0 mg (10 cc) per ET tube in asystolic arrest.
♦ Pediatric: 0.02 mg/kg IV.
SIDE EFFECTS AND SPECIAL NOTES
♦ 2nd and 3rd degree block may be chronic and without symptoms. Symptoms occur mainly with
acute change. Treat the patient not the arrhythmia.
♦ Remember in cardiac arrest situations that Atropine dilates pupils.

7/01 M7.1
DIPHENHYDRAMINE (BENADRYL®)***
CLASS
♦ Antihistamine
♦ An antihistamine which blocks action of histamines released from cells during an allergic
reaction.
♦ Direct CNS effects, which may be stimulant, or more commonly depressant, depending on
individual variation.
♦ Anticholinergic, antiparkinsonism effect, which is used to treat acute dystonic reactions to

antipsychotic drugs (e.g., Haldol®, Inapsine®, Thorazine®) and antiemetic drugs (Compazine®).
These reactions include: oculogyric crisis, acute torticollis, and facial grimacing.
INDICATIONS
♦ The second-line drug in Anaphylaxis and severe allergic reactions (after Epinephrine).
♦ To counteract acute dystonic reactions to antipsychotic drugs.
♦ May have additive effect with alcohol or other CNS depressants.
♦ Although useful in acute dystonic reactions, it is not an antidote to phenothiazine toxicity or

overdose.
♦ May cause Hypotension when given IV.
ADMINISTRATION
♦ 25 to 50 mg slow IV push or deep IM in an adult.
♦ 1.0 mg/kg in pediatric patients.
♦ IV is the preferred route of administration.
♦ Diphenhydramine is not a mandatory drug for Anaphylaxsis. It may be useful for relief of the
irritation and itching associated with allergic reactions.
7/01 M8.1
CALCIUM CHLORIDE
CLASS
♦ Electrolyte
♦ Calcium Chloride 10%, supplies free calcium immediately on an intravascular basis.

Calcium is an essential component for functional integrity of the nervous and muscular
systems, normal cardiac contractility, and the coagulation of blood.
INDICATIONS
♦ Treatment of symptomatic calcium channel blocker overdose (bradycardia, hypotension).

♦ Treatment of documented hypocalcemia.
♦ Treatment of presumed severe hyperkalemia (slow, wide complex, “sine wave” rhythm
with hypotension).
♦ Extremely tissue toxic. Should only be used in an IV that is freely flowing.

Extravasation will cause necrosis requiring extensive grafting.
ADMINISTRATION
♦ Bolus 10 cc of 10% Calcium Chloride ever 10 minutes in a freely flowing IV.

1/02 M9.1
DEXTROSE 50%*1
CLASS
♦ A simple sugar
♦ Glucose is the body's basic fuel. It produces most of the body's quick energy. Its use is
regulated by insulin, which stimulates storage of excess glucose from the bloodstream
and glucagon which mobilizes stored glucose into the bloodstream.
INDICATIONS
♦ Hypoglycemic states usually associated with insulin shock in diabetes.
♦ The unconscious patient with a documented blood sugar below 80mg%
♦ In hypoglycemic patients with a focal or partial neurologic deficit or altered state of

consciousness.
♦ In hypothermia patients with a documented blood sugar below 80mg%
♦ Extravasation of D50W will cause necrosis of tissue. IV should be secure, and free return
of blood into the syringe or tubing should be checked 2 - 3 times during administration.
If extravasation does occur, immediately stop administration of drug. Report
extravasation of the drug to receiving hospital personnel and document.
ADMINISTRATION
♦ 50 ml amp (1.0 ml/kg) IV into secure vein, if patient unable to tolerate oral fluids.
♦ Give solution orally (or sugared juice, honey, molasses, Karo Syrup) if patient is awake
and able to maintain own airway.
♦ Dilute to 25% Dextrose in newborns and give 2.0 ml/kg.

1/02 M9.2
♦ D50W is remarkably free of side effects and should be used whenever Hypoglycemia
exists.
♦ D50W may worsen myocardial infarctions and strokes.
♦ Do not draw blood for glucose determination from site proximal to an IV containing
Glucose or Dextrose.
♦ Dextrose may precipitate Wernicke's Encephalopathy in alcoholics. Should be given

with caution and followed by 100 mg Thiamine*** in suspected alcoholic or
malnourished patients.
1
Basics may administer orally only
7/01 M10.1
DILTIAZEM (CARDIAZEM®)***
CLASS
♦ Calcium channel blocker
♦ Diltiazem is a calcium channel blocker. Its effects are believed to be related to its ability
to inhibit the influx of calcium ions during membrane depolarization of cardiac and
vascular smooth muscle.
♦ Diltiazem decreases SA and AV conduction, thereby decreasing the heart rate. It has a
mild inotropic effect, and relaxes vascular smooth muscle. The combination of these two
effects causes a mild drop in blood pressure.
INDICATIONS
♦ As the second agent in the treatment of PSVT.
♦ As the first line agent in the treatment of stable atrial fibrillation or stable atrial flutter
with a rapid ventricular rate (>150).
PRECAUTIONS
♦ Do not use in patients with congestive heart failure or hypotension, as the mild negative
inotropic effect may worsen these conditions.
♦ Do not use in unstable patients. Consider cardioversion instead.
♦ Treatment of patients with ventricular tachycardia can result in hemodynamic

deterioration and ventricular fibrillation. Accurate pretreatment diagnosis should
determine QRS width to be less than 120 milliseconds in patients to be treated.
♦ Do not use in patients with known hypersensitivity to diltiazem.
♦ Should not be used in patients with known Wolff-Parkinson- White (WPW) Syndrome or
a known short PR Syndrome.
ADMINISTRATION
♦ Bolus 0.25 mg/kg (standard adult dose, 20 mg) IV over 2 minutes. If needed, re-bolus 15
minutes later 0.35 mg/kg (standard adult dose, 25 mg) IV over two minutes.
7/01 M10.2
♦ Hypotension occurs in 8% of patients. Symptomatic hypotension occurs in 3.2% of

patients, and usually responds to Trendelenburg Position and/or infusion of crystalloid
solution.
7/01 M11.1
DOPAMINE (INTROPIN®)***
CLASS
♦ Alpha and Beta receptor stimulating agent
♦ Chemical precursor of nor-epinephrine which occurs naturally in man and which has both
alpha- and beta- receptor stimulating actions. Its actions differ with dosage given:
1-2 mcg/kg/min - dilates renal and mesenteric blood vessels (no effect on heart
rate or blood pressure).
2-10 mcg/kg/min - beta effects on heart which usually increase cardiac output
without increasing heart rate or blood pressure.
10-20 mcg/kg/min - alpha peripheral effects cause peripheral vasoconstriction and
increased blood pressure.
20-40 mcg/kg/min - alpha effects reverse dilation of renal and mesenteric vessels
with resultant decreased flow.
INDICATIONS
♦ Primary indication is Cardiogenic Shock.
♦ May be useful for other forms of shock, except hypovolemic.
♦ May induce tachyarrhythmias, in which case infusion should be decreased or stopped.
♦ High doses may cause extreme peripheral vasoconstriction. Conversely, low doses may
cause a decreased blood pressure due to peripheral dilation.
♦ MAO inhibitors (Monamine Oxidase) potentiate the effects of this drug. Check for
medications and contact Physician Supervisor or Medical Resource Hospital if patient is
taking Nardil®, Marplan®, or Parnate®.
♦ Should not be added to Sodium Bicarbonate or other alkaline solutions since Dopamine
will be inactivated in alkaline solutions.
ADMINISTRATION
♦ Mix Dopamine in a Volutrol® type device (60 gtts/cc)
7/01 M11.2
♦ For Adults:
1. Mix 400 mg in 250 cc of BSS or 800 mg in 500 cc BSS giving a concentration of
1600 mcg/cc
2. Take the patients weight in POUNDS, round to the nearest ten, drop the zero, and
that number is the number of drops/minute which equals 5 mcg/kg/min
3. An example of this is:
Patient weight 174 pounds, round to 170
Drop the zero and you get 17
17 gtts/min=5 mcg/kg/min
• The Dopamine formula for Pediatrics is***:

o Mix 80 mg in 250 cc BSS or 160 mg in 500 cc BSS giving a concentration of 320
mcg/cc.
o 1 gtt/kg/min of this solution equals 5 mcg/kg/min If the patient weighs 10 kg, run
the infusion at 10 gtts/min to get 5 mcg/kg/min.
• The most common side effects include ectopic beats, nausea and vomiting. Angina has
been reported following treatment. (Tachycardia and arrhythmias are less likely than
with other catecholamines.)
• Can precipitate hypertensive crisis in susceptible individuals, i.e. patients on MAO

inhibitors (Parnate®, Nardil®, Marplan®).
• Consider hypovolemia and treat this with appropriate fluids before administration of
Dopamine. Dopamine is contraindicated for hypovolemic shock.
• Dopamine is best administered by an infusion pump to accurately regulate rate. For this
reason, it is hazardous when used in the field. Monitor closely.
1/02 M13.1
EPINEPHRINE*1
CLASS
♦ Sympathetic agent
♦ Catecholamine with alpha and beta effects.
♦ In general, the following cardiovascular responses can be expected:

1. Increased heart rate.
2. Increased myocardial contractile force.
3. Increased systemic vascular resistance.
4. Increased arterial blood pressure.
5. Increased myocardial O2 consumption.
6. Increased automaticity.
♦ Potent bronchodilator.
INDICATIONS
♦ Ventricular Fibrillation.
♦ Asystole.
♦ Pulseless Electrical Activity.
♦ Systemic allergic reactions.
♦ Asthma in patients under 40 years
♦ Epinephrine increases cardiac work and can precipitate angina, MI, or major
dysrhythmias in an individual with ischemic heart disease.
♦ Wheezing in an elderly person is pulmonary edema or pulmonary embolus until proven

otherwise.
1/02 M13.2
♦ Anxiety, tremor, headache, Tachycardia, palpitations, PVC’s, angina and HTN may be
common side effects.
♦ Can cause vomiting in children
ADMINISTRATION
♦ IN ADULTS:
1. Cardiac arrest: 1.0 mg (10 ml of 1:10,000) IV initially during arrest, then every
three (3) minutes. **
2. Allergic reaction (Anaphylaxis):
With BP greater than 90 mm Hg systolic, administer Epinephrine 0.3 ml
1:1,000 SQ *
With BP less than 90 mm Hg systolic, administer Epinephrine 3.0 ml
1:10,000 slow IV **
♦ IN PEDIATRICS:
1. Cardiac arrest: 0.01 mg/kg (0.1 ml/kg of 1:10,000) IV ** initially during arrest,
then every three (3) minutes.
2. Allergic reaction (Anaphylaxis):

Respiratory distress with good perfusion: Epinephrine 1:1000, 0.01 mg/kg
(0.01 cc/kg) SQ *1 if no IV or ET; maximum dose is 0.3 mg (0.3 cc)
If poor perfusion: Epinephrine 1:10,000, 0.01 mg/kg (0.1 cc/kg) IV *** or
IO; maximum dose is 0.1 mg (1.0 cc)
3. Croup: 0.5 ml/kg of Epinephrine 1:1,000 (1.0 mg/ml) in 3.0 cc NS *** nebulized
via hand held nebulizer.
1
Basics may use by SQ or injection device (e.g. Epi-pen) and a report to the board must follow
each use
7/01 M14.1
GLUCAGON***
CLASS
♦ Antihypoglycemic agent
♦ Glucagon is a hormone which causes glucose mobilization in the body. It works opposite
to insulin, which causes glucose storage, and it is present normally in the body. It is
released at times of insult or injury when glucose is needed and mobilizes glucose from
body glycogen stores. Return to consciousness should be within 20 minutes of IM dose
of patient who is hypoglycemic.
INDICATIONS
♦ Known hypoglycemia when patient is stuporous or comatose, and D50W is not available
or an IV line cannot be established.
♦ May be useful in treating life-threatening beta-blocker overdoses.
♦ IV Glucose or Dextrose is the treatment of choice for insulin shock. Use of Glucagon is
restricted to patients who are seizing, combative, or with collapsed veins and in whom an
IV cannot be established. In these rare situations, it may be invaluable.
♦ Nausea and vomiting may occur as side effects.
♦ Persons with no liver glycogen stores (malnutrition, alcoholism) may not be able to
mobilize any glucose in response to Glucagon.
ADMINISTRATION
♦ ADULTS-1.0 mg IM or SQ. May repeat in 20 minutes.
♦ PEDIATRICS-0.1 mg/kg IM or SQ in children or neonates. Maximum of 1.0 mg.

7/01 M15.1
HANK'S SOLUTION*
CLASS
♦ Cell growth solution
♦ "Save-A-Tooth" contains sterile Hank's Solution, which is a cell growth solution used in biology
to supply cells with all of the nutrients they need so that they can be grown in solution.
♦ Placing avulsed teeth into Hank's Solution before replantation has been shown to increase the rate
of successful replantation. Avulsed teeth can be stored up to 24 hours in this solution.
INDICATIONS
♦ To aid in the successful replantation of avulsed adult teeth when they can be placed in solution
within 1 hour of the time when they are avulsed.
PRECAUTIONS
♦ Not to be used for teeth that have been broken off. The root needs to be intact.
♦ Not for use with baby teeth.
♦ Do not place more than one person's teeth in one container.
♦ Do not attempt to rinse or clean teeth before placing them in solution.
ADMINISTRATION
a. Open "Save-A-Tooth" container.
b. Peel off seal from container and basket.
c. Drop in tooth (or teeth).
d. Close lid tightly.
e. Label with patient's name.
f. Transport in upright position.
g. If there are no other indications for transport, patient may seek out their own dentist for
replantation.
7/01 M16.1
IPATROPIUM (ATROVENT®)
CLASS
♦ Synthetic quartenary anticholinergic agent
PHARMACOLOGY/ACTION
♦ The anitcholinergics block the bronchoconstriction induced by vagal innervation to the

larger central airways promoting bronchodilation
♦ Reduction of cyclic GMP in smooth muscle is a second action that promotes

bronchodilation
INDICATIONS
♦ Used as a supplement to beta agonists (Albuterol) in patients with asthma and COPD
♦ It is beneficial in adults, beneficial in children with moderate to severe asthma, and better
tolerated than the beta agonists in the elderly.
♦ Avoid using in patients with glaucoma.
♦ Dry mouth and throat irritation are side effects of anticholinergics
♦ Anticholinergics can cause increased intraocular pressure in patients with glaucoma
♦ Ipatropium is light sensitive and needs to be stored either in the dark in a foil container
DOSAGE
♦ Administer 0.5 mg via nebulizer

