ABDOMINAL PAIN

GENERAL CONSIDERATIONS

A. It is important to remember that abdominal pain can be caused by a large number of different disease processes. The organ systems that may be involved in abdominal pain include, esophagus, stomach, intestinal tract, liver, pancreas, spleen, kidneys, male and female genital organs, bladder, as well as referred pain from the chest that can involve the heart, lungs or pleura. Abdominal pain may also be caused by muscular and skeletal problems.

B. There are a limited number of problems that present with abdominal pain that are life-threatening or may become life-threatening.

1. Myocardial Infarction

2. Perforated stomach, gallbladder, or bowel

3. Gastrointestinal bleeding with pain - usually due to an ulcer

4. Hemorrhagic pancreatitis

5. Appendicitis

6. Diabetic ketoacidosis

7. Ruptured esophagus (this usually presents with chest pain)

8. Dissecting or ruptured abdominal aortic aneurysm

9. Certain toxic mushroom ingestions and other toxic ingestions

10. Ectopic pregnancy

C. Abdominal pain emergencies are likely to lead to death due to blood or fluid loss with

resultant shock. There may also be severe electrolyte abnormalities that can cause arrhythmias.

Myocardial Infarction may present as abdominal pain especially in the diabetic and elderly.

EMT-B

A. Secure airway

1. Administer oxygen as needed to treat shock and/or respiratory distress

2. Apply Pulse Oximeter and treat per Pulse Oximeter procedure, if available.

B. Evaluate patient's general appearance and relevant history of condition.

C. Assess additional associated signs and symptoms:

1. Nausea / vomiting blood or coffee grounds

2. Constipation / diarrhea - black, tarry or bloody bowel movements

3. Problems with urination

4. Menstrual abnormality

5. Fever

6. Tenderness, rigidity, and presence or absence of bowel sounds.

7. Cardiac associated symptoms: Dyspnea, Diaphoresis, SOB

D. Transport in position of comfort, preferable supine with knees flexed, unless there is respiratory distress

E. Give nothing by mouth

6. PASG only in hypotensive patients with suspected ruptured abdominal aortic aneurysm.

ABDOMINAL PAIN (cont)

EMT-I

A. If there is concern about the possibility of blood or fluid loss, start an IV of saline, and run at a keep open rate or saline lock. If hypotensive, run IV, maintain perfusion.

B. Monitor ECG during transport

C. PASG only in hypotensive patients with suspected ruptured abdominal aortic aneurysm.

EMT-P

A. Obtain orthostatic vital signs and if hypotensive, run IV to maintain perfusion.

B. Monitor ECG during transport

C. PASG only in hypotensive patients with suspected ruptured abdominal aortic aneurysm.

D. Consider administration of Phenergan, 12.5mg to 25mg slow IV push, for nausea per local guidelines.

ABDOMINAL PAIN

ALTERED LEVEL OF CONSCIOUSNESS

EMT-B

A. Secure airway, and consider cervical spine injury

1. Administer 100% oxygen by NRB mask

2. Apply Pulse Oximeter and treat per Pulse Oximeter procedure

3. Be prepared to hyperventilate and/or assist ventilations with oral or nasal airway and BVM or PPV

4. Check blood glucose level

B. Assess the unresponsive patient using the Glasgow Coma scale. Patients with scores of 8 or less have poor prognosis and need ALS as soon as possible.

In possible stroke patients who are alert, assessment of language, motor responses and sensation

must be completed to establish baselines for future changes. Assess prehospital CVA checklist.

C. Consider administration of glucose with intact gag reflex.

D. Transport IMMEDIATELY unless an advanced life support unit is enroute and has an ETA of less than 5 minutes to the scene.

EMT-I

A. Assist EMT, obtain patient condition and circumstance

B. Apply monitor and check rhythm

C. Start IV saline, TKO, while enroute to hospital

D. Check blood sugar or draw blood chemistry tube.

E. If blood sugar greater than 400 and signs of hypoperfusion are present, administer IV fluid bolus of at least 250cc of saline. May be repeated if no response in 10 minutes.

PARAMEDIC

A. Assume charge of situation and confer with EMTs about condition of patient and situation

B. If patient does not have a secure, protected airway, intubate per Intubation Procedure

C. Apply monitor and check rhythm

D. Start IV saline TKO.

E. If signs of CVA, contact Med Control.

ALTERED LOC (cont)

F. Consider determination of blood sugar level, if available.

1. If blood sugar less than 80, administer IV bolus, 50cc of 50% dextrose. May be repeated in 10 minutes if blood sugar remains below 80.

2. If blood sugar greater than 400 and signs of hypoperfusion are present, administer IV fluid bolus of at least 250cc of saline. May be repeated if no response in 10 minutes.

3. If unable to check blood sugar and LOC is decreased administer IV bolus, 50cc of 50% dextrose

G. If respirations are impaired, or there is a high index of suspicion of narcotic overdose and patient does not respond to dextrose or fluid bolus, administer Narcan 2mg IV push If patient improves somewhat with Narcan but is not fully awake, repeat dose

CONSIDER PATIENT RESTRAINT BEFORE ADMINISTRATION OF NARCAN

SEE RESTRAINT POLICY

H. Re-evaluate patient condition, contact Medical Control, and transport to hospital

ALTERED LEVEL OF CONSCIOUSNESS

EMT-B EMT-I PARAMEDIC

OPEN & MANAGE EVALUATE PT. OBTAIN MEDICAL CONTACT

AIRWAY CONDITION HISTORY MEDICAL

100% 02 NRB VS,LOC,PUPILS SEIZURES, STROKE CONTROL

CONSIDER PULSE OX DIABETIC &

C-SPINE MED ALERT DRUG ABUSE TRANSPORT

ASSESS FOR STROKE

UNRESPONSIVE ALERT

USE GLASGOW SCALE EVALUATE LANGUAGE,

SCORE <8 - ALS NEEDED MOTOR RESPONSE &

CHECK BLOOD SUGAR UNABLE TO CHECK SIGNS OF CVA

BLOOD SUGAR BLOOD SUGAR RESTRAIN PATIENT

ORAL GLUCOSE IF BP GREATER ADMINISTER

1 TUBE THAN 90 SYSTOLIC NARCAN 2mg IV

ADMINISTER PATIENT RESPONDS

50cc, 50% DEXTROSE BOLUS WITH REPEAT NARCAN

REEVALUATE REEVALUATE INTUBATE IF NEEDED

REPEAT REPEAT

ORAL GLUCOSE FLUID BOLUS IF

IV DEXTROSE

IF BLOOD SUGAR

REMAINS < 80

ARRHYTHMIAS

GENERAL CONSIDERATIONS

A. In the treatment of cardiac arrhythmias, current American Heart Association guidelines were referred to for guideline development

B. Always provide oxygen support, make the patient comfortable, and provide reassurance

C. Transport is essential when Advanced Cardiac Life Support is not available within 10 minutes of receipt

of the call

EMT-B / EMT-I

A. Open and manage the airway and provide 100% oxygen by NRB mask. Apply pulse oximeter and treat per pulse oximeter procedure

B. Make patient comfortable and provide reassurance

C. Evaluate patient's general appearance, relevant history of condition.

D. If patient is experiencing an unusual and/or irregular heart rate or pulse, if available, the cardiac monitor may be applied and a strip run for evaluation by the Physician at the Emergency Department. This should only be done during transport, and you must advise the patient you are doing this for the Physician and you do not have the ability to interpret the strip.

1. Perform 12-lead EKG if time permits

2. EMT-I: Start IV saline TKO or saline lock

E. Establish communications with Medical Control and advise of patient condition. Transport IMMEDIATELY unless an advanced life support unit is enroute and has an ETA of less than 5 minutes to the scene

PARAMEDIC

A. Assume charge of situation and confer with EMT's about condition of patient and situation

B. Apply cardiac monitor and determine arrhythmia

C. Start IV saline, TKO or saline lock

ARRHYTHMIAS (cont)

D. Treat arrhythmia as follows:

1. Bradycardia, Second and Third degree AV blocks

a. Serious Signs or Symptoms:

1. In the absence of acute pulmonary edema, infuse fluid bolus, 250cc. Reassess and repeat as necessary.
2. External pacemaker set at 80 beats per minute and start at 20 milliamps increasing by 20 milliamps until mechanical capture is obtained;

NOTE: Atropine may be administered while preparing for pacing

iii. Atropine 0.5 -1.0mg IVP, subsequent doses 1.0mg every 5 minutes up to 3mg (0.04mg/kg), or until heart rate is 60 and an adequate SBP is obtained (SBP greater than 90 with adequate level of consciousness).

iv. If perfusion is poor after maximum dose of atropine, dopamine drip: 400mg dopamine (5ml) in 500ml D5W or NS to yield a solution of 800 mcg/ml;

Titrate the infusion until heart rate is 60 with an adequate SBP of 90 and LOC is improved.

2. Atrial Flutter/Fibrillation with rapid ventricular rate:

a. Unstable with serious signs or symptoms:

i. Synchronous cardioversion:

(a) Consider sedation (versed/valium, 3-5mg IV)

(b) Cardiovert 50 joules

(c) Cardiovert 100 joules

(d) Cardiovert 200 joules

(e) Cardiovert 300 joules

(f) Cardiovert 360 joules

ii. Transport; contact Medical Control for further orders

3. Paroxsymal Supraventricular Tachycardia

a. Patients who are alert and oriented with normal blood pressure and ventricular rate less than 150 are considered stable.

i. Transport

b. Patients with ventricular heart rate greater than 150 beats per minute, hypotensive, with chest pain, shortness of breath and/or altered level of consciousness are considered unstable.

i. Administer adenosine, 6mg RAPID IV bolus over 1 to 3 seconds followed

IMMEDIATELY with a 20cc bolus of saline(within 5 seconds)

ii. If no conversion, repeat adenosine in 1-2 minutes, 12mg RAPID IV bolus

followed IMMEDIATELY with a 20cc bolus of saline(within 5 seconds)

iii. If no conversion, repeat adenosine in 1-2 minutes, 12mg RAPID IV bolus

followed IMMEDIATELY with a 20cc bolus of saline(within 5 seconds)

MAXIMUM OF 3 DOSES (30mg) OF ADENOSINE

ARRHYTHMIAS (cont)

iv. If no response to adenosine synchronous cardioversion:

(a) Consider sedation (versed/valium, 3-5mg IV)

(b) Cardiovert 100 joules

(c) Cardiovert 200 joules

(d) Cardiovert 300 joules

(e) Cardiovert 360 joules

6. PVCs in suspected heart related difficulty: i.e. chest pain, pulse greater than 60, multifocal, more than six per minute and more than two in a row

a. Treat underlying causes; hypoxia, hypoperfusion, etc.

b. Contact Medical Control if required

c. Lidocaine bolus IV - 1.0mg/kg (75-100mg)

INITIATE TRANSPORT AFTER FIRST DOSE OF LIDOCAINE

d. If no response - Repeat lidocaine bolus IV 0.5mg/kg every 8 minutes to a 3mg/kg maximum

e. At any time during treatment the patient converts, initiate lidocaine drip

7. Sinus Tachycardia - Transport

8. Ventricular Tachycardia:

a. Patient with a pulse (stable):

i. Lidocaine bolus IV - 1.5mg/kg (75-100mg)

INITIATE TRANSPORT AFTER FIRST DOSE OF LIDOCAINE

ii. If no response - Repeat lidocaine bolus IV 0.75mg/kg every 5 minutes to a 3mg/kg maximum

iv. If no response with maximum dose of lidocaine:

Consider Synchronous Cardioversion:

(a) Consider sedation (versed/valium, 3-5mg IV bolus)

(b) Cardiovert 100 joules

(c) Cardiovert 200 joules

(d) Cardiovert 300 joules

(e) Cardiovert 360 joules

iv. At any time during treatment the patient converts, repeat lidocaine IV bolus,

50 mg every 20 minutes OR start lidocaine drip at 2 to 4mg/min.