7/01 M17.1
IPECAC
CLASS
♦ Emetic agent
♦ Ipecac alkaloids act both locally on the gastric mucosa and centrally on the
chemoreceptor trigger zone to induce vomiting. Usually effective within 20 - 30 minutes.
INDICATIONS
♦ To induce vomiting for patients who have ingested poisons or drugs (other than strong
acids, alkalis, hydrocarbons, or phenothiazine.)
♦ EMT must contact Poison Control Center before administering Ipecac.
♦ Ipecac should NOT be given to patients who are unconscious or who have a rapidly
diminishing level of consciousness.
♦ Should NOT be given to patients who are seizing.
♦ Ipecac should NOT be used to induce vomiting in the field in patients who have ingested
acids, alkalis (lye), silver nitrate, iodides, strychnine, hydrocarbons, tri-cyclics, camphor,
INH (Isoniazid), phenothiazenes, or short acting sedatives.
♦ Ipecac Syrup should not be confused with Ipecac Fluid Extract. The latter is very
concentrated and has caused death.
♦ Ipecac should NOT be given to women in the third trimester of pregnancy.
ADMINISTRATION
♦ Poison Control must be contacted.
♦ Adult: 30 ml p.o., followed by 2 - 3 glasses of water.
♦ Pediatric (over 1 year): 15 ml p.o., followed by 1 - 2 glasses of water.
♦ The emetic action is improved if fluids are given orally just before or after the Ipecac (2 -
3 glasses of water in adults).
7/01 M17.2
♦ Emetic action may be enhanced by ambulation.
♦ The gag reflex may be an unreliable indicator of whether or not someone will be able to
protect his/her airway in the event of emesis. Additionally, testing for a gag reflex in a
patient with depressed level of consciousness may actually cause aspiration. USE
CAUTION.
♦ Always stand by with suction. Patient should be in lateral decubitus position, or sitting.
♦ May not be successful in phenothiazine overdose due to strong antiemetic action of

phenothiazine.
7/01 M18.1
KETOROLAC (TORADOL®)***
CLASS
♦ Nonsteriodal Anti-inflammatory . (NSAID)
MECHANISM OF ACTION
♦ Ketorolac (Toradol®) is an injectable nonsteroidal anti-inflammatory drug (NSAID) that

demonstrates analgesic, anti-inflammatory, and antipyretic activity. Ketorolac (Toradol®)
inhibits prostaglandin synthesis, and appears to relax ureteral spasm (and thus pain) in
patients with kidney stones. Usually effective in 20-30 minutes.
INDICATIONS
♦ In patients with known kidney stones and/or patients who have classic symptoms for
passage of a kidney stone (e.g. acute onset of unilateral back pain with radiation to lower
quadrant/groin/testicles/ labia).
♦ Ketorolac (Toradol®) is contraindicated in patients with known hypersensitivity and

patients with previously demonstrated allergic manifestations to aspirin or other
nonsteroidal anti-inflammatory drugs (NSAIDs).
♦ Ketorolac (Toradol®) inhibits platelet function and is, therefore, contraindicated in

patients with high risk for bleeding.
♦ Ketorolac (Toradol®) should be used with caution in patients with impaired hepatic
function or a history of liver disease.
♦ Ketorolac (Toradol®) is contraindicated in nursing mothers because of the potential

adverse effects on neonates.
ADMINISTRATION
♦ 30 mg IV or IM over 15 seconds.
♦ 15 mg IV over 15 seconds in geriatric patients and those weighing less than 50 kgs (110
lbs).
7/01 M18.2
SPECIAL CONSIDERATIONS:
♦ Ketorolac (Toradol®) is a potent NSAID and may cause serious side effects such as
gastrointestinal bleeding or kidney failure.
®
♦ Ketorolac (Toradol ) should be used with caution in patients taking anticoagulants such
as Heparin or Warfarin (Coumadin®).
7/01 M19.1
FUROSEMIDE (LASIX®)***
CLASS
♦ Diuretic
♦ Potent diuretic with a rapid onset of action and short duration of effect. It acts primarily
by inhibiting sodium reabsorption throughout the kidney. Increase in potassium
excretion occurs along with the sodium excretion.
♦ As an IV bolus, causes immediate (3 - 4 minutes) increase in venous capacitance. This

decreases venous back-up and probably accounts for its immediate effect in pulmonary
edema.
♦ Peak effect: 1/2 - 1 hour after IV administration: duration about 2 hours. (Duration 6 - 8
hours if given orally, with a peak in one 1 - 2 hours)
INDICATIONS
♦ Acute pulmonary edema or congestive heart failure to decrease extracellular volume and
reduce venous pressure on the lungs in cardiac failure.
PRECAUTIONS/CONTRAINDICATIONS:
♦ Contraindicated in hypovolemia or hypotension.
♦ Can lead to profound diuresis with resultant shock and electrolyte depletion. Do not use
in hypovolemic states and monitor closely, particularly after IV administration.
♦ Should not be used in children or pregnant women.
ADMINISTRATION
♦ Give 40 mg slowly IV over 2 minutes. May also be given IM.
♦ If the patient is already taking diuretics, Furosemide (Lasix®) according to the following
dosage schedule***:
• If the patient is not currently taking, give 40 mg IV
• Give the patient the same dosage that they are currently taking, IV
(e.g. if the patient takes 40 mg/day, give 40 mgIV)
• Do not give more than 80 mg
7/01 M19.2
♦ Hypovolemia, hypotension, hyponatremia, and hypokalemia are the main toxic effects.
Because of the potency of Lasix and need for close monitoring, give only with specific
indications.
♦ The hypokalemia induced is of concern in digitalized patients and particularly those who
have digitalis toxicity.
7/01 M20.1
LIDOCAINE® (XYLOCAINE)
CLASS
♦ Antiarrhythmic
♦ Depresses automaticity of Purkinje fibers; therefore, raises stimulation threshold in the

ventricular muscle fibers (makes ventricles less likely to fibrillate).
♦ Little antiarrhythmic effect at sub-toxic levels on atrial muscle.
♦ CNS stimulation: tremor, restlessness and clonic convulsions followed by depression and
respiratory failure at higher doses.
♦ Cardiovascular effect: decreased conduction rate and force of contraction, mainly at toxic
levels.
♦ The effect of a single bolus on the heart disappears in 10-20 minutes due to redistribution
in the body. Metabolic half-life is about 2 hours and, therefore, toxicity develops with
repeated doses.
INDICATIONS
♦ Stable Ventricular Tachycardia or recurrent Ventricular Tachycardia if clinical condition

is not rapidly deteriorating.
♦ Recurrent Ventricular Fibrillation.
♦ Pulseless Ventricular Tachcardia and Ventricular Fibrillation
♦ Following successful defibrillation or cardioversion from Ventricular Tachycardia or

chemical conversion from magnesium sulfate.
♦ Use with extreme caution in presence of advanced AV Block unless artificial pacemaker
is in place.
♦ In Atrial Fibrillation or Flutter, quinidine-like effect may cause alarming ventricular

acceleration.
7/01 M20.2
PRECAUTIONS/CONTRAINDICATIONS (CONT)
♦ Lidocaine is generally not recommended for treatment of supraventricular arrhythmias.
♦ Midazolam*** should be available to treat convulsions if they occur.
♦ Relatively contra-indicated with heart rate less than 50.
♦ Lidocaine should NOT be given (unless patient is in cardiac arrest or Ventricular

Tachycardia) if:
1. Blood pressure is less than 90 systolic
2. Heart rate is less than 50
3. Periods of sinus arrest or any AV Block are present.
ADMINISTRATION
♦ The protocol for Lidocaine administration will depend upon the clinical setting in which
it is used:
1. Cardiac Arrest: Ventricular Fibrillation or Pulseless Ventricular Tachycardia:
ADULTS-Lidocaine bolus 1.5 mg/kg load. Repeat in 3 minutes if still in

V-Fib/Pulseless V-Tach.
PEDIATRICS-1 mg/kg IV or IO per dose; Infusion: 20 - 50 mcg/kg/min
Only bolus therapy should be used in the Cardiac Arrest setting (should
the arrest be followed by successful resuscitation, a continuous infusion
should be initiated at 2.0 - 4.0 mg/min.
May be administered through endotracheal tube 2.0 mg/kg, not to exceed a

total volume of 10 ml.
2. Ventricular Tachycardia with pulse:
• ADULTS-Lidocaine bolus 1.5 mg/kg load, then 0.5 - 0.75 mg/kg every 3 -
5 minutes to total dose of 3.0 mg/kg or cessation of dysrhythmia.
7/01 M20.3
• PEDIATRICS-1 mg/kg IV or IO per dose; Infusion: 20 - 50 mcg/kg/min.
3. If cardioversion is successful, an infusion at 2.0 - 4.0 mg/min should be started.
• Side effects are as follows:
1. CNS disturbances: sleepiness, dizziness, disorientation, confusion, convulsions.
2. Hypotension: decreased myocardial contractility and increased AV Block at toxic

levels only.
3. Rare instances of sudden cardiovascular collapse and death.
• Drug is metabolized in the liver and, therefore, patients with Hepatic Disease, Shock or
Congestive Heart Failure will have impaired metabolism. All doses must be decreased
by 50% in patients over 70 and those referred to above.
• Toxicity is more likely in elderly patients.
• As high as 50% of patients who develop Ventricular Fibrillation in the setting of an

Acute Myocardial Infarction may have no warning arrhythmias.
7/01 M22.1
MAGNESIUM SULFATE
CLASS
♦ Naturally occurring cation
♦ Magnesium is the second most common cation of the intracellular fluids.

♦ It plays a critical role in many enzyme systems, acts in neuromuscular transmission, and
acts as a membrane stabilizer.
♦ Magnesium has been used to treat pre-term labor, eclampsia and pre-eclampsia, status
asthmaticus, seizures, alcohol withdrawal, torsades de pointes, ventricular fibrillation and
ventricular tachycardia.
INDICATIONS
♦ As an antiarrhythmic in the treatment of ventricular fibrillation and ventricular

tachycardia.
♦ Treatment of Torsade de pointes.
♦ Eclampsia with seizures.
PRECAUTIONS
♦ Administration of magnesium to patients with preexisting hypermagnesemia (typically

patients in renal failure) or the administration of excessive amounts of magnesium to any
patient may lead to weakness, hypotension, loss of deep-tendon reflexes, and, at very
high levels, respiratory arrest.
ADMINISTRATION
♦ Pulseless ventricular tachycardia/ventricular fibrillation - 2.0 grams rapid IV push/IO.
♦ Stable/Unstable ventricular tachycardia - 2.0 grams IV slowly over 2 minutes.
♦ Eclampsia: 4.0 grams IV slowly over 5 minutes.
♦ Administration may be accompanied by a sensation of generalized warmness, with a

visible flushing being noted. This is associated with a peripheral vasodilation.
7/01 M22.2
MIDAZOLAM (VERSED®)
CLASS
♦ Benzodiazepine
♦ Midazolam acts as a central nervous system depressant, anticonvulsant, and

causes retrograde amnesia.
INDICATIONS
♦ Status seizures
♦ Produce amnesia during cardioversion, pacing, or burn treatment
♦ As an induction agent for paralytic intubation (see AIRWAY and AIRWAY

MANAGEMENT protocols)
♦ Allergy to midazolam or benzodiazepines
♦ Midazolam can cause respiratory depression and/or hypotension
♦ Midazolam is most likely to cause respiratory depression in patients who have

take alcohol or other depressant drugs
ADMINISTRATION
♦ For status seizures:

Adults- 2.5 mg IV or 5 mg IM. May repeat the dose once in 1-2 minutes
if the seizure continues, up to 5 mg IV or 10 mg IM
Pediatrics- 0.1 mg/kg IV (maximum 2.5 mg) or 0.2 mg/kg IM (maximum
5 mg)
♦ For Cardioversion/Pacing:
2.5-5.0 mg IV (maximum 5 mg IV)
♦ For Rapid Sequence Intubation:

0.1 mg/kg IV (maximum 5 mg IV)
7/01 M22.3
♦ Midazolam should not be administered without having a BVM ready to use.
♦ In burn patients in which pain control is not adequate with morphine at 10 mg IV

alone, you may add midazolam at a dose of 2.5 mg IV. If there is a need to
exceed this dosage, contact OLMC.
♦ The patient must be monitored closely for hypotension

7/01 M23.1
MORPHINE SULFATE
CLASS
♦ Opioid Analgesic
♦ Morphine Sulfate is a narcotic with potent analgesic and hemodynamic properties. It exerts its
analgesic effects on the central nervous system, simultaneously inducing drowsiness, mental
clouding and mood changes.
♦ Morphine has several hemodynamic actions of considerable importance:
1. It increases venous capacitance and thereby pools blood peripherally and decreases its
return (reduced preload). This assists in relieving pulmonary congestion and reduces left
ventricular and diastolic dimensions and myocardial wall stress. These all result in
decreased myocardial oxygen requirement.
2. Reduces systemic vascular resistance at the arteriolar level (reduced afterload). This
reduction in afterload also tends to decrease myocardial oxygen requirement. Central
sedative effects of morphine also will reduce myocardial oxygen requirements and the
chance of malignant arrhythmias due to reduction of apprehension and fear in patients.
The hemodynamic effects of morphine are probably mediated through the central nervous
system by a sympatholytic mechanism. Given intravenously, the onset of action is
prompt (2 - 3 minutes), peaks at 7 - 10 minutes, and lasts 3 - 5 hours.
INDICATIONS
♦ Severe chest pain unaffected by respirations or body movements with suspected ischemic cardiac
pain unresponsive to Nitroglycerine.
♦ Severe pain (do not use if a patient has undiagnosed abdominal pain or head injury - see contra-
indications).
♦ Congestive heart failure/Pulmonary Edema
PRECAUTIONS /CONTRAINDICATIONS
♦ Contraindications to the use of Morphine:

Known allergy to morphine.
Volume depletion.
Hypotension or blood pressure less than 90 mmHg
Undiagnosed head or abdominal pain.
Trauma or suspected trauma to abdomen or head.
7/01 M23.2
PRECAUTIONS /CONTRAINDICATIONS (CONT)
♦ Morphine Sulfate causes predictable respiratory depression. This is quickly reversible with
Narcan®. Respiratory depression is much more likely to occur in patients with pre-existing
respiratory insufficiency (COPD).
♦ Narcan® and respiratory support should always be at hand when administering Morphine.
ADMINISTRATION
♦ Morphine should be given by titration of small intravenous doses at frequent intervals until the
desired response is achieved.
♦ There is considerable variation from patient to patient is the amount of drug required to acquire
the given effect. Give up to 20 mg maximum per patient; call OLMC if more is required
♦ Patients in respiratory distress with presumed congestive heart failure should receive a maximum
of 10 mg.
♦ A dose of 2.0 - 5.0 mg given intravenously is repeated every 5 - 30 minutes until the desired
effect has been achieved.
♦ Vital signs should be taken with particular attention to blood pressure and respiratory rate after
every incremental dose is administered.
♦ The end points of administration should be:

1. Achievement of desired effects. This may mean the dulling of sharp pain without
complete dissolution of the pain
2. Blood pressure less than 90 mm Hg.
3. Respiratory rate of less than 12 per minute.
♦ Respiratory depression, nausea and vomiting are all common side effects
♦ The analgesic effect of morphine should not be gauged solely by the total elimination of pain.
More importantly, morphine reduces the perception of pain by the patient while he/she still may
recognize the painful stimulus.
♦ Hypotension may develop as a consequence of the hemodynamic effect of Morphine especially in

older patients, volume depleted patients, or patients who have required elevated systemic vascular
resistance for the maintenance of their blood pressure. The value of small, frequent, incremental
doses is evident in this situation. Hypotension is usually responsive to Narcan® administration
and the Trendelenburg Position; if not, a cautious fluid challenge with 250 ml of Balanced Salt
Solution is indicated.
7/01 M23.3
SIDE EFFECTS/SPECIAL CONSIDERATIONS (CONT)
♦ In burn patients in which pain control is not adequate with morphine at 10 mg IV alone, you may
add midazolam at a dose of 2.5 mg IV. If there is a need to exceed this dosage, contact OLMC.
1/02 M24.1
NALOXONE (NARCAN®)
CLASS
• Synthetic Opiod Antagonist
• Narcan is a narcotic antagonist which competitively bonds to narcotic sites, but which
exhibits almost no pharmacologic activity of its own.
• Onset within 2 minutes with duration of action lasting 1 - 4 hours.
INDICATIONS
• Reversal of narcotic effects, particularly respiratory depression, due to narcotic drugs

either ingested, injected or administered in the course of treatment. Narcotic drugs
include Morphine, Demerol, Heroin, Dilaudid, Percodan, Codeine, Lomotil,
Propoxyphene (Darvon®), Pentazocine (Talwin®).
• Diagnostically in coma of unknown etiology to rule out or reverse narcotic depression.
PRECAUTION/CONTRAINDICATIONS
• In patients physically dependant on narcotics, frank and occasionally violent withdrawal

symptoms may be precipitated.
• Be prepared to restrain the patient. May become violent as the Narcan reverses the
narcotic effect.
• Do not give if patient is older than 40 and on Clonidine (Catapress®). This may
precipitate malignant hypertension and induce or worsen hemorrhagic strokes or
myocardial infarcts.
• The duration of some narcotics is longer than Narcan® and the patient must be monitored
closely. Repeated doses of Narcan® may be required. Patients who have received this
drug must be transported to the hospital because coma may re-occur when Narcan® wears
off.
• May need large doses to reverse Propoxphene (Darvon®) overdoses.