ARRHYTHMIAS (cont)

b. Patient with a pulse and hypotension (SBP less than 90 mmHg), chest pain, shortness of breath and/or altered level of consciousness, is considered unstable

i. Synchronous Cardioversion:

(a) Consider sedation (versed/valium 3-5mg IV bolus)

(b) Cardiovert 100 joules

(c) Cardiovert 200 joules

(d) Cardiovert 300 joules

(e) Cardiovert 360 joules

ii. Lidocaine bolus IV - 1.5mg/kg (75-100mg)

INITIATE TRANSPORT AFTER FIRST DOSE OF LIDOCAINE

iii. If no response - Repeat lidocaine bolus IV 0.5mg/kg every 8 minutes to a 3mg/kg maximum

v. Repeat Synchronous Cardioversion:

(a) Cardiovert 100 joules

(b) Cardiovert 200 joules

(c) Cardiovert 300 joules

(d) Cardiovert 360 joules

vi. If no conversion - Bretylium bolus 5mg/kg 300-500mg over an 8 to 10 minutes

c. Unconscious patient with no pulse

i. Treat as Ventricular Fibrillation

BRADYCARDIA

OPEN & MANAGE EVALUATE PT. OBTAIN MEDICAL CONTACT

AIRWAY CONDITION HISTORY MEDICAL

100% 02 NRB VS,LOC, JVD REASSURE PT CONTROL

PULSE OX

IV SALINE LOCK MONITOR EKG TRANSPORT

SLOW HEART RATE - LESS THAN 60 MIN. WITH UNSTABLE S/S

SINUS OR SECOND DEGREE SECOND DEGREE THIRD DEGREE

JUNCTIONAL AV BLOCK AV BLOCK AV BLOCK

EXTERNAL PACING

SET AT 80 BPM & START AT 20 ma TRANSPORT

INCREASE MILLIAMP BY 20 UNTIL CAPTURE

ATROPINE MAY BE GIVEN WHILE PREPARING PACER

OR

ATROPINE 0.5 - 1.0mg, IVP

ATROPINE 0.5 - 1.0mg

IV, q 5 MIN.

3 MG MAX. (0.04mg/kg)

DOPAMINE DRIP

TITRATED TO

HR>60 BP>100

STABLE TACHYCARDIA

EMT-B EMT-I PARAMEDIC

OPEN & MANAGE EVALUATE PT. OBTAIN MEDICAL CONTACT

AIRWAY CONDITION HISTORY MEDICAL

100% 02 NRB VS,LOC, JVD REASSURE PT CONTROL

PULSE OX

IV SALINE LOCK MONITOR EKG TRANSPORT

P S V T ATRIAL FIB/FLUTTER VENTRICULAR TACH.

TRANSPORT TRANSPORT LIDOCAINE, BOLUS

1.0 mg/Kg

TRANSPORT

LIDOCAINE, BOLUS

0.5 mg/Kg EVERY 8 MINUTES

3mg/Kg MAX.

SYNCHRONOUS CARDIOVERSION

CONSIDER SEDATION (VALIUM/ VERSED, 3-5 mg)

100 JOULES

200 JOULES

300 JOULES

360 JOULES

UNSTABLE TACHYCARDIAS

PATIENTS WITH POOR PERFUSION, CHEST PAIN, SHORTNESS OF BREATH

AND/OR ALTERED LEVEL OF CONSCIOUSNESS ARE CONSIDERED UNSTABLE.

EMT-B EMT-I PARAMEDIC

OPEN & MANAGE EVALUATE PT. OBTAIN MEDICAL

AIRWAY CONDITION HISTORY

100% 02 NRB VS,LOC, JVD REASSURE PT

PULSE OX

IV SALINE LOCK MONITOR EKG TRANSPORT

ADENOSINE CHEST PAIN, HR > 60 BPM SYNCHRONOUS

6 mg > 6 PER MIN., MULTIFOCAL CARDIOVERSION

NO RESPONSE IF REQUIRED 100 JOULES

(1-3 SECONDS) NO RESPONSE 1.5 mg/Kg

SYNCHRONOUS 3 mg/Kg MAX. TRANSPORT

(VERSED/VALIUM,3-5 mg) LIDOCAINE BOLUS

50 JOULES 3 mg/Kg MAX.

200 JOULES 2 to 4mg/MIN REPEAT

BRETYLIUM

UNSTABLE ATRIAL TACHYCARDIAS

PATIENTS WITH POOR PERFUSION, CHEST PAIN, SHORTNESS OF BREATH

AND/OR ALTERED LEVEL OF CONSCIOUSNESS ARE CONSIDERED UNSTABLE.

EMT-B EMT-I PARAMEDIC

OPEN & MANAGE EVALUATE PT. OBTAIN MEDICAL CONTACT

AIRWAY CONDITION HISTORY MEDICAL

100% 02 NRB VS,LOC, JVD REASSURE PT CONTROL

PULSE OX

IV NS TKO MONITOR EKG TRANSPORT

ATRIAL FIB/FLUTTER ATRIAL FIB/FLUTTER ATRIAL TACHYCARDIA

RAPID VENTRICULAR ATRIAL JUNCTIONAL TACHY. JUNCTIONAL TACHCARDIA

VAGAL MANEUVERS

ADENOSINE* 6mg RAPID IV BOLUS

FOLLOWED BY A 20cc BOLUS

ADENOSINE*

12 mg RAPID, IV BOLUS

SYNCHRONOUS ADENOSINE*

CARDIOVERSION 12 mg RAPID, IV BOLUS FOLLOWED BY 20 cc BOLUS

(VALIUM,/ VERSED 3-5 mg)

50 JOULES 100 JOULES

300 JOULES

360 JOULES

TRANSPORT

BURNS

GENERAL INSTRUCTIONS

A. The first priority is to assure scene safety and then remove the patient from heat and flame, electrical or chemical exposure

B. Airway, Breathing, and Circulation must be stabilized before attending to the burn

C. Patient with extensive burns must be monitored for hypothermia. Avoid use of ice and/or prolonged cold compresses. When in doubt, always cover with dry dressing

D. In caring for the burn, the EMT should:

1. Stop the Burning

2. Reduce the Pain

3. Prevent Contamination

E. Patients with critical burns only, transport per local protocol.

F. When dealing with contaminated environments, EMTs must have appropriate protective clothing. If not available, contact appropriate Haz Mat service for such equipment.

G. Gross decontamination must be done at the scene. Advise receiving facility if complete decontamination was not done at the scene, and be prepared to transport to decontamination area.

EMT-B

A. Open and manage airway and provide 100% oxygen by NRB mask or bag valve mask (BVM)

B. Determine type of burn and treat as follows:

1. Thermal (dry and moist):

a. Stop burning process: i.e. remove patient from heat source, cool skin, remove clothing

b. If patient starts to shiver or skin is cool, stop cooling process

c. Estimate extent (%) and depth of burn (see Rule of 9’s chart). Determine seriousness of burn. Contact Medical Control and transport accordingly.

d. Dress burns <10% BSA with wet dressing, dress burns >10% BSA with dry dressing

2. Radiation Burns:

a. Treat as thermal burns except when burn is contaminated with radioactive source, then treat as chemical burn

b. Wear appropriate protective clothing when dealing with contamination

c. Contact HAZ MAT TEAM for assistance in contamination cases

BURNS (cont)

3. Chemical Burns:

a. EMTs must wear appropriate protective clothing and respirators

b. Remove patient from contaminated area to decontamination site (NOT SQUAD)

c. Determine chemicals involved; contact appropriate agency for chemical information. Determine need for HAZMAT team involvement.

d. Remove patient's clothing and flush skin

e. Leave contaminated clothes at scene. Cover patient over and under before loading into squad.

f. Patient should be transported by personnel not involved in decontamination process

h. Relay type of substance involved to Medical Control.

i. If significantly contaminated, consider transport to Community Hospital’s Decon Room

4. Electrical Burns

a. Shut down electrical source; do not attempt to remove patient until electricity is CONFIRMED to be shut off.

b. Assess for visible entrance and exit wounds and treat as thermal burns

c. Assess for internal injury, i.e., vascular damage, tissue damage, fractures, and treat accordingly

d. Determine severity of burn, contact Medical Control and transport accordingly

5. Inhalation Burns:

a. Always suspect inhalation burns when the patient is found in closed smoky environment

and/or exhibits any of the following: burns to face/neck, singed nasal hairs, cough and/or stridor, soot in sputum,

b. Provide oxygen therapy, contact Medical Control and transport

EMT-I

A. Assist EMT with airway

B. Assist in determining type of burn and its treatment

C. For Hypovolemia, start IV per shock guidelines

DO NOT DELAY TRANSPORT FOR IV

BURNS (cont)

PARAMEDIC

A. Assume charge - confer with EMTs about patient condition and circumstances

B. Apply cardiac monitor and treat arrhythmia, especially with electrical burns

C. Provide endotracheal intubation per procedure guidelines

D. Consider pain relief per local protocol:

RULE OF NINES

1% is equal to the surface of the palm of the patient's hand. If unsure of %, describe injured area.

SERIOUSNESS OF BURNS

MINOR MODERATE CRITICAL

1st degree < 70% 1st degree > 70% 2nd degree > 30%

2nd degree < 10% +2nd degree 10-30% 3rd degree > 2% +3rd degree < 2% Any burns with trauma. Any burns with head, face, + Only if hands, face, feet or genitalia are NOT involved. feet, genitalia involved.

BURNS

EMT-B EMT-I PARAMEDIC

PROTECT SELF OPEN AIRWAY DETERMINE CONTACT

100% O2 TYPE, %, DEPTH MEDICAL

REMOVE PT FROM PULSE OX SEVERITY CONTROL

ENVIRONMENT

SECURE AIRWAY - INTUBATE IF NEEDED

THERMAL CHEMICAL ELECTRICAL RADIATION

BURN BURN BURN BURN

COVER WOUND DETERMINE COVER WOUND DETERMINE

DRESS WITH MOIST CHEMICAL TYPE DRY DRESSINGS EXPOSURE OR

REDUCE IF CONTAMINATED

CONTAMINATION

BEFORE REDUCE

TRANSPORT TREAT CONTAMINATION

ARRHYTHMIAS BEFORE

TRANSPORT

COVER WOUND

DRY DRESSINGS

DRY DRESSINGS

TRANSPORT TO

CONSIDER PAIN

RELIEF PER LOCAL

PROTOCOL

CARDIAC ARREST

GENERAL INSTRUCTIONS

A. CPR should not be interrupted for more than 15 seconds until spontaneous pulse is established.

B. If IV cannot be established, epinephrine, atropine or lidocaine may be administered through the endotracheal tube @ two times the IV dose & mix with NS for total volume of 10cc’s.

C. When a defibrillator (Automated or Manual) is immediately available three shocks should be administered, if indicated, after assessment and ventricular fibrillation is identified.

D. If there is no response to an adequate trial of ALS on the scene, Termination of resuscitation should be

considered. (See Termination guidelines)

E. CPR should not be interrupted for more than 15 seconds and each IV push medication should be followed by a 20cc flush.

EMT-B

A. If an Automated External Defibrillator (AED) is available:

1. Assess patient for respiratory and cardiac arrest.

2. Apply AED and activate device.

a. "No Shock Advised"

i. CPR as recommended by the American Heart Association.

ii. Ventilate with 100% oxygen by two-person bag valve mask or oxygen powered, manually triggered ventilation device and oral or nasal airway.

Ventilation should be delivered over two seconds and cricoid pressure can be considered to help reduce gastric distention.

1. Intubate

iv. Establish communications with Medical Control and advise of cardiac arrest.

v. Transport IMMEDIATELY unless an advanced life support unit is enroute and has an ETA of less than 5 minutes to the scene.

CARDIAC ARREST (cont)

b. "Shock Advised"

i. Deliver three stacked shocks (shocks without pulse checks)

1. Defibrillate 200 joules

2. No Change - Second defibrillation 300 joules

3. No change - Third defibrillation 360 joules

ii. After third shock - CPR as recommended by the American Heart Association for one minute. Intubate if not already done.

iii. Ventilate with 100% oxygen by two-person bag valve mask or oxygen powered, manually triggered ventilation device and oral or nasal airway.

Ventilation should be delivered over two seconds and cricoid pressure should be considered to help reduce gastric distention.

iv. Establish communications with Medical Control and advise of cardiac arrest.

v. After one minute of CPR - Activate AED to assess rhythm and deliver three stacked shocks, if indicated.

1. Defibrillate 360 joules

2. No Change - Second defibrillation 360 joules

3. No change - Third defibrillation 360 joules

vi. After third shock - CPR as recommended by the American Heart Association. - Transport patient to ambulance.

CONSIDER TURNING OFF AED WHEN MOVING PATIENT

vii. Before transport - Activate AED to assess rhythm and deliver three stacked shocks, if indicated.

1. Defibrillate 360 joules

2. No Change - Second defibrillation 360 joules

3. No change - Third defibrillation 360 joules

viii. Transport IMMEDIATELY unless an advanced life support unit is enroute and

has an ETA of less than 5 minutes to the scene.

CARDIAC ARREST (cont)

EMT-I

A. Assume charge and confer with EMT as to patient condition and circumstances

ALLOWS AED TO COMPLETE "STACKED SHOCK" SEQUENCE IF IN PROGRESS.

B. Apply cardiac monitor and check rhythm

C. If monitor shows Ventricular Fibrillation:

1. Defibrillate 200 joules

2. No Change - Second defibrillation 300 joules

3. No change - Third defibrillation 360 joules

4. CPR for one minute and check patient's pulse

5. No Change - Defibrillate 360 joules

6. No Change - Second defibrillation 360 joules

7. No change - Third defibrillation 360 joules

8. Transport patient to ambulance continuing CPR.

9. Assess rhythm, no Change - Defibrillate 360 joules

10. No Change - Second defibrillation 360 joules

11. No change - Third defibrillation 360 joules

12. Transport to advanced life support with continued CPR

D. Check pulse, intubate patient, start IV of saline, contacts Medical Control and advise of patient condition, while continuing CPR

PARAMEDIC

A. Assume charge and confer with EMT as to patient condition and circumstances

ALLOWS AED TO COMPLETE "STACKED SHOCK" SEQUENCE IF IN PROGRESS.

ALLOWS EMT-I TO COMPLETE MANUAL DEFIBRILLATION CYCLE IN PROGRESS.

B. Apply monitor. If one of the following conditions exist, treat as follows:

1. Ventricular Fibrillation / Pulseless Ventricular Tachycardia:

a. No Change - Defibrillate 200 joules

b. No Change - Second defibrillation 300 joules

c. No Change - Third defibrillation 360 joules

d. Check pulse, intubate patient, start IV of saline, and continuing CPR

e. No Change - Administer 1mg 1:10,000 epinephrine IV bolus every 3 to 5 minutes.

Epinephrine given through ET tube as a 2mg bolus of 1:1,000 diluted with 10ml of normal saline.

f. Continue CPR to circulate drugs

g. No Change - defibrillate at 360 joules

h. No Change - lidocaine 1.5mg/kg IV bolus. Repeat boluses every five minutes to a maximum of 3mg/kg.

Lidocaine given through ET tube at 3mg/kg

i. No Change - defibrillate at 360 joules

j. No Change - lidocaine 1.5mg/kg IV bolus

k. No Change - defibrillate at 360 joules

l. No Change - bretylium at 5mg/kg IV bolus

m. Sodium bicarbonate 1mEq/kg

NOTE: Value of sodium bicarbonate is questionable during cardiac arrest, and it is not recommended for the routine cardiac arrest sequence. Consideration of its use is appropriate with prolonged resuscitation with return of perfusing rhythm, hemodialysis patients in cardiac arrest, drowning, hyperkalemia or when tricyclic overdose is suspected.

n. Defibrillate at 360 joules

o. Bretylium at 10mg/kg IV bolus

p. Defibrillate at 360 joules, No Change - TRANSPORT

t. Change to Rhythm:

i. Strong pulse

1. If converted with Lidocaine, start lidocaine drip at 2 to 4mg/min.

(b) If converted with Bretylium, start Bretylium drip at 2 to 4 mg/min.

ii. Hypotension and bradycardia - See Arrhythmia Protocol

iii. No pulse - CPR

2. Asystole / Pulseless Electrical Activity (PEA):

a. Check pulse, intubate patient, start IV of saline, administer 500cc saline bolus and while continuing CPR

CARDIAC ARREST (cont)

b. TREAT CAUSE: consider hypovolemia or hypothermia, cardiac tamponade, tension pneumothorax, pulmonary embolism, hypoxemia or acidosis, hypoglycemia.

c. CONSIDER EXTERNAL PACING IN WITNESSED ARREST.

Set rate at 100 beats per minute and set amperage at 200 milliamps.

d. Administer 1mg 1:10,000 epinephrine IV bolus every 3 to 5 minutes

Epinephrine given through ET tube as a 2mg bolus of 1:1,000 diluted with 10ml of normal saline.

e. CPR - circulate drugs

f. Administer atropine - 1mg IV bolus every 5 minutes until maximum dose of 0.04mg/kg is achieved to a 3mg maximum.

NOTE: In PEA atropine is administered only when the rate is less than 60

g. CPR - circulate drugs

h. Sodium bicarbonate 1mEq/kg

NOTE: Value of sodium bicarbonate is questionable during cardiac arrest, and it is not recommended for the routine cardiac arrest sequence. Consideration of its use is appropriate with prolonged resuscitation with return of perfusing rhythm, hemodialysis patients in cardiac arrest, drowning, hyperkalemia or when tricyclic overdose is suspected.

i. CPR - circulate drugs

j. No Change

k. Contact Medical Control for possible consideration of termination of resuscitation.

CARDIAC ARREST

V-FIB / PULSELESS V-TACH

ASSESS PATIENT FOR RESPIRATORY AND CARDIAC ARREST ACTIVATE ACLS SYSTEM /

CONTACT MED CONTROL

APPLIES AED

I F AVAILABLE APPLIES MONITOR, ASSESSES RHYTHM

START VERBAL DOCUMENTATION

DELIVERS THREE STACKED SHOCKS DELIVERS THREE SHOCKS RAPIDLY

200J / 300-360J / 360J 200J / 300-360J / 360J

NO PULSE CHECKS BETWEEN CHECK PULSE AFTER EACH SHOCK

MANAGES AIRWAY - ORAL / NASAL MANAGES AIRWAY - ORAL / NASAL MANAGES AIRWAY - INTUBATION

BVM / PPV BVM / PPV MONITOR WITH CO MONITOR

CPR FOR ONE MINUTE CPR FOR ONE MINUTE IV SALINE - CPR

DELIVERS THREE STACKED SHOCKS DELIVER THREE SHOCKS 1mg 1:10,000 EPINEPHRINE , IVP

360 J 360 J EVERY 3 - 5 MINUTES

NO PULSE CHECKS BETWEEN CHECK PULSE AFTER EACH SHOCK ET - 2mg in 10ml NS

MOVE PATIENT TO AMBULANCE MOVE PATIENT TO AMBULANCE DEFIBRILLATE - 360 J

MAINTAIN CPR MAINTAIN CPR

LIDOCAINE 1.5mg / Kg, IV or ET

REPEAT q5 MIN - 3mg/kg MAX

360 J 360 J

NO PULSE CHECKS BETWEEN CHECK PULSE AFTER EACH SHOCK DEFIBRILLATE - 360 J

LIDOCAINE 1.5mg / Kg, IV or ET

TRANSPORT TRANSPORT

DEFIBRILLATE - 360 J

BRETYLIUM 5mg /Kg, IV

IF RHYTHM CHANGES - CHECK PULSE & PERFUSION

STRONG PULSE - START LIDOCAINE INFUSION 2 TO 4 MG/MIN DEFIBRILLATE - 360 J

OR

BRETYLIUM INFUSOIN 2 TO 4 MG/MIN

BRETYLIUM 10mg / Kg, IV

NO PULSE - CPR AND TRANSPORT

CONSIDER SODIUM BICARBONATE IN DEFIBRILLATE - 360 J

TRICYCLIC OVERDOSE or HYPERKALEMIA

TRANSPORT

CARDIAC ARREST

ASYSTOLE / PEA

EMT-B EMT-I PARAMEDIC

INITIATE CPR VENTILATE PT. BVM/PPV CONTACT

ORAL or NASAL AIRWAY MEDICAL

CONTROL

APPLY MONITOR, CHECK RHYTHM TRANSPORT

INTUBATE / IV, TKO

CONSIDER CAUSE

HYPOTHERMIA, HYPOVOLEMIA

CARDIAC TAMPONADE

PULMONARY EMBOLISM

HYPOXEMIA, ACIDOSIS

1mg 1:10,000 EPINEPHRINE

EVERY 3 MINUTES

ET EPI. 2mg 1:1,000 DILUTED w 10cc NS

ATROPINE 1mg BOLUS IN PEA, ATROPINE

ABSOLUTE BRADYCARDIA

MAXIMUM DOSE .04 mg/Kg RATE < 60

CONSIDER

SODIUM BICARB IF NO RESPONSE AFTER

IN INTUBATION / IV / MEDS

TRICYCLIC OD

HYPERKALEMIA TRANSPORT

OR

CONSIDER TERMINATION PROTOCOL

SPECIAL RESUSCITATION SITUATIONS

Special resuscitation situation are cardiopulmonary arrest or other life-threatening emergencies that require modification or extension of conventional life support techniques.

NEAR DROWNING

GENERAL INFORMATION

A. The key to success is the provision of early, effective ventilatory support.

B. It is essential that the EMT exercise caution and take steps to insure their own safety while retrieving the victim from the water.

EMT-B

A. Open airway and start rescue breathing as soon as possible, even if the victim has not been removed from the water

B. Ventilate with 100% oxygen by two-person bag valve mask or oxygen powered, manually triggered ventilation device and oral or nasal airway. Oxygen should be warmed to 42o C, if available

Ventilation should be delivered over two seconds and cricoid pressure should be considered to help reduce gastric distention

Always consider C-spine injury.

C. It is not recommended to drain fluid from lungs unless ventilations are impaired. If ventilation impairment should occur, suction the airway for not more than 15 seconds.

D. Start chest compressions as soon as victim is removed from the water and onto a hard surface

E. Patient may show signs of hypothermia. Handle patient VERY gently; rough handling or movement can cause cardiac arrhythmia. Warm the patient removing wet cloths and covering with blankets then

transport IMMEDIATELY.

EMT-I

A. Assume charge and confer with EMT as to patient condition and circumstances

B. Apply cardiac monitor and check rhythm. Follow normal cardiac arrest guidelines

C. Start IV of saline warmed to 46o C if possible.

D. Check pulse, intubate patient and continuing CPR

NEAR DROWNING (cont)

PARAMEDIC

A. Assume charge and confer with EMT as to patient condition and circumstances

B. If EMT is in a cycle of defibrillation, complete cycle before continuing

C. Intubate patient, suction airway and provide ventilation with positive end expiration pressure (PEEP)

if available. Start PEEP at 5cm/H2O. Maintain oxygen saturation between 92% to 100%.

D. Apply cardiac monitor and check rhythm. Follow hypothermia cardiac arrest guidelines.

CARDIAC ARREST

NEAR DROWNING

EMT-B EMT-I PARAMEDIC

START AIRWAY REMOVE PT. HANDLE PT GENTLY

SUPPORT ASAP FROM WATER ON TO C-SPINE CONTROL

(IN WATER) FIRM SURFACE FOR CPR

VENTILATE PT. BVM/PPV CONSIDER RE-WARMING CONTACT

ORAL or NASAL AIRWAY HEATED HUMIDIFIED MEDICAL

OXYGEN CONTROL

ENDOTRACHEAL INTUBATION

WITH "PEEP"

TRANSPORT

APPLY MONITOR "WARMED"

IV NS, TKO

TREAT ARRHYTHMIAS

REMEMBER

PT. MAY NOT RESPOND

TO TREATMENT UNTIL WARMED

CARDIAC CHEST PAIN

EMT-B

B. Make patient comfortable and provide reassurance.

C. Evaluate patient's general appearance, relevant history of current condition.

D. Utilize PREHOSPITAL CHEST PAIN CHECKLIST

THIS ASSESSMENT SHOULD BE DONE DURING TRANSPORT

E. If patient is conscious and alert with previous history of angina pain and is taking nitroglycerin or nitrostat, administer 0.4 mg tablet or spray of nitroglycerin sublingually. Assure medication is prescribed for patient, is not out of date, systolic B/P > 100 and contact Medical Control.

Monitor patient's condition, especially blood pressure. Dosage may be repeated in 5 minutes if pain does not subside, B/P does not drop below 100 systolic and there is no change in level of consciousness.