1/02 M24.2
ADMINISTRATION
• ADULTS-0.4 to 2.0 mg slowly injected every 2 minutes IV, IM, SQ, SL, or by ET tube.
IV administration is preferred.
• If no response is observed, this dose may be repeated at 3 - 5 minute intervals up to 5

times (10 mg total) in patients suspected of having narcotic overdose.
• PEDIATRICS-0.1 mg/kg to 5 years of age or 20 kg weight, then adult dose IV, IM, SQ
or ET.
• In suspected opiate addicted patients, titrate doses until ventilations are adequate.
1/02 M25.1
NITROGLYCERIN1
CLASS
♦ Vasodilator and Antianginal agent
♦ Cardiovascular effects include:
1. Reduced venous tone - this causes pooling of blood in peripheral veins and decreased
return of blood to the heart. (Preload and afterload)
2. Decreased peripheral resistance.
3. Dilation of coronary arteries (if not already at maximum).
♦ General smooth muscle relaxation.
INDICATIONS
♦ Angina
♦ Chest, arm or neck pain thought possible to be related to coronary ischemia; may be used
diagnostically as well as therapeutically.
♦ Control of Hypertension in Angina or Acute Myocardial Infarction.
♦ Pulmonary edema; to increase venous pooling, lowering cardiac preload and afterload.
♦ Hypertensive crisis.
♦ Because NTG causes generalized smooth muscle relaxation, it may be effective in

relieving chest pain caused by esophageal spasm.
PRECAUTION/CONTRAINDICATIONS
♦ Generalized vasodilation may cause profound Hypotension and reflex Tachycardia,

particularly orthostatic.
♦ Nitroglycerin loses potency easily, it should be stored in a dark glass container with a
tight lid and not exposed to heat.
1/02 M25.2
PRECAUTION/CONTRAINDICATIONS (CONT)
♦ Be cautious with administering nitroglycerin to patients who have taken Viagra® less than
24 hours prior to encounter as these patients are more likely to have hypotensive
episodes.
♦ Avoid administration if blood pressure is less than 90 mmHG systolic,
SIDE EFFECTS
♦ Common side effects include throbbing headache, flushing, dizziness and burning under
the tongue (if these side effects are noted, the pills may be assumed potent, not outdated).
ADMINISTRATION
♦ O.4 mg or 1 dose of Nitro spray SL. May be repeated every 5 minutes.

Maximum 3 doses ** . If Nitro is controlling the chest pain, it may be repeated for more
than 3 doses ***.
1
EMT Basics can assist patients who are taking their own nitroglycerine
1/02 M26.1
NALBUFINE HYDROCHLORIDE (NUBAIN®)***

OPTIONAL
CLASS
♦ Synthetic narcotic agonist/antagonist
♦ Nubain® (Nalbufine Hydrochloride) is a synthetic narcotic agonist/antagonist analgesic.

It is an analgesic equivalent, milligram for milligram, to morphine.
♦ Its onset of action is 2-3 minutes after IV administration, and less than 15 minutes after
SQ/IM administration.
♦ The respiratory depression associated with increasing doses of narcotics is not seen with
Nubain®, as it plateaus at a low dosage.
INDICATIONS
♦ Severe pain (do not use in patients with undiagnosed abdominal pain or head injury - see
contraindications)
♦ Substitute for pain management in morphine allergic patients.
♦ Known allergy to Nubain®, Numorphan®, Oxymorphan®, or Narcan®.
♦ Volume depletion, hypotension, undiagnosed head or abdominal pain.
♦ Trauma or suspected trauma to abdomen or head.
♦ Chronically addicted to narcotics, to include patients on methadone (will precipitate acute

withdrawal).
ADMINISTRATION
♦ May be administered IV/IM/SQ. Usual IM/SQ dose is 10 mg.

1/02 M26.2
ADMINISTRATION (cont)
♦ Titrate IV doses (only) to desired effect, with usual starting dose being 5.0 mg.
Endpoints of administration are:
o Achievement of desired effects.
o Blood pressure less than 90 mm Hg.
o Respiratory rate less than 12.
♦ Precipitation of withdrawal in narcotics addicts.
♦ Nausea, vomiting, respiratory depression, hypotension. Treat respiratory depression with

Narcan®, hypotension with IV fluids/Trendelenburg position/Narcan®. (see ALTERED
MENTAL STATUS/COMA and SHOCK protocols)
1/02 M27.1
OXYGEN
CLASS
♦ Element
PHARMACOLOGY AND ACTION
♦ Oxygen added to the inspired air raises the amount of oxygen in the blood and therefore,
the amount delivered to the tissues. Tissue hypoxia causes cell damage and death.
Breathing in most persons is regulated by small changes in acid/base balance and CO2
levels. It takes relatively large drops in blood oxygen concentration to stimulate
respiration.
INDICATIONS
♦ Suspected hypoxemia or respiratory distress from any cause.
♦ Acute chest pain in which a myocardial infarction is suspected.
♦ Shock (decreased oxygenation of tissues) from any cause.
♦ Major trauma.
♦ Carbon Monoxide poisoning.
PRECAUTIONS/CONTRAINDICATIONS:
♦ If the patient is not breathing adequately on his/her own, the treatment of choice is
ventilation, not just O2. A nasal cannula without a breath is a waste of O2 (and
patients!!).
♦ A small percentage of patients with chronic lung disease breathe because they are
hypoxic. Administration of O2 will shut off their respiratory drive. DO NOT
WITHHOLD OXYGEN BECAUSE OF THIS POSSIBILITY. BE PREPARED TO
ASSIST VENTILATION IF NEEDED. Initial O2 flow should be no greater than 2 LPM
in these patients.
ADMINISTRATION
DOSAGE INDICATIONS
Low 1-2 LPM) Patients with chronic lung disease.
Moderate (4-6 LPM) Precautionary use for trauma, abdominal pain, etc.
High (10-15 LPM) Severe respiratory distress, either medical or traumatic.
1/02 M27.2
♦ Non-humidified O2 is drying and irritating to mucous membranes.
♦ Restlessness may be an important sign of hypoxia.
♦ Oxygen supports combustion.
♦ Oxygen toxicity (overdose) is not a hazard from acute administration.
♦ Nasal prongs work equally well on nose and mouth breathers.
♦ Most hypoxic patients will feel quite comfortable with an increase of inspired O2 from 21
- 24%.
METHOD FLOW RATE O2 %

NASAL CANNULA 1 LPM 24%
2 LPM 28%
6 LPM 40%
FACE MASK 8 LPM 50-60%
OXYGEN RESERVOIR 10-12 LPM 90%
MOUTH TO MASK 10 LPM 50%
15 LPM 80%
30 LPM 100%
BAG-VALVE MASK ROOM AIR 21%
12 LPM 40%
INFLATE BAG 90+%
7/01 M28.1
PROPARACAINE HYDROCHLORIDE (ALCAINE®)

OPTHALMIC SOLUTION, 0.5%***
CLASS
♦ Topical anesthetic agent.
♦ Alcaine® contains a local anesthetic agent and is administered topically to the cornea to
induce corneal anesthesia.
INDICATIONS
♦ To induce corneal anesthesia to relieve pain before ocular lavage and from corneal
foreign bodies not requiring ocular lavage.
♦ Penetrating ocular trauma.
♦ Allergy to Procainamide or to all amide type anesthetics (e.g. lidocaine, Marcaine®)
ADMINISTRATION
♦ Administer two drops to the cornea or inferior conjunctival sac.
♦ May be repeated in fifteen minutes by the administration of two more drops topically.
♦ In a patient who is undergoing ocular lavage with a Morgan Lens, instill the rest of the
bottle of Alcaine® into the liter of crystalloid being used to lavage the eye using a syringe
and needle.
7/01 M29.1
RETAVASE™ (RECOMBINANT RETAPLASE)

St Helens Only
CLASS
♦ Thombolytic.
♦ Retavase™ is a sterile, purified protein of 355 amino acids which represents the active
portions of native TPA. It is synthesized using recombinant DNA technology.
♦ When introduced in pharmacologic concentrations into the human body, Retavase™

produces a systemic lytic state, breaking down clots throughout the body.
INDICATIONS
♦ For the treatment of the acute myocardial infarction, as defined in the Cardiac Chest Pain
Protocol.
♦ Age less than 18 years.
♦ Pain lasting less than 15 minutes or longer that 12 hours.
♦ No confirmation of acute myocardial infarction.
♦ Systolic blood pressure less than 90 or greater than 200.
♦ Systolic blood pressure difference greater than or equal to 20 mm Hg between right and
left arm.
♦ Pregnant or lactating.
♦ History of stroke, brain tumor, or aneurysm.
♦ Recent (less than 2 months) intracranial or intraspinal surgery or trauma.
♦ Active internal bleeding.
♦ Active GI/GU bleeding within 10 days.
♦ Taking coumadin (Warfarin®).
♦ Major surgery within 2 months.

7/01 M29.2
PRECAUTIONS/CONTRAINDICATIONS(CONT)
♦ CPR longer than 10 minutes.
♦ Significant trauma within the last 10 days.
♦ Terminal/DNR patient.
♦ No informed consent.
ADMINISTRATION
♦ Mix and administer Retavase™ using sterile technique:

1. Inject 10 ml of Sterile Water for Injection into the vial of Retavase™.
2. Swirl gently to dissolve. DO NOT SHAKE.
3. Withdraw 10 ml of the solution from the vial, and inject into a patent, running IV
over a 2 minute period.
4. Repeat steps 1-3, timing the administration of the second bolus to begin thirty
(30) minutes after the start of the first bolus.
♦ Death.
♦ Hemorrhagic stroke.
♦ Internal bleeding.
♦ Time is of the essence. Early identification facilitates rapid thrombolysis.

7/01 M30.1
SODIUM BICARBONATE
CLASS
♦ Alkalyzing agent
♦ Acidosis depresses cardiac contractility, depresses the cardiac response to catecholamines

and makes the heart more likely to fibrillate and less likely to defibrillate.
♦ Acids are increased when body tissues become hypoxic due to cardiac or respiratory
arrest. Sodium Bicarbonate reacts with hydrogen ions (acids) to form water and CO2,
acting as a buffer in metabolic acidosis
INDICATIONS
♦ To control arrhythmias in Tricyclic Antidepressant overdose (see POISONING AND

OVERDOSE protocol).
♦ Cardiac arrest- see Cardiac Arrest protocol.
♦ Treatment of presumed severe hyperkalemia (slow, wide complex “sine wave” rhythm
with hypotension).
♦ Addition of too much NaHCO3 may result in alkalosis which is difficult to reverse and
can cause as many problems in resuscitation as acidosis.
♦ May increase cerebral acidosis, especially in diabetics who are ketotic.
ADMINISTRATION
♦ For Cardiac Arrest:

• Adult and Pediatric: 1.0 mEq/kg initially (approximately 2 amps for adults) Then
0.5 mEq/kg or 1.0 amp every 10 minutes until pulse restored.
♦ For Cyclic Antidepressant overdose or hyperkalemia:

• Administer 1 mEq/kg slow IVP
7/01 M30.2
♦ Each amp of Sodium Bicarbonate contains 44 or 50 mEq of Na+. This may increase
intravascular volume and hyperosmolarity conditions which result in cerebral
impairment.
♦ In the presence of a Respiratory Arrest without Cardiac Arrest, the treatment of choice is
ventilation to correct the respiratory acidosis. No NaHCO3 should be given unless
Cardiac Arrest has also occurred and then only after other first line interventions such as
defibrillation and other pharmacological interventions.
♦ Consider NaHCO3 in patients with renal failure who are on dialysis and may have
unstable cardiac activity secondary to hyperkalemia
7/01 M31.1
SUCCINYCHOLINE (ANECTINE®)
CLASS
♦ Depolarizing type neuromuscular blocking agent.
MECHANISM OF ACTION
♦ Succinylcholine (Anectine®) is an ultra short acting depolarizing- type skeletal muscle

relaxant for IV or IM administration. The depolarization may be observed as
fasiculations.
♦ Onset of flaccidity occurs within one minute of IV administration and within two to three
minutes of IM administration and lasts for four to six minutes.
INDICATIONS
♦ As an agent to provide skeletal muscle relaxation to facilitate endotrachael intubation in

combative or tightly clenched patients.
♦ Penetrating ocular injury.
♦ History of stroke, paralysis, or existing neuro-muscular disease which has been present
for more than seven days.
♦ Extensive burns or crush injury more than seven days old.
♦ Family history of problems with general anesthesia.
♦ Personal or family history of malignant hyperthermia.
♦ Succinylcholine (Anectine®) is contraindicated in patients with known hypersensitivity.
ADMINISTRATION
♦ See AIRWAY and AIRWAY MANAGEMENT protocols
♦ The dosages are as follows:
• Adult - 1.5 mg/kg IV push for ages > 8.