F. If patient is experiencing an unusual and/or irregular heart rate or pulse, if available, the cardiac monitor may be applied and a strip run for evaluation by the Physician at the Emergency Department. This should only be done during transport, and you must advise the patient you do not have the ability to interpret the strip, but the ED Physician will. Perform 12-lead EKG if available.

G. Establish communications with Medical Control and advise of patient condition. Transport IMMEDIATELY.

EMT-I

A. Assist EMT, obtain patient condition and circumstance.

B. Apply monitor and check rhythm.

C. Start IV saline, TKO, or saline lock, while enroute to hospital. DO NOT DELAY TRANSPORT

PARAMEDIC

A. Assume charge of situation and confer with EMT’s about condition of patient and situation.

B. With chest pain, even if it clearly cannot be determined to be cardiac in origin, the Paramedic should:

1. Support the airway and provide oxygen.

2. Hypotension with signs of shock and patient is suspected of being in cardiogenic shock

(BP less than 70-90 mm Hg systolic with poor profusion):

1. Establish IV saline. Trial volume infusion 250cc’s, may be repeated

b. Establish second IV in large major vessel for dopamine administration,

400mg dopamine in 500ml D5W to yield a solution of 800 mcg/ml;

IF IV INFILTRATES, REPORT TO THE ED PHYSICIAN AS SOON AS POSSIBLE

3. Relieve pain

a. If patient is conscious and alert , administer 0.4 mg tablet or spray of nitroglycerin sublingually after establishment of an IV. Monitor patient's condition. Dosage may be repeated in 5 minutes intervals if pain does not subside and SBP is above 100mm Hg.

1. Morphine dosage: Small frequent titrated IV dose 5mg every 5 minutes

ii. Do not use morphine on COPD or volume depletion.

4. Correct cardiac arrhythmia - Arrhythmia guidelines.

5. Transport to a medical facility.

6. When patient fits thrombolytic profile, administer 4 chewable aspirin.

BE SURE TO CHECK FOR TRUE ASPIRIN ALLERGY vs PEPTIC DISTRESS

CARDIAC CHEST PAIN

EMT-B EMT-I PARAMEDIC

OPEN & MANAGE EVALUATE PT. OBTAIN MEDICAL CONTACT

AIRWAY CONDITION HISTORY MEDICAL CONTROL

100% 02 NRB O.P.Q.R.S.T.I. REASSURE PT. &

INITIATE ASA THERAPY A.M.P.L.E. TRANSPORT

START IV, TKO APPLY MONITOR ASSESS PATIENT FOR

CHECK RHYTHM THROMBOLYTIC POTENTIAL

ADVISE MEDICAL CONTROL

ARRHYTHMIA SEVERE PAIN HYPOTENSION

SEE NITROGLYCERIN

PROTOCOL 0.4mg TAB. OR SPRAY START SECOND

2 DOSE MAX. LARGE CATHETER

FLUID BOLUS 25O CC

TITRATE TO

BP> 100 mm Hg

IMPROVED LOC

5mg, IVP q 5 MIN

CHILDBIRTH/OBSTETRICAL EMERGENCIES

GENERAL INSTRUCTIONS

A. Unless delivery is imminent, follow Clark County Prehospital Transport of Obstetric Patients algorhythm.

B. Imminent delivery is when the baby's head is visible in the vaginal opening during a contraction (crowning)

C. A visual inspection of the perineal area should only be done when contractions are less than 5 minutes apart and/or there is bleeding or fluid discharge

D. The EMT should not place a gloved hand inside the vagina except in the case of breech delivery with entrapped head or a prolapsed umbilical cord.

E. During delivery, gentle pressure with a flat hand on the baby's head should be applied to prevent an explosive delivery

F. A mother in active labor should be placed on the cot or floor to prevent the newborn from falling after delivery

EMT-B

A. Obtain history of patient condition and pregnancy: Contraction duration and interval, Due date, Number of pregnancies and number of live children, Pre-natal care and possible complications.

B. Determine transport or delivery. Transport unless crowning is present during a contraction; contact Medical Control

C. Always try to transport mother to her hospital designated for delivery.

Transport mother on left side with head slightly elevated to relieve pressure on mother's vena cava created by baby. Pressure could cause a decrease in mother's and baby's heart rate.

D. If delivery is imminent, prepare equipment and follow guidelines for delivery.

1. Equipment: OB Kit, Oxygen and BVM, towels and blankets, cot, large dressings

F. Keep mother and child warm and monitor airways and signs of shock

EMT-I / PARAMEDIC

A. Assist EMT, obtain patient condition and circumstance

B. Start IV saline if hypovolemic shock or excessive bleeding is present

NORMAL DELIVERY

EMT-B EMT-I PARAMEDIC

OBTAIN HISTORY VISUAL EXAM CONTACT

OF IF MEDICAL

PREGNANCY CONTRACTION < 5 MIN CONTROL

APART OR

GATHER EQUIPMENT

PREPARE MOTHER

FOR DELIVERY

FOLLOW DELIVERY TRANSPORT TO

GUIDELINES APPROPRIATE

O2, 5L, NC FACILITY

POSITION

IV SALINE, TKO MOTHER ON

COMPLICATION FOLLOW OB

PROTOCOL

AFTER DELIVERY

CLAMP & CUT CORD

ASSESS

APPROPRIATE

PROTOCOL

KEEP MOTHER &

CHILD WARM &

WELL OXYGENATED

TRANSPORT

MOTHER ON COT

OR HELD BY PARENT or EMT

DELIVERY COMPLICATIONS

CONTACT MEDICAL CONTROL AS SOON AS ANY COMPLICATION IS DISCOVERED

A. Cord Around Baby's Neck:

1. As baby's head passes out the vaginal opening, feel for the cord. Initially try to slip cord over baby's head; if too tight, clamp cord in two places and cut between clamps.

B. Breech Delivery:

1. Footling Breech, which is one or both feet delivered first

2. Frank Breech, which is the buttocks first presentation

a. When the feet or buttocks first become visible, there is normally time to transport patient to nearest facility.

b. If upper thighs or the buttock have come out of the vagina, delivery is imminent.

c. If the child's body has delivered and the head appears caught in the vagina, the EMT must support the child's body and insert two fingers into the vagina along the child's neck until the chin is located. At this point, the two fingers should be placed between the chin and the vaginal canal and then advanced past the mouth and nose.

d. After achieving this position a passage for air must be created by pushing the vaginal canal away from the child's face. This air passage must be maintained until the child

is completely delivered.

C. Excessive Bleeding Pre-delivery:

1. If bleeding is excessive during this time and delivery is imminent, in addition to normal delivery procedures, the EMT should use the hypovolemic shock guidelines.

2. If delivery is not imminent, patient should be transported on her left side and shock guidelines followed.

D. Excessive Bleeding Post-delivery:

1. If bleeding appears to be excessive, start IV of saline.

2. If placenta has been delivered, massage uterus and put baby to mother's breast.

3. Follow hypovolemia shock guidelines.

E. Prolapsed Cord:

1. When the umbilical cord passes through the vagina and is exposed, the EMT should check cord for a pulse.

2. The patient should be transported with hips elevated or in the knee chest position and a moist dressing around cord.

3. If umbilical cord is seen or felt in the vagina, insert two fingers to elevate presenting part away from cord, distribute pressure evenly when occiput presents

4. DO NOT attempt to push the cord back

5. High flow oxygen and transport IMMEDIATELY

DELIVERY COMPLICATIONS

EMT-B EMT-I PARAMEDIC

DELIVERY IS IMMINENT OR IN CONTACT

PROGRESS AND A MEDICAL

COMPLICATION ARISES CONTROL

SECURE AIRWAY

EXCESSIVE CORD AROUND PROLAPSED CORD BREECH

BLEEDING NECK

IV, NS LOOSEN CORD TRANSPORT ASAP IF BODY

Lg BORE OR MOTHER’S HIPS DELIVERED CUT IF ELEVATED OR KNEE CREATE

FOLLOW TOO TIGHT CHEST POSITION AIR PASSAGE

PROTOCOL

INSERT FINGERS

CONTINUE TO CONTINUE

ON CORD

IF UNABLE

TO DELIVER

POST INFANT

DELIVERY TRANSPORT

ASAP WITH

TRANSPORT MOTHER’S

ELEVATED

SHOCK

POSITION

PRE-DELIVERY TRANSPORT

TRANSPORT CHILD IN CAR SEAT

ON LEFT OR HELD BY PARENT or EMT

SIDE

OBSTETRICAL EMERGENCIES

A. Miscarriage: Premature termination of a pregnancy

1. Assess for shock and treat per shock guidelines.

2. Give psychological support to patient and/or family

3. Be sure to take all expelled tissue with you to the hospital

B. Ectopic Pregnancy: When growth and development of a fertilized egg occurs outside the uterus

1. Patient may experience severe abdominal pain.

2. May have intra-abdominal and/or vaginal bleeding and discharge.

3. Patient may not know she is pregnant

4. Treat for Hypovolemic Shock except for abdominal section of PASG

5. Transport supine with knees flexed

6. Take any expelled tissue with you to the hospital

C. Cardiac Arrest: Cardiac resuscitation of the expectant mother is unique due to the changes in the maternal cardiovascular and respiratory physiology

1. Precipitating events for cardiac arrest include: Pulmonary embolism, trauma, hemorrhage or

congenital or acquired cardiac disease.

2. Standard resuscitative guidelines should be carried out.

3. When the mother is supine, the fetus may compress the iliac vessels, the inferior vena cava, and the abdominal aorta. To minimize effects of the fetus pressure on venous return:

a. Place a wedge (pillow) under the right abdominal flank and hip, or

b. Apply continuous manual displacement of the uterus to the left

D. Third Trimester Bleeding.

1. Abruptio placenta - premature separation of placenta from uterine wall. Characterized by abdominal pain and vaginal bleeding

a. Bleeding may be dark

b. Uterus tender

2. Placenta previa - placenta partially or completely covers the cervical (birth) canal Characterized by painless vaginal bleeding

a. Bleeding may be bright red

b. Uterus may be non-tender

3. Never do vaginal exam

OB / GYN EMERGENCIES

EMT-B EMT-I PARAMEDIC

OPEN & MANAGE OBTAIN MEDICAL CONTACT

AIRWAY HISTORY & MEDICAL

100% 02 NRB/BVM VITAL SIGNS CONTROL

CARDIAC ARREST

VAGINAL GYNECOLOGICAL ECTOPIC

BLEEDING TRAUMA PREGNANCY

FOLLOW

IV, SALINE CARDIAC ARREST

PROTOCOL

WITHOUT UNDER RIGHT HIP

ABD SECTION OR

DISPLACE UTERUS

TO RELIEVE

PRESSURE ON

PROVIDE VENA CAVA

EMOTIONAL

SUPPORT

TRANSPORT

FLUID/TISSUE

DISCHARGE

TRANSPORT PT.

TO

FACILITY

DIABETIC EMERGENCIES

EMT-B

A. Secure and maintain airway. Support with 100% O2 by NRB mask.

B. Obtain relevant medical history:

1. Has patient eaten today?

2. Has patient taken insulin?

3. Onset

4. Medication - Type and time taken

C. Determine blood sugar level

1. Blood sugar less than 80, administer oral glucose to conscious and alert patients only

2. Unable to obtain blood sugar, transport and contact Medical Control for guidance

D. Establish communications with Medical Control and advise of patient condition. Consider transport time of < 5 minutes.

EMT-I

A. Assist EMT, obtain patient condition and circumstance

B. Apply monitor and check rhythm

C. Start IV saline, TKO, while enroute to hospital.

DO NOT DELAY TRANSPORT

PARAMEDIC

A. Assume charge of situation and confer with EMTs about condition of patient and situation

B. Apply monitor and check rhythm

C. Start IV saline, TKO.

D. Determine blood sugar level.

1. Blood sugar less than 80, administer 50cc D50 IV push immediately or Glucagon 1mg IM.

2. Blood sugar greater than 400, and hypoperfusion is present, infuse patient with 250cc bolus of saline

3. Unable to obtain blood sugar, transport and contact Medical Control for guidance

E. If patient has an altered level of consciousness, follow Altered LOC Protocol

DIABETIC EMERGENCIES

EMT-B EMT-I PARAMEDIC

OPEN & MANAGE EVALUATE PT. OBTAIN MEDICAL CONTACT

AIRWAY CONDITION HISTORY MEDICAL

100% 02 NRB VS,LOC,PUPILS OPQRST CONTROL

PULSE OX MED ALERT

IV, NS, TKO MONITOR EKG

CHECK BLOOD SUGAR UNABLE TO CHECK BLOOD SUGAR

BLOOD SUGAR NORMAL

BLOOD SUGAR BLOOD SUGAR

LESS THAN 80 GREATER THAN 400

IF PATIENT SALINE

ALERT 250ml BOLUS

BP < 90

HYPOPERFUSION

ADMINISTER

DEXTROSE D50

50ml IV BOLUS

OR

GLUCAGON

1mg IM

CHECK

LESS THAN 80

DEXTROSE

EYE INJURY

GENERAL CONSIDERATIONS

A. Do not allow eye injury to distract you from the basics of trauma care

B. Do not remove any foreign body imbedded in the eye or orbit. Stabilize any large protruding foreign bodies.

C. With blunt trauma to the eye, if time permits, examine the globe briefly for gross laceration as the lid may be swollen tightly shut later. Scleral rupture may lie beneath an intact conjunctiva.

1. Exert no pressure on the globe when doing the exam or when covering for transport

2. A light sterile wet dressing may be used to cover the eye for transport - avoid pressure directly to the eye by covering with a protective shield, (metal patch, drinking cup)

Do not delay transport by covering the eye if the patient has other life-threatening injuries.

D. Covering both eyes when only one eye is injured may help to minimize trauma to the injured eye, but in some cases the patient is too anxious to tolerate this

E. Transport patient sitting upright unless other life threats prohibit this from being done.

CHEMICAL BURNS

A. When possible determine type of chemical involved first. The eye should be irrigated with copious amounts of water or saline, using IV tubing wide open for a minimum of 20 minutes started as soon as possible. Any delay may result in serious damage to the eye.

B. Consider the use of topical ophthalmic anesthetic should be placed in the eye prior to irrigation. Always check to determine if the patient has any allergy to anesthetic agents

C. Always obtain name and, if possible, a sample of the contaminant or ask that they be brought to the hospital as soon as possible

CONTACT LENSES

A. If possible, contact lenses should be removed from the eye; be sure to transport them to the hospital with the patient. If the lenses cannot be removed, notify the ED personnel as soon as possible.

B. If the patient is conscious and alert, it is much safer and easier to have the patient remove their lenses

ACUTE, UNILATERAL VISION LOSS

A. When a patient suddenly loses vision in one eye with no pain, there may be a central retinal artery occlusion. Urgent transport and treatment is necessary.

B. Patient should be transported flat.

EYE INJURIES (cont)

EMT-B / EMT-I

A. Keep patient calm and lying flat, unless otherwise indicated

B. Obtain history of injury: Type, Where, When, How.

C. Establish communications with Medical Control and advise of patient condition. Transport immediately, unless an advanced life support unit is enroute and has an ETA of less than 5 minutes.

PARAMEDIC

A. Assume charge of situation and confer with EMTs about condition of patient and situation.

B. In cases where eyes may need irrigation, administer two (2) drops of topical ophthalmic anesthetic (i.e. Tetracaine) in eyes. Use of the Morgan Eye Lens is recommended.

EYE INJURIES

EMT-B EMT-I PARAMEDIC

KEEP PATIENT REMOVE OBTAIN HISTORY CONTACT

FLAT & CALM CONTACT LENSES WHEN,WHERE,HOW MEDICAL

CONTROL

TRAUMA BURN NON TRAUMA

PENETRATING NON DETERMINE DETERMINE

SECURE DUST/DIRT FLUSH ACUTE

OBJECT WITH H20 VISION LOSS

DO NOT WITH H20 CONSIDER TRANSPORT

ANESTHETIC MINIMUM

APPLY

LIGHT,COOL

DRESSING

HYPOTHERMIA / FROSTBITE

GENERAL CONSIDERATIONS

A. This guidelines was written to assist those instances of hypothermic injury involving long evacuation and transport time. When possible, all treatment should be left for a hospital setting.

B. Generalized Hypothermia:

1. The most common mechanism of death in hypothermia is ventricular fibrillation. If the hypothermia victim is in ventricular fibrillation, CPR should be initiated. If V fib is not present, then all treatment and transport decisions should be tempered by the fact that V fib can be caused by rough handling, noxious stimuli or even minor mechanical disturbances, this means that respiratory support with 100% oxygen should be done gently, including intubation, avoiding hyperventilation.

2. In the absence of monitor-confirmed V fib, the decision to initiate CPR must consider the following:

a. Hypothermia may produce profound bradycardia and the pulse should be taken for at least 60 seconds before concluding that the patient is pulseless.

b. Hypothermia can exert a protective effect on body tissues. The hypothermia victim’s own cardiac activity, even when profoundly bradycardic may be preferred to CPR perfusion, especially in light of the fact that CPR may well precipitate V fib.

3. The heart is most likely to fibrillate between 85-88 degrees F. (29-31 degrees C.) Defibrillate VF / VT up to a total of three shocks (200 J, 300 J, 360 J).

4. Since fibrillation is so difficult to convert without rewarming, measures to rewarm should be instituted in any hypothermia victim with V fib. The decision to rewarm should be made in consultation with Medical Control and should consider the following factors:

a. Method of rewarming available

b. Time / distance from hospital

c. Squad capability of treating V fib (ALS? BLS?)

5. Shivering stops below 90 degrees F. (32 degrees C).

6. Consider hypoglycemia in the hypothermic patient.

7. Wet clothing robs heat from the body more than it insulates and should be removed, protecting victim from wind.

8. Never give hot liquids by mouth.

9. Generalized hypothermia can occur whenever the ambient temperature is less than body temperature and the body is not capable of maintaining that temperature. For example, an elderly debilitated patient sitting over night in a room which is at 66 degrees F. may become hypothermic from that exposure alone. Suspect hypothermia in the injured, elderly, or debilitated patient.

C. Local Hypothermia (frostbite):

1. Thawing should be done under controlled conditions. It is extremely painful.

Hypothermia/Frostbite (cont)

2. Complete rewarming requires active heating for prolonged period. Partial rewarming is worse than none. Therefore, rewarming should rarely be done in the field.

EMT-B

A. Secure airway, and consider cervical spine injury

1. Administer warmed 100% oxygen, if available, by NRB mask and or BVM.

B. Move patient to warm environment , remove any wet clothing and cover with blankets.

C. Evaluate patient's general appearance and relevant history of condition.

D. Assess vital signs, mental status, temperature of patient and environment and evidence of local injury.

E. Generalized Hypothermia with Arrest

1. CPR and Transport unless AED or ALS is available in less than 5 minutes.

2. If an Automated External Defibrillator (AED) is available:

a. Assess patient for respiratory and cardiac arrest.

b. Apply AED and activate device.

i. "No Shock Advised"

(a) CPR as recommended by the American Heart Association.

(b) Establish communications with Medical Control and advise of cardiac arrest.

(c) Transport IMMEDIATELY unless an advanced life support unit is enroute and has an ETA of less than 5 minutes to the scene. )

ii. "Shock Advised"

(a) Deliver three stacked shocks (shocks without pulse checks)

(i) Defibrillate 200 joules

(ii) No Change - Second defibrillation 300 joules

(iii) No change - Third defibrillation 360 joules

F. Generalized Hypothermia Without Arrest

1. Do not initiate CPR if there is any pulse present, no matter how bradycardic.

2. Use oxygen, high flow. Do not hyperventilate. Do not use adjunctive airway equipment unless absolutely necessary. If necessary, use least intrusive measures which will adequately assure airway and ventilation.

3. Avoid rough handling, unnecessary stimulation.

4. If rewarming is undertaken, rewarm rapidly by applying warm packs or hot water bottles to trunk, neck and groin only.

5. Do not allow conscious patients to ambulate, exercise or move about.

Hypothermia/Frostbite (cont)

G. Local Hypothermia (frostbite):

1. Protect the injured areas from pressure, trauma, friction. Remove all covering from injured parts. Do not rub. Do not break blisters.

2. Do not thaw injured part with local heat in excess of 100-110 degrees F. (water that is comfortably hot to the touch without burning).

3. Do not allow limb to thaw if there is a chance that limb may refreeze before evacuation is complete.

4. Maintain core temperature by keeping patient warm with blankets, warm fluids, etc.

5. Transport and contact Medical Control of situation

EMT-I

A. Confer with EMT-B’s and confirm assessment.

B. During Transport :

1. Apply cardiac monitor, check rhythm and treat according to cardiac guidelines.

Maximum defibrillations three (3) shocks, 200 J, 300 J, 360 J.

2. Intubation, oxygenate with 100% O2, warm/humidified if available.

3. IV / warm NS, if available. If hypotension, 200-300 cc push. Contact Medical Control.

EMT-P

A. Confer with EMT’s and confirm assessment.

B. During Transport :

1. Apply cardiac monitor, check rhythm and treat according to cardiac guidelines.

2. Intubation, oxygenate with 100% O2, warm/humidified if available.

3. IV / warm NS, if available. If hypotension, 250 cc push.

4. Evaluate Blood sugar for possible dextrose administration

5. One round of ACLS medication.

6. When rewarming patients consider pain relief:

HYPOTHERMIA / FROSTBITE

EMT-B EMT-I PARAMEDIC

OPEN & MANAGE EVALUATE PT. OBTAIN A,M,P,L,E CONTACT

AIRWAY CONDITION HISTORY MEDICAL

100% 02 NRB O,P,Q,R,S,T,I LENGTH OF EXPOSURE CONTROL

PULSE OX

GENERAL HYPOTHERMIA GENERAL HYPOTHERMIA LOCALIZED HYPOTHERMIA

WITHOUT ARREST WITH ARREST FROSTBITE

VENTILATE WITHOUT CPR & TRANSPORT PROTECT INJURED AREAS

ADJUNCTS DO NOT RUB

REWARM WITH HOT APPLY MONITOR / AED REWARM INJURED AREAS

PACK, BLANKETS & HEATED

OXYGEN TREAT RHYTHMS PER HOT PACKS - TEPID WATER

ARRHYTHMIA & ARREST ONLY IF UNINTERRUPTED

MAXIMUM 3 SHOCKS

AVOID ROUGH HANDLING CONSIDER PAIN RELIEF

KEEP PT. STILL

INTUBATE, OXYGENATE

IV NS, WARMED IF AVAILABLE

250cc INITIAL FLUID BOLUS

ACLS DRUG THERAPY X 1

CONTACT MEDICAL

CONTROL

B. Heat exposure can occur either due to increased environmental temperatures or prolonged exercise or a combination of both. Environments with temperature above 90° F and humidity over 60% present the most risk.

C. Types of heat related illness:

1. Heat Stroke - The most serious type of exposure illness, usually due to prolonged exposure to heat, inadequate fluid replacement and deficient thermoregulatory function.

The patient will often experience inadequate perspiration with body temperatures reaching

105° F or greater. The skin is usually hot and dry and there may be an altered LOC and/or coma. Seizures may also occur.

Cardiovascular collapse is the usual cause of death.

2. Heat Exhaustion - A more moderate form of heat exposure associated with dehydration combined with overexertion.

The skin is cooler and the core temperature is below 105° F. The patient may experience syncope with orthostatic hypotension.

3. Heat Cramps - The mildest form of heat exposure caused by dehydration, overexertion and electrolyte abnormalities.

The skin is moist with muscle cramps, usually affecting large muscle groups.

D. When altered mental status is present consider other causes such as hypoglycemia, stroke and/or

shock.

EMT-B

A. Secure airway, and consider cervical spine injury.

B. Move patient to cool environment, remove any tight clothing.

C. Evaluate patient's general appearance and relevant history of condition.

Heat Exposure (cont)

D. Assess vital signs every 15 minutes, mental status, temperature of patient and environment.

E. Determine type of exposure:

1. Heat Stroke (hot and insufficient sweating)

a. Patient alert and oriented, may give fluid orally if there is no nausea and/or vomiting.

b. Patient with altered LOC, transport and:

i. cool with mist or cool wet sheet with fan, air conditioning and/or open windows:

ii. apply cold packs to axilla, groin and neck. (Avoid shivering)

2. Heat Exhaustion (pale, moist, may be orthostatic)

a. Patient alert and oriented, may give fluid orally if there is no nausea and/or vomiting.

b. Patient with altered LOC, transport and:

i. apply cold packs to axilla, groin and neck. (Avoid shivering)

3. Heat Cramps

a. Patient alert and oriented, may give fluid orally if there is no nausea and/or vomiting.