• Pediatric - 2.0 mg/kg IV push for ages < 8.
• IM dose - 4.0 mg/kg for all ages. Maximum 150 mg.
7/01 M31.2
♦ Succinylcholine (Anectine®) has no known effect on consciousness, the pain threshold or

cerebration. Administration must be accompanied by adequate anesthesia and/or
sedation.
♦ Succinylcholine (Anectine®) may increase intragastric pressure, which could result in

regurgitation and possible aspiration of stomach contents. This result may also occur due
to the loss of esophageal parastaltic effect.
♦ Succinylcholine (Anectine®) causes a slight, transient increase in intraocular pressure

and therefore should not be used in the presence of penetrating or open ocular injuries.
♦ Succinylcholine (Anectine®) has no direct effect on the myocardium, however, changes

in rhythm may result from vagal stimulation resulting in bradycardia, particularly in
pediatric patients.
♦ Succinylcholine (Anectine®) may cause muscle fasiculations which may cause additional
muscle trauma and be potentially deleterious to head injured patients. Consider pre-
treatment with Vecuronium (Norcuron®) (see AIRWAY and AIRWAY
MANAGEMENT protocol).
♦ Succinylcholine (Anectine®) may cause cardiac arrhythmias including bradycardia,

tachycardia and cardiac arrest.
♦ Succinylcholine (Anectine®) may cause or exacerbate malignant hyperthermia.
♦ The paralytic effect of Succinylcholine (Anectine®) may be prolonged, particularly in

pregnant women.
♦ Succinylcholine (Anectine®) should be administered by adequately trained individuals

familiar with its actions, characteristics and hazards.
♦ Paramedics must be approved to use this medication. An OR rotation and successful

passing of the RSI exam is required for approval.
7/01 M32.1
THIAMINE
CLASS
♦ Vitamin
♦ Thiamine is a B-vitamin (B1) found in adequate amounts in the normal diet, but
frequently deficient in alcoholics. In alcoholics the deficiency causes Wernicke's
Syndrome, an acute and reversible encephalopathy characterized by ataxia, eye muscle
weakness (diplopia and nystagmus), and mental derangements.
♦ Of more serious concern is Korsakoff's Psychosis, also caused by Thiamine deficiency

and characterized by memory disorder. Korsakoff's Psychosis may be irreversible once it
becomes established.
♦ For this reason, treatment with Thiamine is indicated if Wernicke's or Korsakoff's

Syndrome is recognized in an alcoholic. Since Thiamine is utilized in carbohydrate
metabolism, the syndromes may be precipitated by the administration of D50W in the
alcoholic, who often has already depleted Thiamine stores.
INDICATIONS
♦ In suspected alcoholics or malnourished patients after the administration of D50W.
♦ In suspected Wernicke's or Korsakoff's Syndrome.
♦ Allergic reactions occur but are extremely rare.(see ALLERGIES/ANAPHYLAXIS

protocol)
♦ Rapid IV administration has been associated with Hypotension.
ADMINISTRATION
♦ 100 mg IV (IM if necessary).

7/01 M33.2
VECURONIUM (NORCURON®)
CLASS
♦ Non-depolarizing type neuromuscular blocking agent
MECHANISM OF ACTION
♦ Nondepolarizing neuromuscular blocking agent of intermediate duration which

paralyzes skeletal muscle.
INDICATIONS
♦ As a defasiculating agent prior to the administration of Succinylcholine for

suspected head injured patients.
♦ As an agent for the maintenance of paralysis which was initiated for airway
control. Should only be used after endotracheal intubation has been confirmed.
♦ Since vecuronium (Norcuron®) causes prolonged paralysis, careful confirmation

of endotracheal tube placement should be undertaken before administration.
♦ Vecuronium (Norcuron®) is contraindicated in patients with known

hypersensitivity.
ADMINISTRATION
♦ Defasiculating dose: Adult: 1.0 mg IVP. Pediatric: 0.01 mg/kg IVP.
♦ After confirming correct endotracheal tube placement, administer vecuronium

(Norcuron®) 0.1 mg/kg IV push. (Standard adult dose - 7.0 mg).
♦ Vecuronium (Norcuron®) has no known effect on consciousness, the pain

threshold or cerebration. Administration must be accompanied by adequate
anesthesia and/or sedation.
♦ Repeated administration of maintenance doses of vecuronium (Norcuron®) has

little or no cumulative effect on the duration of neuromuscular blockade. Repeat
doses can be administered at relatively regular intervals with predictable results.
7/01 M33.3
SPECIAL CONSIDERATIONS (CONT)
♦ Patients with Hepatic Disease such as cirrhosis may experience a prolonged

recovery time in keeping with the role played by the liver in vecuronium
(Norcuron®) metabolism and excretion.
♦ Vecuronium (Norcuron®) should be administered by adequately trained

individuals familiar with its actions, characteristics and hazards.
♦ Paramedics must be approved to use this medication. An OR rotation and

successful passing of the RSI exam is required for approval.
7/01
Procedural/Operation
Protocols
1/02 P1.1
AIRWAY MANAGEMENT
PURPOSE
♦ To enable proper airway management for the EMT/Paramedic, assuring airway

control and protection, as well as provide adequate ventilation and oxygenation
PROCEDURE
♦ Oxygenation, Ventilation, Airway Maintenance:

o Nasal Cannula (NC)*
Useful for giving small amounts of supplemental oxygen (e.g. 2-4
liters)
o Partial Rebreather Mask (PRB)*
Needed when higher flow and concentrations of oxygen need to be
given (e.g. 5-10 liters)
o Blow-by Oxygen*
Used for infants and toddlers to deliver supplemental oxygen
and/or bronchodilators
o Nasopharyngeal/Oropharyngeal Airway (NPA/OPA)*
Used in patients who are unable to maintain an open airway on
their own
o Bag-Valve Mask (BVM)*
Used when inadequate ventilation is present
1/02 P1.2
COMBI-TUBE**
The Combi-tube is a two-tube device with one distal tube and one proximal tube. When
it is inserted blindly, the distal (blue) tube enters the esophagus 90% of the time and
enters the trachea 10% of the time. Depending on where the distal tube enters, the distal
tube will ventilate the esophagus or the trachea
INDICATIONS
♦ As an airway adjunct for EMT Intermediates

♦ When endotracheal intubation cannot be performed because of inadequate
visualization of the larynx
PROCEDURE
♦ Hyperventilate to prepare the patient for Combi-tube placement

♦ Place the head in a neutral position
♦ Insert the Combi-tube using the jaw lift maneuver to a depth showing the black
ring between the patient teeth
♦ Inflate the blue pharyngeal cuff (#1) with 100 cc’s of air and the clear distal cuff
(#2) with 15 cc’s of air
♦ Ventilate through the longer blue tube (#1) and listen for sounds in the both lungs
and the stomach
♦ If breath sounds (instead of gastric sounds) are clearly heard through tube #1,
ventilate through tube #1
♦ If you hear gastric sounds, ventilate through tube #2, the shorter clear tube
♦ Ventilate with 100% O2
1/02 P1.3
CRICOTHYROIDOTOMY***
DEFINITION
A cricothyroidotomy is the creation of a passage between the external

environment and the trachea through the cricothyroid membrane.
INDICATIONS
This technique should be used only when other attempts at establishing an airway
have been unsuccessful, such as the inability to intubate or ventilate using BVM or
combi-tube and respiratory obstruction exists, such as:
• Foreign body obstruction
• Facial/laryngeal trauma
• Inhalation, thermal or caustic injury to the upper airway
• Angioneurotic edema
• Upper airway bleeding
• Epiglottitis
PROCEDURE
1. Place the patient in a supine position with the head secured; place two towels
under the shoulders and hyperextend the head (if not contraindicated by cervical
spine trauma)
2. Identify the cricothyroid membrane, the soft spot between the thyroid cartilage
and the cricoid ring
3. Prep the skin with betadine
4. Insert the needle trough the membrane at a 45-degree angle toward the feet. Stop
when air is aspirated.
5. Stabilize the needle, remove the syringe, and pass the wire through the needle
until several inches are within the trachea
6. Stabilize the wire; remove the needle and make a vertical incision in the skin next
to the wire with a scalpel
7. Pass the dilator with the cricothyroidotomy tube over the wire and through the
membrane and remove the wire
8. Ventilate the patient, perform a 5 point check, and secure the tube in place
1/02 P1.4
SPECIAL PRECAUTIONS
♦ Advance the needle slowly making sure to stay in the midline; there are major
vessels to either side of the membrane
♦ The vocal cords can be damaged if the puncture is made too high
♦ If the puncture is made too deeply, penetrating the posterior wall of the trachea, it
could lead to mediastinitis or inadvertent esophageal cannulation
♦ Cricothyroidotomy should not be used in children under 8 years. The cricoid
cartilage is easily damaged in small children. If unable to endotracheally
intubate, a Needle Cricothyroidotomy with jet ventilation should be considered
(see below)
♦ Administer Atropine 0.02 mg/kg IV for children under 2 years (minimum dose is
0.1 mg not to exceed the adult dose)
♦ Administer Succinylcholine 2 mg/kg IV for children under 6 years. May repeat
once if there is inadequate relaxation
♦ A formula that is helpful for remembering tube sizes for different age children
younger than 8 years:
Tracheal tube size (mm) = (age in years/4) + 4

♦ Generally use an un-cuffed endotracheal tube until 8 years
♦ Try to utilize a length based resuscitation tape (e.g. Broselow tape) when
available
Needle Cricothyroidostomy
♦ In children under the age of 8, if an endotracheal tube is not possible, consider

Needle Cricothyroidostomy*** if you are unable to ventilate due to upper
airway obstruction or major trauma to the head and face:
1. Find the cricothyroid membrane and prep the area
2. Use a 14 gauge angiocath connected to a 5 cc syringe , stabilize
the trachea with the nondominant hand and puncture the
cricothyroid membrane with the angiocath at a 30o-45o angle
toward the feet
3. Verify placement with the aspiration of air and take special
care to avoid penetrating the posterior wall of the trachea
4. Slide the catheter over the needle when placement is
confirmed, stabilize the needle with your hand and tape
securely
5. Use O2 with jet ventilation tubing connected directly to a high
pressure source of O2 . Start with a PSI of 5 and adjust upward
until adequate chest rise is observed
1/02 P1.5
RAPID SEQUENCE INTUBATION with PARALYTIC

AGENTS
This procedure is reserved only for the paramedics that have passed the airway
exam and have spent a least one day in the operating room with an
anesthesiologist (See OR ANESTHESIA REQUEST FORM)
INDICATIONS
♦ Respiratory insufficiency or impending respiratory failure
♦ Altered mental status with airway compromise (high risk of aspiration) e.g.
overdose, poisoning
♦ Cardiac and/or Respiratory arrest
♦ Situations requiring positive pressure ventilation
♦ IN ADDITION TO:
A. A clenched jaw
B. An active gag reflex
C. Uncontrollable combative behavior
D. Head injured patients with a GCS of 8 or less
E. Clinical conditions requiring airway protection
♦ No contraindications exist (see SUCCINYLCHOLINE protocol)
EQUIPMENT
♦ Bag Valve mask apparatus
♦ NPA/OPA airways
♦ Oxygen
♦ Suction
♦ Larygoscope with blades, including Miller forceps
♦ A full array of endotracheal tube sizes and stylets
♦ Cardiac monitor
♦ Pulse Oximeter
♦ End-tidal CO2 monitor
♦ IV line
♦ Cook® Cricothyroidotomy kit
MEDICATIONS
Midazolam (Versed®) 0.1 mg/kg IV push not to exceed 5 mg in a single

dose
Lidocaine 1 –1.5 mg/kg IV
Succinylcholine (Anectine®) 1.5 mg/kg IV adults
2.0 mg/kg IV children less than 8 Y
4.0 mg/kg IM (if no IV access available)
Atropine 0.01 mg/kg IV in children less than 8 Y
1/02 P1.6
MEDICATIONS (cont)
Vecuronium 0.1 mg/kg IV for paralysis

1.0 mg IV for adult defasiculating dose
0.01 mg/kg IV for children less than 8 Y
PROCEDURE
1. Maintain opening the airway and pre-oxygenate with 100% O2 while maintaining
cricoid pressure
2. Assemble your airway equipment and place the patient on a cardiac monitor and
pulse oximeter
3. Start IV (if not already established)
4. Start the premedication phase and give:
a. Lidocaine 1-1.5 mg/kg IV
b. Midazolam 0.1mg/kg IV not to exceed an initial dose of 5mg
c. Atropine 0.01 mg/kg IV push for all children less than 8 years (minimum
amount is 0.1 mg)
5. Continue cricoid pressure (Sellick maneuver)
6. Administer the paralytic agent:
a. Succinylcholine 1.5 mg/kg adults, 2.0 mg/kg children <8
b. If the patient doe not relax completely within 1 minute, repeat the same
dose
7. About 1 minute after the Succinylcholine is administered, paralysis should occur
and the patient should be intubated at this point
8. If the patient desaturates during the intubation attempt (SaO2 less than 90%),
abort the attempt and ventilate with a BVM and 100% oxygen until the SaO2
moves up into the mid to high 90% range
9. If the intubation attempts are repeatedly unsuccessful you can:

a. Ventilate with the BVM and 100% O2 until spontaneous respirations
return in 6-8 minutes IF you are able to ventilate and Cricoid pressure is
applied
b. If you are unable to ventilate with the BVM and 100% O2, try
repositioning the head and/or using oro/nasopharyngeal airways (use
caution in potential C spine patients)
c. If you are still unable to ventilate, insert a Combi-tube and ventilate with
100% O2 or perform a Cricothyroidotomy
10. Verify tube placement with a 5-point check and the end tidal CO2 monitor, place
an oral airway or bite block and secure the tube recording the tube depth
12. If paralysis is needed during transport, give Vecuronium 0.1 mg/kg IV.
1/02 P1.7
♦ For Head Injury Patients (see HEAD TRAUMA protocol):

a. Consider using a defasiculating dose of Vecuronium to prevent
fasiculations when Succinylycholine is administered. Fasiculations may
lead to increased intracranial pressure which should be avoided in patients
with head injuries and intracranial bleeding or swelling
b. Use the following dose of Vecuronium one minute before administering
the Succinylcholine (this dose will not cause paralysis):
In adults, 1.0 mg IV push
In Children, 0.01 mg/kg IV push
c. Remember that head injury patients need early (pre-hospital) airway
management ensuring adequate oxygenation throughout their treatment
and transport
♦ When using the end-tidal CO2 monitor, monitor for color changes which may
indicate misplacement of the ET tube. In cardiac arrest situations, end tidal CO2
monitoring will not be a reliable method of confirming tube placement
♦ You should use the Pulse Oximeter in addition to the end-tidal CO2 monitor to
monitor tube placement and oxygenation
♦ It is recommended that there should be at least 2 rescuers proficient in intubation,

when possible, before attempting RSI. It is up to the discretion of the Paramedic
on scene as to whether to proceed with RSI with only an EMT Basic or EMT
Intermediate present
♦ Do not rely just on the monitors, continually observe the patient

01/02 P2.1
CONTROL AND MONITORING OF IV SOLUTIONS**

PURPOSE
• To prevent the inadvertent administration of excess fluid volume or medications such as
lidocaine or dopamine or if there is a need to administer a specific amount of fluid to a
child
PROCEDURE
• Initiate IV access
• If there is a need to maintain IV access, a SALINE LOCK should be placed
except when there is a need to administer fluids:
1. Initiate the IV and after confirmation place the extension set1 over the IV
hub.
2. Flush with 10-15cc of normal saline through the adapter (or 2-3 cc if just
using a hub without extension tubing) and observe the area around the IV
to observe for any infiltration
3. The system must be flushed after the administration of each medication
• If there is a small controlled amount of fluid needing to be administered, utilize a

Volutrol or Soluset type device
1. Prepare the solution
2. Connect the Volutrol between the solution bag and the IV tubing
3. Place the amount of fluid that you want to administer over 1 hour in the
Volutrol bag and close the connection to the solution bag
4. Infuse the amount in the Volutrol at the desired rate
• If there is a need to administer IV fluids for replacement of fluid volume losses

such as trauma, burns, dehydration, or shock:
1. Initiate an IV and connect to IV tubing and a solution bag with Normal
Saline or a Balanced Salt Solution.
2. Administer the fluid according to the specific protocol
• Balanced Salt Solutions should be used with caution in patients with renal
impairment (hyperkalemia), cardiac and respiratory disorders (fluid overload), or
extremes of age.
1
The extension set should at least be standard bore hub and it is preferred to be at least 5 inches long containing one
or more injection sites and a slide clamp
7/01 P3.1
CRIME SCENE RESPONSE*