EMT-I

A Confer with EMT-B’s and confirm assessment.

B. During transport:

1. Apply cardiac monitor, check rhythm and treat according to cardiac protocol.

2. IV NS if hypoperfusion is present, 250cc push NS. Contact Medical Control.

EMT-P

A Confer with EMT’s and confirm assessment.

B. During transport:

1. Apply cardiac monitor, check rhythm and treat according to cardiac protocol.

3. IV NS if hypoperfusion is present, 250cc push NS. Contact Medical Control.

4. Treat seizures per seizure protocol.

HEAT EXPOSURE

EMT-B EMT-I PARAMEDIC

OPEN & MANAGE EVALUATE PT. OBTAIN A.M.P.L.E. CONTACT

AIRWAY CONDITION HISTORY MEDICAL

ALERT & ORIENTED DECREASED L.O.C.

CONSIDER OTHER CAUSES

MAY GIVE ORAL FLUID

PLACE IN COOL ENVIRONMENT

IV NS, MAINTAIN SBP OF 90 INTUBATE IF INDICATED

IF HYPOPERFUSION IS PRESENT

250 cc NS BOLUS

HEAT STROKE HEAT EXHAUSTION

APPLY COLD PAK APPLY COLD PAK

AXILLA, GROIN, NECK AXILLA, GROIN, NECK

DISCONTINUE COOLING

RAPID COOLING

MIST, COOL WET SHEETS

FAN, AC, OPEN WINDOW

TREAT SEIZURES PER

SEIZURE PROTOCOL

GENERAL CONSIDERATIONS

EMTs and Paramedics will consider the possibility of accidental or self poisoning under the following conditions:

A. History of observed or admitted accidental or intentional ingestion

B. Coma

C. History of known suicide gesture

D. Suggestive intoxicated behavior (hyperactive, hypoactive, unstable walk, lethargic)

5. Contact Poison Control for recommendation

EMT-B

A. Establish airway

B. Obtain relevant history

1. What, when, why taken (if known)

2. Quantity taken (if known) )

3. Victim's age and weight

C. Take whatever container the substance came from to the hospital along with readily obtainable samples of medication unless this results in an unreasonable delay of transport

D. Evaluate patient's:

1. Breath sounds (rales)

2. Level of consciousness

3. Pupil size

4. Evidence of head injury

E. Depending on route poison entered body apply the following:

1. Ingested Poisons - Transport [Contact Medical Control for prolonged transports, > 30 minutes or

for recommendation for charcoal administration.]

2. Inhaled Poisons -

a. Remove from toxic area

b. Secure airway, support with 100% oxygen

c. Assist in ventilation if necessary

3. Absorbed Poisons

a. Remove victim's clothing

b. Identify substance

c. Flush skin with water before and during transport if possible - at least 10-15 minutes

d. If eyes are involved flush with water or saline for 10-15 minutes

4. Injected Poisons

a. Secure and maintain airway

b. Find substance and introduction system, if possible

POISONING (cont)

EMT-I

A. Assist EMT, obtain patient condition and circumstance

B. Apply monitor and check rhythm

C. Start IV saline, TKO, while enroute to hospital. DO NOT DELAY TRANSPORT

PARAMEDIC

A. Assume charge of situation and confer with EMTs about condition of patient and situation

B. If patient has an altered level of consciousness, follow the Altered Level of Consciousness Protocol

C. Start IV saline, TKO

D. Contact Medical Control for prolonged transports, >30 minutes or for recommended for charcoal administration.

POISONING

MANAGE AIRWAY EVALUATE IDENTIFY

100% 02 NRB / BVM AIRWAY/BREATHING SUBSTANCE

PULSE OX CIRCULATION TYPE - AMOUNT

IF ALTERED LOC CONTACT MEDICAL

FOLLOW CONTROL

ALTERED LOC PROTOCOL

IV, TKO MONITOR EKG

DETERMINE ENTRY OF SUBSTANCE

INGESTED ABSORBED INHALED INJECTED

REMOVE PT. REMOVE PT. INSECT

FROM FROM BITE / STING

CONTAMINATED CONTAMINATED

AREA AREA FOLLOW

ANAPHYLACTIC

REMOVE MAINTAIN

CLOTHING OPEN AIRWAY

100 % 02 SNAKEBITES

BVM / PPV BANDS

TREAT SYMPTOMS

PSYCHIATRIC EMERGENCIES

EMT-B / EMT-I / PARAMEDIC

A. Obtain relevant history:

1. Previous psychiatric hospitalization, when and where

2. Where does patient receive psychiatric care?

3. What drugs does patient take (including alcohol)?

B. Calm the patient

C. Evaluate patient's:

1. Vital signs

2. General appearance

D. Contact Medical Control and advise of patient condition

E. Transport patients to appropriate facility.

F. Contact local law enforcement for assistance with violent patients

NOTE: Restraints may be used to protect the patient ,technicians, and bystanders.

See restraint policy.

G. ALL patients who are not making rational decisions should be transported for medical evaluation. *

Threat of suicide, overdose of medication, drugs, or alcohol, and/or threats to the health and well being of others are NOT considered rational.

* Refer to Refusal Protocol

RESPIRATORY DISTRESS

EMT-B

A. Open airway and check for breathing

1. Airway obstructed:

a. Manual clearing

b. Abdominal or chest thrust

c. Suction

d. If airway cannot be cleared in 60 seconds:

i. Transport immediately to nearest hospital

ii. Do not take history

iii. Do not make further physical assessment

2. Airway is open, breathing absent, pulse present:

a. Ventilate patient 100% oxygen by two person bag valve mask or oxygen powered, manually triggered ventilation device with nasal or oral airway once every five seconds

b. Ventilation should be delivered over two seconds and cricoid pressure should be considered to help reduce gastric distention

3. Airway is open and patient is in distress:

a. Administer 100% O2 by NRB mask;

b. Be prepared to assist ventilations;

c. Evaluate breath sounds:

i. Clear breath sounds: Treat cause - (MI, pulmonary embolism, metabolic disturbance, hyperventilation) Transport

ii. Wheezes present:

(a) Minor allergic reaction: Support with oxygen, observe patient carefully. Transport

(b) Severe allergic reaction (allergy, asthma)

(i) Secure airway and support with oxygen

(ii) Ask patient or bystanders if epinephrine by auto-injector has been prescribed for these situations and do they have the medication with them

(iii) IF MEDICATION IS NOT AVAILABLE - Transport immediately, unless ALS unit is enroute and has an ETA of less than 5 minutes. (Consider transport time)

RESPIRATORY DISTRESS (cont)

(iv) IF MEDICATION IS AVAILABLE:

(aa) Assure medication is prescribed for patient

(bb) Check medication - cloudiness, expiration date, administration method

(cc) Contact Medical Control, if possible

(dd) Administer medication in mid-thigh and hold injector

firmly against leg for at least ten seconds to assure all medication is injected

(ee) Record patient reaction to medication and relay to Medical Control - be sure to have vital signs

(ff) Transport immediately

(c) Patient with COPD (emphysema, asthma, bronchitis)

(i) Minor distress;

(aa) Put patient in position of comfort, support with LOW flow oxygen

(ii) Severe distress;

(aa) Set patient up, assist ventilations with HIGH flow O2

(bb) Ask patient or bystanders if a bronchial dilator by inhaler has been prescribed for these situations and do they have the medication with them

(cc) IF MEDICATION IS NOT AVAILABLE - Transport immediately, unless ALS unit is enroute and has an ETA of less than 5 minutes. (Consider transport time)

(dd) IF MEDICATION IS AVAILABLE:

(i) Assure medication is prescribed for patient

(ii) Check medication - expiration date, administration method

(iii) Contact Medical Control, if possible

(iv) Administer medication by having the patient

exhale, then activate spray during inhalation,

and have patient hold breath for ten seconds so medication can be absorbed

USE SPACER IF AVAILABLE

(v) Record patient reaction to medication and relay to Medical Control - be sure to have vital signs

RESPIRATORY DISTRESS (cont)

(vi) Transport immediately

iii. Rales present (pulmonary edema)

(a) Set patient up, administer HIGH flow oxygen by NRB and/or BVM and transport

iv. Breath sounds absent

(a) Treat cause: pneumothorax, hemothorax, lower airway obstruction

B. Pulse Oximeter and monitor patient condition and treat accordingly

C. Evaluate patient's general appearance and relevant history of condition.

D. Contact Medical Control, advise of patient condition, and TRANSPORT

EMT-I

A. Assist EMT; obtain patient condition and circumstance

B. Reassess breath sounds and treat as follows:

1. Airway open, breath sounds absent

a. Endotracheal intubation

b. Provide 100% O2 by BVM or PPV

c. Treat cause and transport

2. Airway obstructed:

a. Try to visualize obstruction with laryngoscope if basic procedures are unsuccessful

I. Remove foreign body with Magill forceps if possible

3. Wheezes present:

i. Severe systemic allergic reaction

(a) Give 0.3mg (1:1000) epinephrine by injection subcutaneously

(b) May be repeated during transport if patient condition does not improve and Medical Control has been contacted

(c) If caused by sting or bite, apply constricting band between bite and heart, apply ice pack to slow swelling and spread of poison

RESPIRATORY DISTRESS (cont)

D. Apply monitor and check rhythm

E. Start IV saline, TKO, while enroute to hospital DO NOT DELAY TRANSPORT

PARAMEDIC

A. Assume charge of situation and confer with EMT’s about condition of patient and situation

B. Reassess breath sounds and treat as follows:

1. Airway open, breath sounds absent

a. Endotracheal intubation

b. Provide 100% O2 by BVM or PPV

c. Treat cause and transport

2. Airway obstructed:

a. Try to visualize obstruction with laryngoscope if basic procedures are unsuccessful

I. Remove foreign body using Magill Forceps if possible

b. If airway cannot be cleared, perform a cricothyrotomy

3. Spontaneous breathing with breath sounds:

a. Clear breath sounds:

i. Treat cause - (MI, pulmonary embolism, metabolic disturbance, hyperventilation)

b. Wheezes present:

i. Severe systemic allergic reaction

(a) Start IV saline

(b) Give 0.3mg (1:1000) epinephrine by injection subcutaneously

(c) Consider seeking Medical Control

(d) If patient is hypotensive and IV has been established, 0.5mg (1:10,000) epinephrine, IVP, SLOWLY

(e) If caused by sting or bite, apply constricting band between bite and heart, apply ice pack to slow swelling and spread of poison

(f) In patients with hypertension, CVA, CAD, pregnancy, consider Glucagon 1mg IM or IV instead of epinephrine.

(g) Benadryl (diphenhydramine) administered 50 mg IM or IV.

NOTE: This is especially indicated when drug reactions are

suspected and SBP is above 90.

(h) Proventil (albuterol) breathing treatment: 2.5mg (3cc) of proventil in aerosol unit with oxygen flow at 8 liters per minute

ii. Patient with asthma:

(a) Minor distress:

(i) Put patient in position of comfort, support with oxygen

(ii) Consider proventil (albuterol) breathing treatment: 2.5mg (3cc), of proventil (albuterol) in aerosol unit with oxygen flow at 8 liters per minute

(b) Severe distress:

(i) Sit patient up, assist ventilations with HIGH flow oxygen

(ii) Proventil (albuterol) breathing treatment: 2.5mg (3cc) of proventil in aerosol unit with oxygen flow at 8 liters per minute

(iii) Contact Medical Control for possible administration of epinephrine or glucagon.

(c) Start IV saline

iii. Patient with COPD:

(a) Minor distress:

(i) Put patient in position of comfort, support with LOW flow oxygen

(ii) Proventil (albuterol) breathing treatment: 2.5mg (3cc) of proventil (albuterol)in aerosol unit with oxygen flow at 8 lpm.

(b) Severe distress:

(i) Sit patient up, assist ventilations with HIGH flow oxygen

(ii) Proventil (albuterol)breathing treatment: 2.5mg (3cc) of proventil (albuterol)in aerosol unit with oxygen flow at 8 lpm.

(iii) Start IV saline

c. Rales present:

i. Pulmonary edema:

(a) Look for and note cyanosis, hypotension, coughing, wheezing, labored breathing, diaphoreses, pitting edema, tachypnea, apprehension, and inability to talk

(b) Patient has normal blood pressure or is hypertensive:

(i) Administer sublingual nitroglycerin 0.4mg three times at five minute intervals (tablet or spray)

Maintain BP above 100 systolic

RESPIRATORY DISTRESS (cont)

(ii) Establish IV and administer lasix (1 mg/kg) IV over one to two minutes.

(iii) Transport patient.

(iv) Consider morphine sulfate for analgesia as well as hemodynamic response. Morphine sulfate is of considerable usefulness in both AMI and APE

(aa) Dosage: Small frequent titrated IV doses 5mg every

5 minutes as needed until desired effect is achieved

(bb) Do not use on COPD or volume depletion

(cc) Monitor vital signs, especially respirations and blood pressure, every 5 minutes

d. Breath sound asymmetrical or absent:

i. Spontaneous Pneumothorax:

(a) Transport in position of comfort.

ii. Sucking chest wound:

(a) Seal open wound, 3 sides, monitor for tension situation

iii. Tension pneumothorax

(a) Pleural decompression

iv. Lower airway obstruction

(a) Place in position of comfort

(b) 100% humidified O2 by NRB

RESPIRATORY DISTRESS

OBSTRUCTED AIRWAY

EMT-B EMT-I PARAMEDIC

OPEN AIRWAY CLEAR OBSTRUCTION CONTACT

CHECK FOR BY MANUAL METHODS MEDICAL

BREATHING SUCTION CONTROL

AIRWAY BLOCKED UNABLE TO CLEAR

IN LESS THAN 60 SECONDS

TRANSPORT

AIRWAY CLEARED AIRWAY BLOCKED DURING TRANSPORT

PROVIDE OXYGEN VISUALIZE WITH POSITIVE PRESSURE

NRB LARYNGOSCOPE OXYGEN

REMOVE FB WITH

ASSESS AIRWAY MAGILL FORCEPS

LUNG SOUNDS

TREAT CAUSE CRICOTHYROTOMY

CHOKING, ASTHMA

COPD, ANAPHYLAXIS

RESPIRATORY DISTRESS

SPONTANEOUS BREATHING

EMT- B EMT- I PARAMEDIC

OPEN AIRWAY ASSESS PT. OBTAIN HISTORY CONTACT

PROVIDE OXYGEN PULSE OX & MEDICAL

NRB/BVM LUNG SOUNDS MEDICATIONS CONTROL

IV NS, TKO MONITOR EKG

RE-ASSESS LUNG SOUNDS

CLEAR LUNG SOUND

TREAT CAUSE - TRANSPORT

DECREASED SOUNDS RALES ASYMMETRICAL

WITH WHEEZES PULMONARY EDEMA

ANAPHYLAXIS ASTHMA / COPD NITROGLYCERIN DETERMINE &

EPINEPHRINE MEDICATION MAINTAIN B/P

INSECT BITE/STING PROVENTIL PLEURAL

AEROSOL LASIX, IV DECOMPRESSION

EPINEPHRINE 2.5mg (3cc) 1mg/Kg

0.3mg, SUB Q O2 at 8 L

1:1,000

CONTACT MEDICAL

CONTROL

CONSIDER 50 mg I M/IV

1:10,000, 0.5mg IVP

1 MG IM/IV VERSUS

EPINEPHRINE

SEIZURES

GENERAL CONSIDERATIONS

A. The seizure has usually stopped by the time the EMS personnel arrive (Postictal state)

B. The basic rule with seizures is to "protect and support" the patient, if trauma, consider cervical immobilization

C. Aspiration precautions include:

1. Coma position: a side lying position with the head lowered 15 to 30 degrees

2. Suction readily available

3. If possible, mouth cleared of foreign bodies (food, gum, dentures)

EMT-B

A. Place patient away from objects on which they might injure themselves; protect but do not restrain them

B. Clear and maintain airway, consider cervical spine injury

C. Administer 100% oxygen with NRB mask

D. Obtain history from bystanders:

1. Seizure history

2. Description of onset of seizure

3. Medications

4. Other known medical history (especially head trauma, diabetes, drugs, alcohol, stroke, heart disease)

E. Evaluate:

1. Evidence of head trauma

2. Drug abuse

F. Bring medication with patient if available

G. Establish communications with Medical Control and advise of patient condition. Transport immediately, unless an Advanced Life Support unit is enroute and has an ETA of less than 5 minutes.

EMT-I

A. Assist EMT, obtain patient condition and circumstance

B. Apply monitor and check rhythm

C. Start IV, saline, TKO, while enroute to hospital if seizures are persistent or recurrent.

DO NOT DELAY TRANSPORT

SEIZURE (cont)

PARAMEDIC

A. Assume charge of situation and confer with EMTs about condition of patient and situation

B. Make sure patient has good airway, if status epilepticus, nasotracheal intubation may be necessary

C. Start IV saline TKO if seizures are persistent or recurrent .

D. Determine blood sugar level

1. Blood sugar less than 80, administer 50cc of 50% dextrose IV push immediately or 1mg glucagon IM.

E. In repeated seizure activity administer valium(diazepam) IV or consider versed(midazolam) IV/IM

1. Initial bolus of 5mg. and titrate to patient's condition up to a 10 mg. maximum

F. After versed or valium monitor airway; be prepared to intubate and assist ventilation with BVM or PPV

In status epilepticus, nasotracheal intubation may be necessary

SEIZURE

EMT-B EMT-I PARAMEDIC

OPEN AIRWAY EVALUATE PT. OBTAIN HISTORY CONTACT

PROVIDE OXYGEN CONDITION SEIZURES MEDICAL

NRB/BVM PULSE OX, LUNG DIABETIC CONTROL

CONSIDER C-SPINE SOUNDS, LOC, VS DRUG ABUSE

IV NS, TKO MONITOR EKG TRANSPORT

IF SEIZURES ARE PERSISTENT

OR RECURRENT

ACTIVE SEIZURE POST ICTAL

COMPROMISED

HYPOXIA, FEVER

HYPOGLYCEMIA

VERSED IV/IM or VALIUM, IVP OVERDOSE

5mg, SLOWLY HEAD INJURY

CHECK BLOOD SUGAR HYPOTENSIVE

LESS THAN 80

IV FLUID BOLUS

1amp 50% DEXTROSE IVP

1mg GLUCAGON, IM TRANSPORT

SHOCK

GENERAL CONSIDERATIONS

A. Shock is the failure of the body to circulate blood and oxygen properly and perfuse body tissue

B. Shock can be due to:

1. Hypovolemic - fluid loss

2. Cardiogenic - pump failure

3. Neurogenic - vasodilation

4. Anaphylactic - allergic reaction

5. Septic - infection, vasodilatation

6. Respiratory - lack of oxygen

C. Priorities of care in shock situations are:

1. Provide an adequate airway and oxygenation

2. Recognize the type of shock present and its treatment

3. Replace body fluids

EMT-B

A. Establish airway; administer oxygen 100% by NRB mask. Assist ventilation as required with oral or nasal airway and BVM. Obtain Pulse Ox reading and treat accordingly.

B. Obtain relevant medical history: CAUSE

C. Place patient in proper shock position:

1. Hypotension - lying flat with feet elevated

2. Respiratory difficulty - head elevated

D. Maintain body temperature:

1. Patient cold - Warm them up

2. Patient hot - Cool them down

E. Consider PASG per local protocol

G. Evaluate the patient's:

1. Respiratory status

2. Circulatory status - pulse, B/P

3. Level of consciousness

4. Evidence of trauma to abdomen, chest, head

H. Establish communications with Medical Control and advise of patient condition. Transport Immediately, unless an advanced life support unit is enroute and has an ETA of less than 5 minutes.

SHOCK (cont)

EMT-I

A. Assist EMT; obtain patient condition and circumstance

B. Hypovolemic, Neurogenic, or Septic Shock:

1. During transport to the hospital, start IV saline, PASG guidelines. DO NOT DELAY TRANSPORT

C. Anaphylaxis from an insect bite or sting:

1. Breathing difficulty with low blood pressure:

a. Start IV saline, PASG guidelines

b. Give 0.3mg (1:1000) epinephrine by injection subcutaneously

2. Hives, itching, and/or swelling: Contact Medical Control for possible administration of epinephrine.

D. Apply Monitor and check rhythm

PARAMEDIC

A. Assume charge of situation and confer with EMTs about condition of patient and situation

B. Apply monitor and follow guidelines for Arrhythmias

C. Identify type of shock and treat as follows:

1. Hypovolemic, Neurogenic, Septic:

a. Start IV of saline

b. If transport will be prolonged, or if entrapment exists, contact Medical Control

c. If Hypovolemic Shock persists despite above measures start second saline IV

2. Cardiogenic:

a. Treat cause by following Arrhythmia, Chest Pain, and Cardiac Arrest Protocols.

b. If patient has B/P of less than 70-90 mm Hg systolic with poor profusion:

i. IV fluid bolus 250 cc’s, may be repeated

ii. Establish second IV in large peripheral vessel for dopamine administration:

(a) Dopamine 400mg in 500cc D5W or NS

(b) Start infusion at 10mcg/kg/min and titrate the infusion until adequate

heart rate, blood pressure, and level of consciousness are achieved.

NOTE: If IV infiltrates, report to the ED physician as soon as possible

iii. Establish second IV Saline TKO in large peripheral vein if time permits

SHOCK (cont)

3. Anaphylactic:

a. Respiratory distress, follow Respiratory Distress Protocol

b. Hives, itching, and/or swelling normal B/P: Contact Medical Control for possible administration of epinephrine and/or benedryl

SHOCK

EMT-B EMT-I PARAMEDIC

OPEN & MANAGE DETERMINE OBTAIN MEDICAL CONTACT

AIRWAY TYPE & CAUSE HISTORY & MEDICAL

OXYGEN, NRB/BVM SHOCK VITAL SIGNS CONTROL

CONSIDER PASG, TRANSPORT WITHOUT DELAY

PER LOCAL PROTOCOL UNLESS ENTRAPMENT

ACTIVATE ALS RESPONSE

IV NS, TITRATE TO B/P MONITOR EKG

OF 100 SYSTOLIC

ANAPHYLACTIC CARDIOGENIC HYPOVOLEMIC

B/P LESS THAN 90 SEPTIC,METABOLIC

RESPIRATORY HIVES,ITCHING TRANSPORT TRANSPORT

DISTRESS SWELLING

NORMAL B/P IV FLUID BOLUS IV FLUID BOLUS

FOLLOW EXCEPT WITH 250 ml

RESPIRATORY PULMONARY EDEMA

100 SYSTOLIC

TRANSPORT

ACUTE STROKE

General Considerations

A. Patients who experience transient ischemic attack (TIA) develop most of the same signs and symptoms as those who are experiencing a stroke. The signs and symptoms of TIA’s can last from minutes up to one day. Thus the patient may initially present with typical signs and symptoms of a stroke, but those findings may progressively resolve. The patient needs to be transported, without delay, to the most appropriate hospital for further evaluation.

B. Some patients who have had a stroke may be unable to communicate but can understand what is being said around them.

C. Place the patient’s affected or paralyzed extremity in a secure and safe position during patient movement and transport.

D. Hypertension in stroke patients routinely should not be treated in the prehospital setting.

Any treatment of hypertension must be an ON-LINE issue.

Nitroglycerin should not be used unless signs and symptoms consistent with AMI or APE are present.

E. New therapies for stroke are now available. However, successful use is only possible during a short time window after the start of symptoms. Early notification of the receiving hospital and minimizing scene time are important parts of a strategy to treat patients quickly.

F. Time of onset of signs and symptoms must always be obtained, documented and relayed to the receiving facility.

Time of symptom onset needs to be accurately determined for consideration of thrombolytic therapy.

In patients whose symptoms were present upon awakening, their symptom onset is estimated from the last time that the patient’s neurological status was known to be normal, or the time just prior to going to sleep.

G. A simple method of physical exam for the stroke patient is:

1. ask the patient to say " you can’t teach an old dog new tricks,"

2. ask the patient to smile or show their teeth,

3. ask the patient to hold their arms straight up in front with palms up, have the patient close their eyes and watch arm drift. (palm turns down)

a. if only one palm turns down the test is positive

b. if both arms drift down, the result are unclear

H. Complete prehospital CVA checklist.

Acute Stroke (cont)

EMT-B

A. Open and manage the airway and provide oxygen by nasal cannula 4 lpm and increase as needed

with respiratory distress.