PURPOSE: Law enforcement agencies stress that their first interest on any crime scene is the
preservation of life. Effective reconstruction of the crime scene must follow. EMS personnel can be of
assistance by adhering to the following guidelines regarding crime scene response.
PROCEDURE:
♦ Response and Arrival:
2. EMS units responding to the scene of a reported crime should obtain information from
their communications center about the nature of the incident and whether staging is
advised (see STAGING for HIGH RISK RESPONSE protocol)
3. As EMS and Fire units move into location, there should be a conscious evaluation of
physical and weather conditions around the site. Tire tracks of suspect vehicles are often
located in or adjacent to the driveway. Driving your unit over these tracks can obliterate
potentially significant evidence
4. In any crime scene response, it is important to limit the number of personnel allowed into
the scene. It may be advantageous to have one of the EMS personnel consult with police
on the scene and direct the placement of vehicles and personnel response into the scene.
♦ Access and Treatment:

1. When entering the area where the victim is located, it is of great importance for EMS
personnel to select a single route to the victim. Maintaining a single route decreases the
chance of altering or destroying evidence or tracking blood over a suspect's footprints.
2. When moving toward the victim, it is important to note the location of furniture,
weapons, and other articles, and avoid disturbing them. If they need to be moved,
someone should note the location the article was moved from, by whom it was moved,
and where it was placed.
3. Attempt to clean up medical debris left at the scene. This material often confuses the
investigators and leaves unanswered questions.
4. Be conscious of any statements made by the victim or other persons at the crime scene.
As soon as possible, write down what these statements were and report to the
investigating officers.
5. In treating the victim of a crime, it is important to note the specific garments worn by the
patient at the time of treatment. It is also VERY important that EMS personnel do not, if
at all possible, tear the clothing off or cut through any holes, whether made by a knife,
bullet, or other object.
6. The victim should be placed on a clean sheet when ready for transport. At the hospital,
please try to obtain the sheet once the victim is moved off of it, fold it carefully in on
itself, and give it to the investigating officers. This is especially important in close
contact crimes such as rape or serious assault and death cases.
7/01 P3.2
DOCUMENTATION
♦ A detailed report that covers all aspects of your involvement at the crime scene is important in
case you are later called to testify in court
♦ These narratives should cover your observations and conversations with the family or persons
present at the scene, locations of response vehicles and equipment, furniture, weapons, or
clothing that has been moved, items that were handled by EMS responders, and your route to the
victim
♦ This narrative should be a separate report from your Patient Care Form
♦ EMS personnel should consider the following potential crime scenes:
• Domestic violence, suicide attempts
• Fires, MVAs,
• Assaults, near drowning
♦ If EMS personnel feel that there is a potential crime at the scene, report the suspicion to the
police.
7/01 P4.1
DEATH IN THE FIELD
PROCEDURE
♦ Determining Death in the Field (DIF) without initiating resuscitative efforts should be considered
under the following conditions:
• If a bystander, family member, or First Responder has started BLS, these conditions may
still be used to determine DIF without Medical Resource Hospital contact. ORS allows a
layperson, EMT, or Paramedic to pronounce "Death in the Field"
Patient qualifies as a "DNR" patient (see DO NOT RESUSCITATE Protocol)
A pulseless, apneic patient in a Mass Casualty Incident or Multiple Patient Scene
where the resources of the system are required for the stabilization of living
patients
Decapitation
Rigor Mortis in a warm environment
Decomposition
Venous pooling in dependent body parts (dependent lividity)
♦ In traumatic cardiac arrest, in addition to the conditions listed above under Withholding
Resuscitative Efforts, a victim of trauma should be determined to be Dead in the Field if:
The patient is a victim of blunt trauma and has no vital signs in the field
(pulseless, apneic, fixed and dilated pupils). These patients should not be
transported
If opening the airway does not restore the vital signs, the patient should not be
transported unless:
• There is a narrow complex rhythm, suggesting hypovolemia which may
respond to fluid resuscitation**
• There is ventricular fibrillation which would suggest a preceding medical
event.**
♦ In cardiac medical arrest:
The victim of a medical (non-traumatic) Cardiac Arrest should be determined to
be Dead in the Field if:
• The patient's ECG shows Asystole or Agonal Rhythm upon initial
monitoring (and after at least one (1) repositioning of the paddles or
confirm in at least 2 leads), and the patient, in the Paramedic or
Intermediates best judgment, is not resuscitatable.**
• The Paramedic who is the PIC should determine DIF and notify the
Medical Examiner.***
• The patient who has been shown to be unresponsive to appropriate
advanced cardiac resuscitative measures by declining during
resuscitation to Asystole or Agonal Rhythm (after checking all leads,
electrodes, may be determined to be Dead in the Field by the Paramedic
who is PIC.***
♦ All patients in Ventricular Fibrillation should in general be transported, except when DNR or
other withholding resuscitative efforts apply (if in doubt, contact Medical Resource Hospital).
7/01 P4.2
DOCUMENTATION
♦ All patient care provided should be documented with procedure and time
♦ In non-traumatic deaths or any time a cardiac monitor is used to determine death in the field, all
non-resuscitation or stopped resuscitation cases should have an ECG strip which shows
calibration of the ECG machine and the patient's rhythm. This does not apply to conditions listed
under A (Determining Death in the Field).***
♦ All conversations with physicians or Medical Resource Hospital should be fully documented with
physician's name, times, and instructions
♦ Most victims of electrocution, lightning, and drowning should have resuscitative efforts begun
and be transported to the hospital
♦ Hypothermic patients should be treated per the HYPOTHERMIA protocol
♦ Consider the NEEDS OF SURVIVORS when discontinuing a code. The following are some
guidelines:
o Calmly remove children from the resuscitation area
o If the emotional state of the family is appropriate, they may be allowed to watch or
participate in a limited and appropriate way by gathering medicines and providing history
o If family or friends were doing CPR prior to your arrival, commend their efforts
o If family or friends are disruptive, remove them as gently as possible
o If the resuscitation is occurring in the patients home, be respectful of those who live there
by making requests and not giving orders
o Give factual information to survivors regarding an explanation of the resuscitative effort
and why it may have failed.
o Genuine warmth and compassion are most helpful to grieving families; listening provides
grieving people with the most comfort
o Try to see to it that the survivors have a support system in place prior to leaving. Call
friends, family, neighbors, or clergy to be with them.
♦ For the death of a child:
o Suspect SIDS between 1 month and 1 year of age
o Make every effort to resuscitate the child
o Do not accuse the parents of abuse or neglect
o Mottling on a baby’s body and bloody froth around the nose and mouth with a contorted
face may be present in SIDS deaths
♦ After death has been pronounced, contact the Columbia County Medical Examiner before
moving or altering the body unless released to do that by the Medical Examiner
7/01 P5.1
DO NOT ATTEMPT RESUSCITATE

PURPOSE
♦ The goal is to provide comfort and emotional support with the highest quality medical care to
patients in conformity with the highest ethical and medical standards. The patient with decision-
making ability has the right to specify, in advance, their preferences when they may no longer be
able to communicate those preferences. The EMS system will honor “DNR” orders and advanced
directives.
DEFINITIONS
♦ DNR (Do Not Resuscitate) Order

• An order issued by a physician directing that in the event the patient suffers a
cardiopulmonary arrest, (i.e. clinical death)
♦ Clinical death exists when a patient is pulseless and not breathing.

♦ Biological death has occurred when no CNS signs of life exist.
♦ Advanced Directives convey a patient’s wishes regarding their treatment options near the end of
life
♦ Physicians Orders for Life-Sustaining Treatment (POLST) is a form signed by the patient’s
physician indicating treatment and care preferences. It includes a section for documenting DNR
orders but is also specific about various treatment preferences such as diet and comfort care.
When signed by a physician, the form becomes a physician’s order
♦ Attorney in fact is an adult appointed to make health care decisions for the patient
♦ Oregon Death with Dignity Act is a legislative act, which allows for physician-assisted suicide
for individuals who may be terminally ill.
PROCEDURE
• Unless a "DNR" order is issued, any patient who sustains a cardiopulmonary arrest will receive
full cardiopulmonary resuscitation with the objective of restoring life
• Resuscitation includes attempts to restore failed cardiac and/or ventilatory function by procedures
such as endotracheal intubation, mechanical ventilation, closed chest massage, and defibrillation
• BLS protocols at the EMT-B level will be followed while attempts to determine if a written DNR
order from the patient's physician is in the patient's medical file
• If a DNR order is issued, BLS resuscitation efforts will continue until one of the following
occurs:
1. There is a written and signed DNR order produced
2. The patient’s physician directs the EMT/Paramedic not to continue resuscitation
7/01 P5.2
PROCEDURE (CONT)
3. There is a valid Advanced Directive or POLST order directing providers not to

resuscitate
4. The patients Attorney in fact directs the providers not to resuscitate
5. The person, who is terminally ill, has ingested medication under the provisions of the
Oregon Death with Dignity Act and has a DNR order and/or documentation that the
ingestion was an action under the provisions of the Death with Dignity Act. If 911 was
called, make sure that the patient no longer wishes to end their life.
• The EMT must document the DNR order in the Patient Care Report
• It is always appropriate to provide comfort care measures
• The following procedures should NOT be performed on a patient who is the subject of a
confirmed DNR order and who is PULSELESS AND NONBREATHING:
CPR Endotracheal Intubation*** Defibrillation**
Oral/Nasal Airways Suctioning IV lines**
Fluids** Medications *** EKG monitoring.**
Oxygen Assistance with respiratory efforts Combi-Tube**

7/01 P6.1
DOCUMENTATION OF CARE
PURPOSE
• The purpose of this procedure is to describe what documentation is required on

medical responses.
PROCEDURE
• A Patient Care Report should be written for each patient seen, treated, or
transported by an ALS or BLS ambulance. The patient care report should be
completed on the EMS Patient Care Form. Documentation will be in the SOAP
format.
• Documentation should include at least:

1. Patient problem presented
2. Vital signs with time
3. Treatment provided and time
4. EKG strip, if monitored**
5. Any change in condition of patient
6. OLMC (Medical Resource Hospital or receiving hospital) contact
7. Any deviation from protocol.
• A copy of the Patient Care Report or an abbreviated report should be left at the
hospital whenever a patient is transported. The completed Patient Care Report
must reach the hospital as soon as possible within 12 hours of the call.
• If a patient refuses treatment or transport, documentation should include at least

(see PATIENT REFUSAL protocol):
1. Name of patient
2. Reason for ambulance response
3. Reason for patient refusal
4. Vital signs and time
5. Any other physical signs or symptoms
6. Competency of patient
7. Level of consciousness – detailed
8. Any witnesses.
9. A completed Patient Refusal Form
7/01 P7.1
INTRAOSSEOUS INFUSIONS**
DEFINITION
This is an alternative technique for establishing IV access in pediatric patients in whom

peripheral IV access is difficult and time consuming.
INDICATIONS
♦ Intraosseous infusion is indicated in emergencies when life saving fluids or drugs should
be administered and IV cannulation is either too difficult or time consuming to perform
♦ In the pre-hospital setting, intraosseous infusion is generally considered in a child three
years of age or less, in cardiac arrest or shock with a decreased level of consciousness
and with an inability to establish peripheral IV access
♦ This procedure should not delay transport time and airway management should be the
therapeutic priority in all these cases (see AIRWAY and AIRWAY MANAGEMENT
protocols)
♦ May be used on patients older than 3 years as a last resort for vascular access
PROCEDURE
1. Prepare the equipment:

a. Approved bone marrow type needles 15 and 18 gauge size
b. Betadine swabs
c. Two 5 cc syringes
d. Flush solution
e. Sterile gauze pads
f. Tape
g. Tee connector with a 3-way stopcock
2. Select the site over the proximal tibia, avoiding a leg which has been traumatized or
infected
3. Prepare the site by palpating the landmarks and note the entry point which is the
anteromedial flat surface 1-3 cm below the tibial tuberosity. Prep that area with betadine
and dry with a sterile gauze pad.
4. Insert the needle at the proximal tibial site, directing the needle caudally (toward the foot
and away from the knee joint to avoid damaging the growth plate)
a. The needle should penetrate the skin and subcutaneous tissue and be pushed
through the cortex by rotating until a “pop” or loss of resistance is felt. (do not
rock the needle to get it through the cortex)
b. Confirm the placement of the needle in the marrow by:
i. The free aspiration of blood/marrow after the removal of the stylet (take
the blood/marrow sample to the ED) OR
7/01 P7.2
PROCEDURE (CONT)
ii. Infusion of 2-3 cc of sterile solution, palpating for extravasation or

noting significant resistance. If extravasation occurs, all further attempts
at the site and extremity should be avoided
5. Start the infusion:

a. Although gravity infusion may suffice, pressurized infusions (using a 3-way
stopcock and 60 cc syringe or infusion pump) may be needed during
resuscitation.
b. When infusing medications through the IO site, pressure must be applied to the
fluid bag in order to maintain flow rates to ensure delivery of the medication
♦ Do not place an IO where there is cellulitis, burns, or a fracture proximal to the site
♦ Potential complications include osteomyelitis, growth plate injury, or extravasation of
fluid with compression of the popliteal vessels or the tibial nerve
♦ An alternate site for infusions is at the ankle at the medial surface of the distal tibia at the
junction of the medial malleolus and the shaft of the tibia.
7/01 P9.1
OCULAR EXPOSURES***
HISTORY
♦ Type of chemical exposure to the eyes:

• Gas (e.g. Chlorine)
• Solid (e.g. Drano or lye)
• Liquid (e.g. battery acid)
♦ When the exposure occurred
♦ Contact lens use
♦ Visual changes
PHYSICAL FINDINGS
♦ Eye exam looking for:

• Pupil size, reactivity and shape
• Presence of redness to the conjunctiva or lids
• Presence of foreign material
INDICATIONS
♦ To treat chemical exposures to the eyes which could continue to cause damage to
the cornea (this does not include foreign bodies such as glass, dirt, rocks, or
grinding materials; it also does not include welding exposures or exposures to the
sun.
PROCEDURE
1. Explain the eye irrigation procedure to the patient.
2. Place 2-3 drops of the Alcaine® anesthetic solution into the inferior conjunctival
sac of the affected eye. May use 2-3 more drops if the eye is not completely
numbed.
3. Remove the contact lens if present and place the Morgan Lens.
4. Instill the remainder of the Alcaine® solution into a1000 ml bag of NS.
5. Attach the 1000 ml bag of NS to the Morgan Lens and run it in over 30 minutes.
♦ DO NOT instill any drops into an eye which has an irregular pupil or blood in the
anterior chamber (hyphema) These are signs of penetrating ocular injuries; if that
is the case, an eye shield should be placed and they should be transported.
7/01 P9.1
RECEIVING HOSPITAL COMMUNICATIONS

ON LINE MEDICAL CONSULTATION
PURPOSE
• The purpose of contacting the receiving hospital is to provide notification to the

facility prior to the arrival of an emergency patient. There will also be a need to
consult a physician if questions or conflicts arise in the course of providing care.
This protocol will review the procedure for both of these
PROCEDURE
• EMTs should contact the receiving hospital at least 5 minutes before arrival by
telephone or the HEAR system
• The format of the report to the receiving hospital is as follows:
1. Unit identification
2. Age and sex of patient
3. Condition of patient
4. Chief complaint or reason for transport
5. Very brief pertinent medical history (one sentence)
6. Vital signs
7. Pertinent treatment rendered
8. Request for additional information or treatment
9. ETA
• In order to minimize airtime, all reports should be given in this order and in a
maximum of 60 seconds. The HEAR report is not meant to be a full patient
report. The report should relay only patient care information. Patient
identification information, as well as HIV status, is inappropriate to be given on
the HEAR frequency.
• For all OLMC (On Line Medical Consultation):

1. If the receiving hospital is Washington, Columbia, Cowlitz or Clatsop
counties, try to contact the receiving hospital first and speak to a receiving
physician. If that is not possible, contact OHSU-Medical Resource
Hospital (MRH).
2. If the receiving hospital is in Multnomah or Clackamas counties, contact

OHSU-Medical Resource Hospital (MRH).
3. You may call the GSH emergency department and speak to Dr. Wiens or
Dr. Perretta, if they are available, at any time regarding a case.
7/01 P10.1
ON-SCENE MEDICAL CONTROL

Formerly Medical Professional at the Scene
PURPOSE
♦ To describe who is in charge of patient care at the scene of medical emergencies and how
to resolve potential conflicts with other medical professionals who may be at the scene.
PROCEDURE
♦ For EMTs/ Paramedics On-Scene:

a. The first arriving and highest certified EMT will be the person in charge (PIC)
and will take responsibility for directing overall patient care.
b. The PIC will be responsible and accountable for patient care activities performed
at the scene and will be identified on all patient care reports
c. If there is a transfer of care to another service (e.g. Lifeflight) , the transfer of
patient care will be turned over to the transporting agency when:
The patient is placed on the transporting agencies gurney OR
At a time agreed upon by both EMTs (or EMT-flight nurse
♦ EMTs/Paramedics may take direction in the field from the following:

a. Physician Advisor
b. Regional protocols
c. On-line medical control (OLMC) (see OLMC-HOSPITAL
COMMUNICATION protocol)
d. Licensed physicians on scene as allowed in this protocol. Only physicians
(M.D./D.O.) with a valid license in the State of Oregon, as evidenced by their
wallet card license in their immediate possession, are recognized as physicians
under this section.
♦ EMTs/Paramedics in a physicians office or clinic:

a. When EMS is called to an office, paramedics and EMTs should receive
information and attempt to provide the assistance requested by the physician or
their staff while in the office.
b. While in the physicians office, the physician shall remain in charge of the patient
and can direct the EMT providing it is within the scope and protocols of the PIC
c. Once the patient is in the ambulance, the EMTs and paramedics shall follow the
protocols and the PIC is responsible for the patient care. The exception here
would be if the physician accompanies the patient to the hospital
d. If there are any conflicts between the protocols and the physician’s orders at the
scene, contact OLMC for direction (see OLMC-HOSPITAL
COMMUNICATION protocol
7/01 P10.2
PROCEDURE (cont)
♦ EMTs/Paramedics with physicians at a scene:
a. Medical professionals at the scene of an emergency may provide assistance to

paramedics and shall be treated with professional courtesy
b. Medical professionals who offer their assistance at the scene should be asked to
identify themselves and their level of training. The EMT should request that the
medical professional provide proof of his/her identity if he/she wishes to assist
with care given to the patient after the arrival of the EMS Unit.
• The physicians should be thanked by the PIC and informed that the
EMTs/Paramedics work under county protocols
• If the physician requesting medical control is not the patient’s
“physician of record”:
1. The physician should accompany the patient to the hospital
2. The physician should complete and sign the prehospital care
report.
3. OLMC is contacted (see OLMC-HOSPITAL
COMMUNICATION protocol) and agrees to transferring
patient care to the physician from the PIC
4. EMTs/Paramedics must provide care only according to approved
Columbia county protocols. The protocols need to be shared
with any physician requesting medical control.
• If the physician requesting medical control is caring for the patient

prior to arrival of EMS:
1. The physician must accompany the patient to the hospital to
maintain continuity of patient care.
2. The physician on the scene shall have made available to him/her
the services and equipment of the EMS Unit, if requested.
3. There should be full documentation of these events, including
the physician's name.
4. If a conflict arises about patient care or treatment protocols, the
paramedic should contact the Physician Supervisor, the Medical
Resource Hospital, or the receiving hospital for assistance.
c. Nurses working in the aeromedical environment and physicians are the only
medical professionals who may assume control of the patient. The EMT should
recognize the knowledge and expertise of other medical professionals and use
them for the best outcome of the patient.
♦ CONTACT OLMC IF THERE ARE ANY DISPUTES BETWEEN

EMTs/PARAMEDICS AND OTHER MEDICAL PROVIDERS (see OLMC-
HOSPITAL COMMUNICATION protocol)
7/01 P11.1
PATIENT REFUSAL
PURPOSE
♦ To describe the procedure used when obtaining and documenting a patient refusal
after an EMS response
PROCEDURE
♦ Determine if the patient initiated the 911 call for themselves

♦ Determine if the patient is an adult (18 YO or older) or a legally emancipated
minor (see PATIENT TREATMENT RIGHTS protocol)
♦ Determine if the patient is competent with Decision Making Capacity:
• Is oriented to Person, Place, Time, and Situation
• Exhibits no visual evidence of:
Altered level of consciousness
Alcohol or drug ingestion that impairs judgment
Injury, illness or trauma mechanism of injury
• Understands the nature of the medical condition, and the risks and
consequences of refusing care
♦ In the Patient with Competent Decision Making Capacity:

1. Explain the risks and possible consequences of refusing care and/or
transport
2. If a serious medical need exists, contact OLMC
3. Enlist family, friend, and/or law enforcement to help convince the patient
that medical care is needed
4. If the person continues to refuse, complete the REFUSAL
INFORMATION FORM
5. Give the patient a copy of the form and keep the other copy for the
agencies file with the Pre-hospital Care report
♦ In a person with Impaired Decision Making Capacity:

1. An impaired patient should not sign the Refusal Information Form
2. Treat and transport any patient who is impaired and has a potentially life
threatening condition
3. If the person meets criteria for NO PATIENT IDENTIFIED1 but is
impaired, make efforts to leave the person with a responsible individual
4. If there is any medical need, make a reasonable effort to assure that the
patient receives appropriate care by contacting family, friends, and/or law
enforcement to help
5. On cases that the patient is impaired, and there are no responsible
individuals to assure that they receive appropriate care, contact OLMC
(see OLMC-HOSPITAL COMMUNICATION protocol)
7/01 P11.2
PROCEDURE (cont)
6. If transport is needed in the impaired patient who is in need of restraint,

attempt restraint only if this can be done safely
♦ Document:
1. General appearance
2. Vital signs
3. History and physical exam
4. Mental status
5. Presence of drugs and/or alcohol
6. Assessment of decision making capacity
7. Risks explained and advice offered
8. Response to efforts by EMTs to provide care
9. All communications with the patient, family, friends, law enforcement and
OLMC
10. Complete the Refusal Information Form
♦ Remember the EMERGENCY RULE:

• EMTs may treat and/or transport, under the doctrine of implied consent, a
person that requires immediate treatment to save a life or prevent serious
injury
♦ Suggested reasons to contact OLMC:

• Suspected impaired decision making capacity
• Suspected serious medical conditions where transport is advised
• Conflicts at the scene
• If the EMT is uncertain of the risks a patient might encounter by refusing
No patient identified means:

• No significant mechanism of injury
• No significant signs of trauma
• No acute medical conditions
• The individual is 18 years or older
• The individual did not call 911 for themselves
7/01 P11.3
Columbia County Refusal Information Form
Name: ____________________________________Date of Birth: ________________
Run Number: ____________________Date: _________________________________

PLEASE READ AND KEEP THIS FORM!
This form has been given to you because you do not want treatment and/or transport by
_______________________Emergency Medical Services. Your health and safety
concern us. Please remember the following:
1. Your condition may not seem as bad as it actually is. Without treatment your
condition could become worse.
2. Our help cannot replace treatment by a doctor. You should obtain treatment by
going to an Emergency Department, or by calling your doctor. You may be seen
at an Emergency Department without an appointment.
3. If you change your mind or your condition worsens, do not hesitate to call 911.
4. If this number has been circled, you have been advised to go to the hospital by
ambulance for evaluation and treatment.
5. If this number has been circled, we have discussed your condition with a doctor
who agrees that you should go the hospital by ambulance for evaluation and
treatment.
6. Other: ____________________________________________________________
I have received a copy of this information sheet

Patient or Guardian Signature_______________________________Date_____________
• Patient or Guardian Assessment (circle)

1. Oriented to Person? Y N Place? Y N
Time? Y N Event? Y N
2. Altered level of consciousness? Y N
3. Head Injury? Unknown Y N
4. Alcohol, drug or psychiatric impairment? Unknown Y N
5. Does the person understand the advice given an the risks of refusing? Y N
• OLMC Contacted? Y No, not able No , not indicated
• Patient advised? Medical treatment needed Ambulance transport needed

(circle all that apply)
Further harm could result without treatment
• DISPOSITION Patient would not accept the Refusal Information form

(circle all that apply)
Patient refused all EMS services Refused field treatment Refused transport
Patient left in the care or custody of:
NAME_________________________________________RELATIONSHIP__________________
PIC Signature________________________________________________Date____________
ATTACH TO THE PATIENT CARE REPORT
7/01 P12.1
PATIENT RESTRAINT
PURPOSE
Patient restraints (physical and/or chemical) should be utilized only when necessary and
in those situations where the patient is exhibiting behavior that the EMT believes presents
a danger to the patient and/or others. This procedure should not be used on patients
refusing treatment unless they are on a police hold or after consulting with a physician
on-line. This procedure does apply to patient being treated under implied consent.
PROCEDURE
♦ Guidelines for physical restraint

♦ Use the minimal physical restraint required to accomplish necessary patient care
and ensure safe transportation to the hospital:
1. Soft restraints may be sufficient
2. If law enforcement or additional personnel are needed, call for it
before attempting any restraint procedures
3. Do not endanger yourself or your crew in attempting to apply
restraint
♦ Avoid placing restraints in such a way as to preclude evaluation of the patient’s
medical status (airway, breathing, circulation). Consider whether restraints will
interfere with necessary patient care activities or will cause further harm
♦ Physical restraints procedure:

a. Ensure sufficient personnel are present to control the patient while
restraining him/her: USE POLICE ASSISTANCE WHEN AVAILABLE
b. Place patient face up on a long backboard
c. Secure all extremities to the backboard:
1. Try to restrain lower extremities first using Flexcuffs® around both
ankles
2. Next, restrain the patients arms at the side using one Flexcuff® on
each wrist
d. If necessary, utilize cervical spine precautions (tape, foam bags, etc.) to
control violent head or body movements
e. Place padding under the patients head and wherever else needed to prevent
the patient from further harming him/herself or restricting circulation
f. Secure the backboard to the gurney for transport using additional straps if
necessary; remember to secure additions straps to the upper part of the
gurney to avoid restricting the wheeled carriage
g. Check the neurovascular status of each limb, distal to the site or restraint,
every 15 minutes and document the exam
h. Physical restraints must be used any time a potentially violent or unstable
patient (i.e. head injury, altered mental status for any reason, or the patient
is under the influence of intoxicants) is transported by air ambulance or
helicopter
7/01 P12.2
PROCEDURE (cont)
i. In situations where the patient is under arrest and handcuffs are applied by
law enforcement officers:
1. The patient will not be cuffed to the stretcher and a law
enforcement officer shall accompany the patient in the ambulance,
if the handcuffs are to remain applied
♦ Chemical restraint guidelines:

a. Sedative agents can be used to provide a safe method of restraining the
violent, combative patient, preventing injury to the patient and/or others
b. These patients include but are not limited to:
1. Alcohol and/or drug intoxicated patients
2. Restless, combative head injury patients
♦ Chemical restraint procedure:

a. Assess the possibility of using physical restraints first and the personnel
available to safely attempt restraining the patient.
b. Prepare the sedative medications for injection and prepare for potential
hypotensive side effect.
c. Give 1-2 mg of Versed® IM or IV push. Assess vital signs within the first
5 minutes and thereafter. Repeat the dose if the patient is still combative
15 minutes after the initial injection.***
d. Assess the need for sedation carefully; the violent combative patient has a
lesser chance of injury while sedated. Any patient who is fighting their
physical restraints and compromising their airway or cervical spine is a
candidate for sedation.
e. Side effects of Versed® include hypotension. Midazolam should not be

administered without having a BVM ready to use.
7/01 P13.1
PATIENT TREATMENT RIGHTS

PURPOSE
♦ The Columbia County Protocols are intended for use with a conscious,
consenting patient, minors, or an unconscious (implied consent) patient.
♦ If a conscious adult patient who is rational refuses treatment, you should comply
with the patient's request and document the refusal (see PATIENT REFUSAL
protocol)
♦ If a conscious patient who is irrational or may harm him/herself refuses treatment,

you should contact OLMC (see OLMC-HOSPITAL COMMUNICATION
protocol)(see PSYCH/BEHAVIORAL EMERGENCIES protocol).
♦ If a patient's family, patient's physician, or nursing home refuses treatment for a

patient, protocols are contained herein to deal with those situations. (see
TRANSPORT OF THE CHRONICALLY ILL PATIENT protocol)
♦ A patient has the right to select a hospital (within reason) to which to be

transported if he/she is rational, and if in your best judgment, transport to that
hospital will not cause loss of life or limb. Code 3 ambulance should transport the
patient to the nearest appropriate facility.
♦ The age of consent and refusal in Oregon is 18. Exceptions to this rule are
lawfully married patients under the age of 18, and legally emancipated minors
(age 16 and over) who have their “Order of Emancipation” from the court in their
possession. Of critical importance to the EMT is the exception in the law where
the EMT may treat and/or transport under the doctrine of implied consent, a minor
who requires immediate care to save a life or prevent serious injury. This consent
is also provided by these protocols (off-line medical direction).
♦ In situations with no injury, or a relatively insignificant injury involving minors

where no parental contact can be obtained, contact with the Medical Resource
Hospital is mandatory. To err on the side of treatment is the safe approach.
Careful documentation is important.
♦ In addition to the above, all patients are entitiled to be treated at all times with
consideration and full recognition of human dignity and individuality. This
includes:
1. To have access to pre-hospital emergency medical care and transportation

regardless of race, color, creed, national origin, age, sex, disability, or
ability to pay for the service provided.
7/01 P13.2
2. To have a reasonable response to a request for service once the

ambulance/EMS service is engaged.
3. To have reasonable privacy with respect to emergency care and

transportation.
4. To be treated with respect, dignity and compassion
5. To know the names and certification level of all personnel involved in

their care.
6. To be able to talk openly with the ambulance personnel involved and

know that the information will be held in confidence and only shared with
the individuals providing further medical care.
7. To know why each medical procedure needs to be performed, as well as

the alternatives to performing it and the risks involved.
8. To refuse portions of care or revoke consent for procedures after consent

was previously given.
9. To provide reasonable continuity of care once EMS is engaged to provide

service
10. To voice a concern regarding any aspect of the emergency medical care
and transportation received, with the ability to call the district to discuss
the concern, which will not affect any future use of EMS services
11. To be transported in an environment that is safe from recognized hazards

and unreasonable annoyances
7/01 P14.3
PRE-HOSPITAL RESPONSE
TO RADIOLOGICAL MEDICAL EMERGENCIES
PURPOSE
♦ To create a set of procedures and guidelines for dealing with a potential radiological
emergency at the defunct Trojan Nuclear power plant
PROCEDURE
♦ IF THERE IS NO DECLARED EMERGENCY AT TROJAN - AMBULANCE

DISPATCHED TO TROJAN:
A. "Zero" the pocket dosimeter from the radiation kit. Attach the pocket dosimeter
and TLD to your shirt/jacket.
B. Enter the Trojan plant access road from Highway 30. Drive to the main gate. The
main gate will be open and the security guard will let you go through.
C. Drive to the upper gate. It will be open. Stop at this gate. An armed security
guard will get on the ambulance to escort you to the patient.
D. Is there radiation contamination? A Radiation Protection Technician (RPTEC) or

Rainier Paramedic will determine. If there is a contamination, skip to
CONTAMINATION below. If there is no contamination:
E. Perform medical assessment and treatment. Package and load the patient.
F. When leaving, stop at the upper gate to let the escort get off.
♦ IF THERE IS CONTAMINATION FOUND:

A. Simple decontamination measures may be taken, i.e., removing contaminated
clothing, or moving a patient away from a radiation source. However, do not
delay medical treatment of the patient - it is more important to perform life saving
measures than to decontaminate the person!
B. If there is no RPTEC present and the Paramedic determines that there is a

contamination, call a RPTEC in to provide radiation protection coverage.
C. When you transport the patient use your radiation monitoring instruments to
provide radiation protection coverage to you and the patient.
D. Request C-COM call the Oregon Health Division, Radiation Protection Services
at 1-503-731-4014, and request assistance.
7/01 P14.4
♦ FOR PATIENTS NEEDING TRANSPORT TO THE HOSPITAL:

• IF THERE IS NO CONTAMINATION
If this is not a trauma patient, transport to either St. John's Hospital in
Longview, Good Samaritan Hospital, or St. Vincent Hospital in Portland.
If this is a trauma patient, follow your procedures for entry into the
Trauma System.
Tell the hospital if the patient is contaminated.
Additional directions may be given to you by the RPTEC depending on
the radiological condition of the patient
• IF THERE IS CONTAMINATION
An RPTEC will ride with you to provide radiation protection coverage.
When you transport the patient use your radiation monitoring instruments
to provide radiation protection coverage to you and the patient.
Transport the patient to a hospital. If appropriate, consider a travel route
that avoids potential radiation release areas.
When the transport is completed, and the hospital accepts responsibility
for patient treatment, a radiation survey of yourself, the other ambulance
staff, the equipment and ambulance must be done. You must remain at the
hospital until this survey is completed. The hospital staff, the state
radiation team, or the RPTEC can do this survey. If the hospital staff, the
state radiation team, or the RPTEC cannot do the survey, you will have to
do the survey yourself. Any decontamination should be done before
leaving the hospital.
Tell the state radiation team your pocket dosimeter reading and give them
your TLD. If the state radiation team is not there, return to your station,
contact them by phone and request their assistance.
7/01 P15.1
SCOPE OF PRACTICE
PARAMEDIC
• THE PARAMEDIC FOR COLUMBIA COUNTY EMS SCOPE OF PRACTICE

SHALL NOT EXCEED:
a. Perform all procedures at the Intermediate level.
b. Initiate the following airway management techniques:

Endotrachael Intubation/Retrograde Intubation.
Tracheal suctioning techniques.
Cricothyrotomy.
Transtracheal jet insufflation which may be used when no other
mechanism is available for establishing an airway.
c. Initiate a nasogastric tube.
d. Initiate electrocardiographic monitoring and interpret presenting rhythm.
e. Provide advanced life support in the resuscitation of patients in cardiac arrest.
f. Perform emergency cardioversion in the compromised patient.
g. Attempt external transcutaneous pacing of bradycardia that is causing

hemodynamic compromise.
h. Initiate or administer any medications or blood products under specific written

protocols authorized by the supervising physician, or a direct order from a
licensed physician.
i. Initiate needle thoracentesis for tension pneumothorax in the field.
j. Initiate placement of a femoral intravenous line when a peripheral line cannot be

placed.
k. Initiate placement of a urinary catheter for trauma patients in the field who have
received diuretics and where the transport time is greater than 30 minutes.
7/01 P15.2
INTERMEDIATE
• THE EMT-INTERMEDIATE FOR COLUMBIA COUNTY EMS SCOPE OF

PRACTICE SHALL NOT EXCEED:
a. Perform all procedures at the Basic level.
b. Initiate and maintain peripheral IV lines and initiating saline locks
c. Initiate and maintain intraosseous infusions
d. Infuse isotonic crystalloid solution
e. Draw peripheral blood specimens
f. Initiate and administer the following medications:

Epinephrine 1:10,000
Atropine
Lidocaine
Naloxone
Hypertonic glucose
Nitroglycerine
ß-2 specific nebulized bronchodilators1
g. Insert a Pharyngeal Esophageal Airway device (e.g. Combi-tube, EOA,

Pharyngeal Tracheal Lumen airway)
h. Insert an orogastric tube
i. Maintain IV medication infusions initiated at the sending medical facility, under

their direction, during transport
j. Perform defibrillation with a manual defibrillator2
1
After completing a Health Division of the Department of Human Resources approved course in
the administration of nebulized bronchodilators
2
After completing a Health Division of the Department of Human Resources approved training
course and in the service of an agency that has been granted a “EMT-Intermediate Manual
Defibrillation Waiver” by the Division
7/01 P15.3
BASIC
THE EMT-BASIC FOR COLUMBIA COUNTY EMS SCOPE OF PRACTICE SHALL

NOT EXCEED:
a. Conduct primary and secondary patient exams
b. Take and record vital signs
c. Open and maintain airways using Oropharyngeal and nasopharyngeal airways and
pharyngeal suctioning devices
d. Administer O2 by nasal cannula or by partial or non-rebreather mask
e. Operate BVM ventilation device with reservoir
f. Provide standard CPR and obstructed airway care for infants, children, and adults
g. Provide care for soft tissue injuries and fractures
h. Provide care for suspected shock including the pneumatic anti-shock garment
i. Provide care for suspected medical emergencies, including:

Obtaining a peripheral blood glucose specimen for monitoring obtained via
fingerstick, heelstick or earlobe puncture
Administer oral glucose for hypoglycemia
Administer epinephrine by SQ or automatic injection device for anaphylactic
shock1
Administer activated charcoal for poisonings
Administer aspirin for suspected myocardial infarction2
j. Assist with pre-hospital childbirth care
k. Perform cardiac defibrillation with an automatic or semi-automatic defibrillator
l. Transport stable patients with saline locks, heparin locks, foley catheters, or in-
dwelling vascular devices
m. Perform other emergency tasks as requested if under the Direct Visual supervision of
a physician, under order of that physician.
n. Complete a clear and accurate pre-hospital care report form on all patient contacts,
leaving a copy of the form with the medical facility receiving the patient
o. Assist patients with the administration of their own Nitroglycerine and metered dose
inhalers that have been prescribed by their own physician
7/01 P15.4
FIRST RESPONDER
THE FIRST RESPONDER FOR COLUMBIA COUNTY EMS SCOPE OF PRACTICE

SHALL NOT EXCEED:
a. Open and maintain airways using Oropharyngeal and nasopharyngeal airways and
pharyngeal suctioning devices
b. Administer O2 by nasal cannula or by partial or non-rebreather mask
c. Operate BVM ventilation device with reservoir
d. Perform cardiac defibrillation with an automatic or semi-automatic defibrillator3

1
A copy of the pre-hospital care report form needs to be sent to the Board of Medical Examiners
each time epinephrine is administered
2
After completing a Health Division of the Department of Human Resources approved course in
the administration of aspirin
3
Only when the FIRST RESPONDER is certified by the Health Division of the Department of
Human Resources as a FIRST RESPONDER and:
Has completed successfully a Division approved course on the use of the automatic and
semi-automatic defibrillator
Complies with periodic re-qualification requirements for automatic and semi-automatic
defibrillators as established by the Health Division of the Department of Human
Resources
7/01 P16.1
SLOW DOWN/CANCELLATION
PURPOSE
♦ The purpose of this protocol will be to describe the situations when EMS responding
units might be slowed down in their response or cancelled by other EMS units or law
enforcement agencies.
♦ It is in the best interest of patient care and the public safety to cancel or slow down units
(from emergency to non-emergency priority) responding to low priority emergency
medical calls when it is determined that the patient or situation does not require an
emergency response.
PROCEDURE
♦ BLS first responders may slow down ALS responders when they determine, after patient
assessment, that the patient does not require ALS treatment or is refusing treatment
and/or transport (see PATIENT REFUSAL protocol).
♦ BLS first responders may cancel ALS responders if there is nothing found or the patient
requires only first aid. (bandaging or simple splinting)
♦ Law enforcement agencies may slow down EMS response if a patient requires only first
aid (bandaging or simple splinting) or the patient is refusing treatment and/or transport
(see PATIENT REFUSAL protocol).
♦ ALS first responders, BLS first responders, and law enforcement units should not cancel
or slow down EMS response because an air ambulance (Lifeflight) has been activated.
Only after an air ambulance has landed, and the ALS/BLS responders or law enforcement
agent has conferred with the flight personnel, should they cancel or slow down further
EMS response
7/01 P17.1
STAGING EMS UNITS

PURPOSE
♦ To establish guidelines for the response of EMS providers to incidents that involve
violence, or are anticipated to be potentially violent in nature, or place EMS providers in
jeopardy
♦ These incidents include (but may not be limited to):
1. Assaults (shooting, stabbing)
2. Hazardous materials incidents (see HazMat protocol)
PROCEDURE
♦ The following are the reasons for a unit to consider staging:
1. If the unit recognizes a violent situation or scene that could expose EMS
providers to danger.
2. If the scene is a hazardous materials situation, the unit should stage and wait for
the hazardous material personnel to declare the scene safe.
3. If there is a previous unit at the scene that has staged.
4. If the unit is dispatched to a MPS/MCI incident and receive no assignment from

command or operations, they should proceed to the established staging area, or, if
one is not established, do so.(see MCI/MPS protocol)
5. If dispatch advises the unit of a known violent scene
♦ When staging, the unit should:

1. Stage about 2 blocks from the incident and out of the line of sight.
2. Announce the staging location and that the unit is staging.
3. When staging, turn off the headlights and warning devices unless there is a traffic
hazard.
4. Once staged, the unit will not enter the scene until the scene is declared safe and
secure by the police or dispatch.
7/01 P18.1
TIME AT THE SCENE

PURPOSE
♦ The purpose of this protocol is to delineate on-scene time limitations.
PROCEDURE
♦ If at any time an EMT cannot provide or protect a patent airway to a patient within 5
minutes after patient encounter and initiating emergency medical care, he/she is required
to transport the patient immediately.
♦ For TRAUMA cases, time spent on the scene should be 10 minutes or less where
extrication has been accomplished and the patient can be moved away from the site.
♦ Scene time should be limited to evaluating the need for ambulance transport and
immediate stabilization of the patient. Most procedures should be performed in the
ambulance.
Revised 04-96
7/01 P19.1
TENSION PNEUMOTHORAX DECOMPRESSION***
DEFINITION
• The emergent decompression of a tension pneumothorax using an over the needle

catheter and a Heimlich® type valve.
INDICATIONS
• Tension Pneumothorax as defined by the following signs and symptoms:

a. History (e.g. chest trauma, COPD, patient who is deteriorating on positive
pressure ventilation)
b. Hypoxia (low oxygen saturation)
c. Progressive respiratory distress along with agitation and restlessness
d. Jugular venous distension or distended neck veins
e. Asymmetrical movements on inspiration
f. Shift of the trachea toward the unaffected side
g. Shock with a low or rapidly decreasing blood pressure
• A simple pneumothorax or non-tension pneumothorax should NOT be decompressed.

Signs and symptoms of this include:
a. Mild to severe respiratory distress
b. Chest pain
c. Decreased or absent breath sounds
d. Subcutaneous air or crepitus
PROCEDURE
1. Expose the chest and clean with alcohol, Betadine®, or soap.

2. Locate the mid clavicular line and the third rib on the affected side.
3. Insert a large gauge over the catheter needle (10-14 G) with a syringe attached, over the
top of the third rib. Hit the rib and slide OVER IT.
4. If the air is under tension, the barrel of the syringe will easily pull out or may even “pop”
out. If that happens, advance the catheter.
5. Attach a Heimlich® type valve to the catheter and keep the closed end pointed away from
the patient.
6. Tape the catheter and the valve securely.
7/01 P19.2
• The patients chest should be auscultated often to diagnose the return of the tension or
other possible complications. (e.g. bleeding)
• Oxygenate these patients with 100% O2.
• Tension pneumothorax can result as a complication of CPR or aggressive positive
pressure ventilation, the latter causing the progression to tension rapidly.
• Complications of needle thoracostomy:
o Creation of a pneumothorax (where one did not exist)
o Lung laceration
o Bleeding or hemothorax (avoid going under the rib since that is where the
neurovascular bundle is located)
o Skin or lung infection
• Tension pneumothorax can be caused by completely covering an open chest wound;
always leave one side of the dressing open or un-taped when covering an open chest
wound.
7/01 P20.1
TRANSCUTANEOUS PACING***
DEFINITION
♦ This is the technique of electronic cardiac pacing achieved by using skin

electrodes to pass repetitive electrical impulses through the thorax to the heart,
stimulating the heart to contract
INDICATIONS
♦ Should be considered in cases of symptomatic bradycardia defined as:

8. Hypotension (heart rate <60/min)
9. Shortness of Breath (pulmonary edema) (heart rate <60/min)
10. Ventricular Ectopy (heart rate <60/min)
11. Chest Discomfort (heart rate <40/min)
PROCEDURE
1. Ensure that the pacemaker leads are attached and the monitor is displaying the
cardiac rhythm.
2. Attach the pacing electrodes to the anterior and posterior chest just to the left of
the sternum and spinal column respectively.
3. Begin pacing at a heart rate of 80 beats per minute and zero current output.
Increase the current in increments of 20 mAs while observing the cardiac monitor
for evidence of capture (see diagram) and confirm mechanical capture by
checking pulse and blood pressure.
4. If the patient is comfortable, continue pacing; if the patient is uncomfortable,
decrease the current output in increments of 5 mAs to a level just above capture
threshold.
5. If the patient continues to complain of pain during pacing despite decreasing the
current output, consider the administration of midazolam (see MIDAZOLAM
protocol)
6. If the patient is or becomes unconscious during pacing, assess capture by
observing the monitor and evaluating pulse and blood pressure changes. If the
patient has electrical capture but no pulses, treat according to the PEA protocol
(see CARDIAC ARREST protocol)
7. If there is no response to pacing or ACLS protocols, consult OLMC (see
OLMC/HOSPITAL COMMUNICATION protocol)
♦ Transcutaneous pacing should not be used in the following situations:

1. Asystole
2. Patients under the age of 14
3. Patients meeting death in the field criteria
4. Patients with signs of penetrating or blunt trauma
7/01 P21.1
TRAUMA PROTOCOL
Patients are to be entered into the Trauma System in ATAB I (Multnomah,
Washington, Clackamas, Columbia, Tillamook, and Yamhill Counties) when they meet
the following criteria and have been involved in a trauma incident. The EMT is required
to report the exact reason for patient entry to MRH and document the incident fully,
including the reason(s) for entry:
ENTRY CRITERIA
♦ Physiological Criteria:
A systolic blood pressure of less than 90 mm/Hg.
Respiratory distress as evidenced by a respiratory rate of less than 10 or

greater than 29.
Altered Mental Status as evidenced by a Glasgow Coma Scale of 13 or less.
♦ Mechanism of the patient injury:
Extrication from a motor vehicle which takes greater than 20 minutes and uses
heavy tools.
Death of an occupant in the same car as the patient.
Ejection of the patient from an enclosed vehicle.
♦ Anatomical criteria:
The patient has a flail chest.
The patient has two or more obvious proximal long bone fractures (humerus,
femur).
The patient has a penetrating injury of the head, neck, torso, or groin
associated with an energy transfer.
The patient has in the same body area a combination of trauma and burns
(partial and full thickness) of 15 percent or greater, or burns involving the
face and/or airway.
The patient has an amputation proximal to the wrist or ankle.
The patient has numbness or paralysis in one or more limbs.

7/01 P21.2
♦ EMT Discretion:
If in the EMT's judgement, the patient has been involved in a trauma incident,
which, because of a high energy exchange, causes the EMT to be highly
suspicious that the patient is severely injured, the patient should be entered into
the Trauma System.
The EMT's suspicion of trauma injury may be raised by the following factors:
a. Age greater than 60.

b. Age less than 12.
c. Extremes of environment (hot/cold).
d. Patient's previous medical history.
e. Pregnancy.
f. Communication with the patient is impaired.
MEDICAL DIRECTION
♦ Off-line medical direction for trauma patients is controlled by the BLS/ALS

Protocols as adopted by ATAB I, the EMS agencies, and the Physician
Supervisors.
♦ On-line medical direction within radio range of Medical Resource Hospital is

controlled by Medical Resource Hospital.
♦ On-line medical direction in areas where radio communications with Medical

Resource Hospital is impossible are the responsibility of the Level III or Level IV
designated centers in their service areas. These areas are: Tillamook Hospital for
Tillamook County, Columbia Memorial for Clatsop County, St. John's for
Columbia County, and Newberg Hospital for Yamhill County.
♦ On-line medical direction may override off-line medical direction. Any instances
of this will be reported to ATAB QA.
COMMUNICATIONS
♦ Emergency Medical Technician at Scene to destination Trauma Center:
♦ IT IS ESSENTIAL THAT EARLY RADIO COMMUNICATIONS BE

ESTABLISHED CONCERNING THE TRAUMA VICTIM. After assessing a
trauma situation and making the determination that the patient should enter the
Trauma System, the EMT certified to the highest level should contact the
destination Trauma Center at the earliest time practical and provide the following:
1. Number of patients (age and sex).

2. Mechanism of injury.
7/01 P21.3
COMMUNICATIONS (CONT)
3. Anatomic site of injury.

4. Vital signs (blood pressure, respiratory rate, level of consciousness).
5. Geographic location of incident.
6. Estimated time of departure from the scene/ETA.
7. Unit number of transporting unit and mode of transport.
♦ In case of radio failure with medical direction, contact the EMS dispatch point for
hospital information.
TRANSPORT PROTOCOL
♦ Patient to Level I hospital if 30 minutes or less transport time.
♦ Designated Trauma Center destination from the scene, if by ground transport, to

be determined by the EMT based upon the following criteria:
Columbia County-Scappoose, St Helens: Emanuel Hospital Service Area.

Columbia County-Rainier, Clatskanie, Mist-Birkenfeld: St Johns-
Longview or Columbia Memorial in Astoria
♦ Designated Trauma Center destination from the scene if by air transport to be

determined by flight personnel based upon the following criteria:
Regardless of patient origin, the patient destination to be alternated

between the Designated Trauma Centers.
If two patients are transported in the same transport, patient destinations to

be same Designated Trauma Center.
In the event that the Designated Trauma Center which is to be the patient
destination, is unable to accept the patient, Medical Resource Hospital will
assist the flight crew in determining patient destination.
♦ In Columbia County, existing patient referral trends which use out-of-state

hospitals are to be maintained until the ATAB plan addresses out-of-state
hospitals.
MODE OF TRANSPORT
♦ Ground vs. Air (Level I):
An air ambulance should be used when it would reduce total pre-hospital
time of a Trauma System by 10 minutes or greater. The EMT must
recognize that any patient entered in the Trauma System should receive
the most rapid transportation mode possible.
The air ambulance can be put on stand-by and/or activated by request
through C-COM.
7/01 P21.4
PATIENT EVALUATION PROTOCOL:
♦ Treatment priority should be approached in this order:
1. Airway maintenance including control of the cervical spine. If unable to

establish and maintain an adequate airway, the patient should be
transported to the nearest acute facility to obtain definitive airway control
by a qualified individual
2. Breathing
3. Control of circulation
4. Control of hemorrhage
5. Treatment of shock
6. Splinting of fractures
7. Neurological examinations
8. Secondary patient assessment
TRAUMA CARE PRIORITIES FOR PRE HOSPITAL CARE PERSONNEL
♦ Assess and maintain the airway; protect the cervical spine
1. Chin lift/jaw thrust

2. Clean airway of foreign bodies
3. Oropharyngeal/ nasopharyngeal airway
4. Bag valve mask with oxygen supplementation as indicated
5. Endotracheal intubation*** or needle cricothyroidotomy***.
Endotracheal intubation is the preferred method of maintaining a patent
and protected airway. (see AIRWAY and AIRWAY MANAGEMENT
protocols)
♦ Breathing Control
1. Assessment
a. Expose the chest and neck.
b. Measure the rate and depth of respirations.
c. Inspect and palpate for unilateral and bilateral chest movement,
subcutaneous emphysema, and sucking chest wounds.
d. Look for distended neck veins or a deviated trachea.
e. Auscultate the lungs.
2. Management
a. Cover an open pneumothorax with a 3 way occlusive dressing.

b. Start oxygen therapy.
c. Alleviate tension pneumothorax (see TENSION
PNEMOTHORAX DECOMPRESSION protocol
d. Support ventilation.
7/01 P21.5
TRAUMA CARE PRIORITIES FOR PRE HOSPITAL CARE PERSONNEL

(CONT)
♦ Circulatory Control
1. Identify exsanguinating hemorrhage
a. Apply direct pressure

b. Apply a tourniquet if there is uncontrolled bleeding from an
extremity
c. Open PASG on the stretcher and place the patient on the stretcher-
apply if necessary (see SHOCK protocol)
2. Assess for pulses
Generally if:
1. The radial pulse is present, the systolic pressure is 80 mmHG
2. The femoral pulse is present, the systolic pressure is 70 mmHG
3. The carotid pulse is present, the systolic pressure is 60 mmHG
3. Evaluate perfusion
a. Pulse rate and character
b. Capillary refill
c. Skin Color (i.e. pink, pale, cyanotic, mottled)
4. Initiate 2 large bore IVs with a balanced Salt Solution during transport
5. Obtain blood pressure. This is a low priority, consider during transport.
♦ Assess Neurologic Status per Glascow Coma Scale
1. Eye opening
2. Best verbal response
3. Motor response
• Standardized pain stimulus is either supraorbital ridge pressure or
fingernail pressure
SCENE TIME
After gaining access to the patient, scene time should not exceed ten
minutes for any patient who is entering the Trauma System. Plan to
start IVs and initiate other care once en route to the hospital if
necessary
7/01 P21.6
Patient transfer from a Level 3 or 4 hospital to a Level 1 hospital
The following guidelines shall be utilized to identify patients who are at a particularly
high risk of dying from multiple and severe injuries. Ideally, such patients should be
treated at a Level 1 Trauma Center when continued exposure to such problems by multi-
disciplinary team systems may afford the patient an optimum outcome. Such patients
shall be transferred to Level 1 centers from Level 3 or 4 centers. The transfer should take
place only after the receiving physician in the Level 3 or 4 center has conferred with the
Level 1 receiving trauma surgeon.
♦ Central Nervous System

a. Head Injury
1. Penetrating injury
2. Depressed skull fracture
3. Open injury
4. CSF leak
5. GCS less than or equal to 13
6. Deterioration in GCS of 2 or more score points
7. Lateralizing signs
b. Spinal Cord Injury
♦ Chest
a. Wide superior mediastinum
b. Major chest wall injury
c. Cardiac injury
d. Patients who may require protracted ventilation
♦ Pelvis
a. Pelvic ring disruption with shock, more than 5 units transfused, evidence
of continued hemorrhage, and compound (open) pelvic injury or pelvic
visceral injury
♦ Multiple System Injury

a. Severe face injury with head injury
b. Chest injury with head injury
c. Abdominal or pelvic injury with head injury
d. Second degree or greater burns with head injury
♦ Secondary Deterioration (late sequelae in trauma system patients who were

not transferred)
a. Patients requiring mechanical ventilation
b. Sepsis
c. Single or multiple organ system failure (deterioration in CNS, cardiac,
pulmonary, hepatic, renal, or coagulation system)
d. Osteomyelitis
7/01 P21.7
Patient transfer from a non-trauma hospital to a designated trauma hospital
♦ In the event that a non-trauma designated hospital receives a trauma patient who
meets Trauma System entry criteria, or the trauma patient is unstable, or the
hospital does not have the resources to take care of the patient, the non-trauma
hospital should:
a. Stabilize and care for the patient to the best of the facility’s ability
b. The non-trauma hospital emergency physician or surgeon should contact
the Level 1 or 2 trauma surgeon and mutually agree on whether patient
transfer is needed
c. Report all cases to ATAB 1 Quality Assurance
Patient transfer between non-trauma designated hospitals
♦ For all trauma patients meeting trauma system entry criteria and/or inter-hospital
transfer criteria (with possible exceptions), the non-trauma hospital should
consider transfer of these patients to a Level 1 trauma hospital
♦ Trauma patient transfers who meet entry or transfer criteria and are also
transferred from one non-trauma hospital to another should have reports of these
transfers sent to ATAB 1 Quality Assurance
Patient transfer between trauma designated hospitals and a non-designated hospital
♦ When the HMO patient is treated at a designated trauma facility, the HMO facility
will be notified within 48 hours of patient arrival. The stabilized patient can be
transferred to a HMO hospital when the trauma surgeon and the HMO physician
mutually agree that transfer is in the patient’s best interest
7/01 P22.1
TRANSPORT OF THE CHRONICALLY ILL PATIENT

PURPOSE
• Informed consent process for the alert, conscious patient who requests no
transport or treatment. The EMT shall:
1. Contact the attending physician for advice and try to establish

communication between the patient and physician. If communication
cannot be established:
Contact OLMC (see OLMC-HOSPITAL COMMUNICATION
protocol) and try to establish communication between the patient
and the physician, or
The EMT shall explain the risks and benefits of transport and
treatment but the EMT shall accept the right of the patient to refuse
treatment and transport.
2. In all events the EMT shall follow the patient's directions regarding
transport and treatment.
3. In all events the EMT shall document this process (to include patient
competence).
• For the chronically ill patient who is unable to control his or her own decisions,
(unconscious, incapacitated, etc.) and where care is refused:
1. If physically possible, BLS protocols at EMT-B level will be followed

during attempts to establish communication.
2. There should be complete disclosure and discovery of any Advanced

Directives present.
3. The EMT will attempt to contact the patient's attending physician, inform
the attending physician of the situation, and follow his or her orders.
4. If that communication cannot be quickly established, the EMT will contact

the OLMC (see OLMC-HOSPITAL COMMUNICATION protocol)
and establish contact among the EMT, the family, and the physician. After
this contact has been made, the EMT will follow the orders of the
physician.
• In all events, the EMT shall document this process (to include patient
competence).

Columbia Co (OR) Protocols (2009)

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01/02

Columbia County Emergency Medical Services Protocols

M1. Activated Charcoal (Actidose®)

Columbia County Emergency Medical Services Protocols

Columbia County Emergency Medical Services Protocols

This statement is intended to be consistent with the Oregon Administrative Rules

Louis J Perretta MD, FACEP

ADVANCED AIRWAY MANAGEMENT

[ONLY TO BE DONE BY PARAMEDICS WHO HAVE DONE AN OR

ALTERED MENTAL STATUS/COMA

ANAPHYLAXIS AND ALLERGIC REACTIONS

PHYSICAL FINDINGS (CONT)

BURN CENTER CRITERIA

CARDIAC ARREST ALGORITHM

Start ABC’s and set up/attach AED

Initiate IV Initiate IV Initiate IV

1:10000 Epinephrine Lidocaine 1:10000 Epinephrine

Defibrillate 360 J Check Pulse & rhythm

CARDIAC ARREST ALGORITHM

Ventricular Fibrillation and

Hypoxia-oxygenate and ventilate

Pulseless Electrical Activity

Consider and treat the possible causes:

Atropine** Bradycardia, asystole 0.1 mg

Dextrose 25%** Hypoglycemia 0.5 gms/kg

Epinephrine** Bradycardia, Cardiac 0.01 mg/kg

Sodium Bicarbonate*** Metabolic acidosis 1 mEq/kg

Adenosine*** SVT 0.05 mg/kg

Atropine** Bradycardia, asystole 0.02 mg/kg

Dextrose 25%** Hypoglycemia 0.5 gm/kg(dilute

Dopamine*** Low cardiac output 5-20 mcg/kg/min

Epinephrine** V fib, low cardiac output 0.01 mg/kg

Lidocaine** V tach, V fib 1.5 mg/kg bolus

Naloxone** Respiratory depression 0.1 mg/kg

Sodium Bicarbonate*** Metabolic acidosis 1 mEq/kg/dose

Midazolam (Versed)*** Sedation for Pacing, IV or IO 0.1 mg/kg

CARDIAC CHEST PAIN

♦ Place cardiac monitor and pulse oximeter (see CARDIAC DYSRHYTHMIA

2. The patient is ASYMPTOMATIC if:

 There is NO hypotension, shortness of breath, ventricular ectopy, and chest

♦ For patients with SUPRAVENTRICULAR TACHYCARDIA:

Synchronous Cardioversion Synchronous Cardioversion

Synchronous Cardioversion Synchronous Cardioversion

Synchronous Cardioversion Synchronous Cardioversion

WIDE COMPLEX TACHYCARDIA***

Magnesium Sulfate 2.0 gms slowly over 2 minutes

Consider sedation with midazolam 2.5-5 mg

♦ For patients with Premature Ventricular Complexes (PVC’s):

PEDIATRIC CONSIDERATIONS (cont)

♦ Wide Complex tachycardia-QRS>0.08 sec

PHYSICAL FINDINGS (cont)

SPECIFIC PRECAUTIONS (cont)

♦ Administration of D50W in the alcoholic with depleted thiamine stores may

Score 5 social smile, fixes and follows

GLASGOW COMA SCALE

BEST VERBAL RESPONSE:

BEST MOTOR RESPONSE:

♦ If the patient is exhibiting signs or symptoms of hypertensive emergency, such as

♦ Assure airway, breathing, circulation, control hemorrhage

♦ How long patient was submerged

♦ Vital signs; especially temperature, respiratory rate

♦ Clear upper airway

♦ Be prepared for vomiting

♦ Neonatal vital signs

There is NO hypotension, shortness of breath, ventricular ectopy, and chest

♦ Consider a Combitube or endotracheal intubation* in a rapidly deteriorating patient (see