Be prepared to hyperventilate and/or assist ventilations with oral or nasal airway and BVM or PPV

B. Determine blood sugar level.

1. Blood sugar less than 80, administer 1 tube of oral glucose. May be repeated in 10 minutes if blood sugar remains below 80.

PATIENT MUST HAVE A GAG REFLEX.

2. Blood sugar greater than 80 TRANSPORT..

C. If unable to check blood sugar, with signs of stroke, establish communications with Medical Control and advise of patient condition.

Transport IMMEDIATELY unless an advanced life support unit is enroute and has an ETA of less than 5 minutes to the scene.

EMT-I

A. Assist EMT, obtain patient condition and circumstance

B. Apply monitor and check rhythm

C. Start saline IV TKO, while enroute to hospital

PARAMEDIC

A. Assume charge of situation and confer with EMTs about condition of patient and situation

B. If patient does not have a secure, protected airway, intubate per Intubation Procedure

C. Apply monitor and check rhythm

D. Establish IV saline TKO.

E. Determine blood sugar level.

1. If blood sugar less than 80, administer IV bolus, 50cc of 50% dextrose or

2. Glucagon 1mg IM/IV, may be repeated in 10 minutes if blood sugar remains below 80.

H. Re-evaluate patient condition, contact Medical Control, and transport to hospital

ACUTE STROKE

OPEN & MANAGE EVALUATE PT. OBTAIN MEDICAL CONTACT

AIRWAY CONDITION HISTORY MEDICAL

RESP. DISTRESS PULSE OX DIABETIC &

CALCULATE G.C.S. EVALUATE LANGUAGE,

SCORE LESS THAN 8, CALL ALS MOTOR RESPONSE & SENSATION

IV NS, TKO - MONITOR EKG

CHECK BLOOD SUGAR UNABLE TO CHECK

BLOOD SUGAR CONTACT MEDICAL

LESS THAN 80 CONTROL

ADMINISTER

ORAL GLUCOSE

1 TUBE

ADMINISTER

50cc, 50% DEXTROSE

GLUCAGON 1mg IM/IV

TRAUMA EMERGENCIES

GENERAL CONSIDERATIONS

A. Scene size up - assure scene is safe, determine mechanism of injury, determine number of patients and request additional help if needed

B. Rapid assessment and recognition of major trauma/multiple system trauma is essential to the subsequent treatment.

1. Determine the need for rapid extrication/removal of patients with life or safety threats

C. Once the patient is determined to be an actual or potential major trauma/multiple system patient, personnel on scene must quickly determine the appropriate course of action including:

1. Requesting aeromedical evacuation from scene (See Aeromedical Evacuation Procedure)

2. Ground transportation directly to an appropriated facility. (When requesting bypass of nearest facility, this action must be approved by Medical Control)

D. In cases where the victim must be transported by ground units, because of transport times every effort should be made to limit on-scene time to 10 minutes or less

THIS CANNOT BE STRESSED ENOUGH !!!

E. If patient is entrapped or inaccessible, contact Medical Control and advise of condition and circumstances

F. If time permits, each patient should be evaluated by the Glasgow Coma Scale and the score relayed to Medical Control

EMT-B

A. Trauma Assessment

1. Initial assessment - establish life threats, chief complaints, assess airway and initiate appropriate therapies, assess circulation and control major bleeding, establish a general impression of patient condition and prioritize patient for transport

2. Urgent patient

a. Rapid trauma assessment - quick head to toe survey utilizing DECAP BTLS. Obtain baseline vital signs and SAMPLE history.

b. TRANSPORT IMMEDIATELY

c. Detailed physical exam and ongoing assessment - during transport, evaluate patient head to toe and assess effectiveness of treatments to this point.

3. Non-urgent patient - single or non-life threatening injury

a. Focused physical exam of injured area and management of the situation.

b. Detailed physical exam and ongoing assessment - evaluate patient head to toe and assess effectiveness of treatments to this point.

TRAUMA EMERGENCIES (cont)

c. Transport patient

B. Urgent trauma treatment

1. Establish airway, breathing and circulation; maintain C-spine immobilization

2. Administer 100% oxygen and apply Oximeter

3. Control hemorrhage by appropriate method - Apply PASG if indicated

1. Refer to shock protocol for symtommatic patients

4. TRANSPORT immediately

5. During transportation

a. Splint individual fracture

b. Evaluate patient's:

i. Pulses distal to the fracture site

ii. Distal skin color, temperature, neurological status

c. Obtain relevant history:

i. Where, When, How

ii. Mechanism of injury

6. Establish communications with Medical Control and advise of patient condition and need for Trauma Team.

C. Non-urgent trauma treatment

1. Establish airway, breathing and circulation; maintain C-spine immobilization

2. Administer 100% oxygen and apply Oximeter

3. Control hemorrhage by appropriate method - Apply PASG if indicated

4. Splint all fracture(s) (IN NON-LIFE THREATENING SITUATION ONLY)

1. When practical, splint all possible fractures prior to transport
2. Evaluate patient's:

i. Pulses distal to the fracture site

ii. Distal skin color, temperature, neurological status

5. Obtain relevant history:

a. Where, When, How

b. Mechanism of injury

H. Establish communications with Medical Control and advise of patient condition.

TRAUMA EMERGENCIES (cont)

EMT-I

A. Assist EMT; obtain patient condition and circumstance

B. Start IV saline to maintain perfusion and SBP of 90, PASG guidelines

IV MUST NOT DELAY TRANSPORTATION

C. Apply cardiac monitor and check rhythm

PARAMEDIC

A. Assume charge of situation and confer with EMTs about condition of patient and situation

B. Treat for shock per Shock Protocol

C. If the patient is conscious and alert and complaining of severe pain, administer Nitrous Oxide per guidelines and/or administer Morphine Sulfate as follows:

1. Small frequent doses of 5mg every 5 minutes and titrate to patient condition

2. DO NOT USE ON HEAD TRAUMA, CHEST INJURY, RESPIRATORY DISTRESS DUE TO TRAUMA, OR ON ANY PATIENT WITH VOLUME DEPLETION OF ANY CAUSE.

SPECIFIC INJURIES

A. Chest Wounds:

1. For sucking chest wounds or open pneumothorax, always cover the wound with a non-porous dressing and seal 3 sides.

2. Stabilize flail chest with trauma dressing

B. Evisceration:

1. Cover organs with sterile dressing moistened with saline

2. Lay the patient flat and elevate the knees

C. Complete Amputations:

1. Control bleeding by the most appropriate method; remember tourniquet is a last resort

a. Put part in a cool, dry sterile dressing

D. Pneumothorax / Hemothorax / Tension Pneumothorax:

1. Transport patient in position of comfort and watch for signs of a tension pneumothorax

TRAUMA EMERGENCIES (cont)

2. Symptoms of tension pneumothorax:

a. Chest pain or evidence of trauma

b. Tachypnea

c. Tachycardia

d. JVD

e. Hyperresonance on affected side

f. Diminished or absent breath sounds of affected side

g. Tracheal deviation away from affected side (latent sign)

NOTE: Significant tension pneumothorax may present exhibiting any or all of the

above

3. Pleural decompression per procedure

E. Head Injury:

1. Evaluate patient condition:

a. Level of Consciousness

b. Pupillary size and reaction

c. Glasgow Coma Scale results

2. Transport with head elevated 8 to 10 inches by tilting backboard, and C-spine immobilized

3. Maintain airway, support with 100% oxygen by NRB mask and/or BVM

a. Orotracheal, nasotracheal, or digital intubation may be indicated and should be accomplished gently with in-line C-spine immobilization

b. Do not hesitate to take control of airway

c. Hyperoxygenate when there are signs of cerebral herniation:

i. Blown pupils, bradycardia, posturing

F. Spinal Injuries:

1. Immobilize spine - See Cervical Immobilization Assessment Protocol

2. Cervical Immobilization Assessment

a. Cervical immobilization should be used if the following criteria are met.

i. The patient complains of neck pain

ii. The patient has pain on palpation of the neck

iii. The patient complains of neurologic deficits or is found upon physical exam to have neurologic deficits. (subjective: numbness, tingling, weakness) (objective: loss or diminished sensation or motor weakness)

iv. The patient with altered LOC and impaired competence whether from drugs, alcohol or head injury and suggestive mechanism of injury for neck injury (refer to Refusal of Service for impaired competence criteria)

v. The patient with suggestive mechanism of injury for neck injury and the patient has other major distracting injuries.

vi. The patient has neck pain with any head motion

b. All patients that DO meet the above criteria shall have full cervical immobilization.

3. If patient is wearing a helmet, see Helmet Removal Protocol in the Special Procedures Section

TRAUMA EMERGENCIES (cont)

4. Always contact Medical Control and relay information regarding patient to the hospital. Spinal cord injury patients may need to be delivered to another facility if the hospital initially contacted cannot handle this injury.

5. If patient is alert and complaining of severe pain consider pain relief per local protocol.

TRAUMA EMERGENCIES

EMT-B EMT-I PARAMEDIC

SCENE SIZE-UP - SAFETY, MECHANISM OF INJURY, NUMBER OF PATIENT, IDENTIFY THE

NEED FOR AND SUMMONS ADDITIONAL RESOURCES.

CONSIDER RAPID REMOVAL WHEN APPROPRIATE – IMMOBILIZE AS INDICATED

INITIAL ASSESSMENT - DETERMINE LIFE-THREATS, PRIORITIZE PATIENT FOR TRANSPORT,

ASSESS AND MANAGE AIRWAY, CIRCULATION, BLEEDING

INTUBATE PATIENT WITH C-SPINE CONTROL

URGENT PATIENTS NON-URGENT PATIENTS

"DCAP-BTLS" OF INJURED AREA(S)

"DCAP-BTLS"

TWO IVs SALINE TITRATED MEDICAL CONTROL

TO SBP > 90 mmHg

CHEST ABDOMINAL HEAD EXTREMITY

EVALUATE EVISCERATION EVALUATE EVALUATE

PNEUMO/HEMO MOIST SPLINTING

ELEVATE KNEES OF BACKBOARD

POSITION ON PROTECT AMPUTATION

INJURED SIDE C-SPINE

HEAD BLUNT INJURY COOL & DRY

ELEVATED HYPER-

STABILIZE w / HERNIATION PAIN RELIEF PER

FLAIL CHEST LOCAL PROTOCOL

PENETRATING INJURY

SECURE OBJECT DO NOT REMOVE

TRAUMA ARREST

GENERAL INFORMATION

A. Resuscitation should not be attempted in cardiac arrest patients with hemicorporectomy, decapitation, or total body burns, nor in patients with obvious, severe blunt trauma who are without vital signs, pupillary response, or an organized or shockable cardiac rhythm at the scene. Patients in cardiac arrest with deep penetrating cranial injuries and patients with penetrating cranial or truncal wounds associated with asystole and a transport time of more than 15 minutes to a definitive care facility are unlikely to benefit from resuscitative efforts.

Trauma victims who are initially found by EMTs in cardiac arrest or found at the scene without vital signs may be considered dead and follow the DOA policy.

B. Extensive, time-consuming care of trauma victims in the field is usually not warranted. Unless the patient is trapped, they should be enroute to a Medical Facility within 10 minute after arrival of the ambulance on the scene

EMT-B

A. Ventilate with 100% oxygen by two-person bag valve mask or oxygen powered, manually triggered ventilation device and oral or nasal airway

Ventilation should be delivered over two seconds and cricoid pressure should be considered to help reduce gastric distention

Always consider C-spine injury

B. Basic CPR with consideration of C-spine

C. Immobilize C-spine, apply PASG's and TRANSPORT IMMEDIATELY

EMT-I

A. Assist EMT, obtain patient condition and circumstance

B. Start two IVs, saline, after PASGs have been utilized and during transport to the hospital

C. Check pulse, intubate patient, contact Medical Control and advise of patient condition, while continuing CPR

PARAMEDIC

A. Assume charge and confer with EMT as to patient condition and circumstances

B. Intubate patient:

1. Patients should be intubated orotracheally without movement of the C-spine

2. If orotracheal intubation is not possible, or an obstruction is present, then a cricothyrotomy may be necessary per local protocol

C. Assess cause of patient's condition and treat according to appropriate guidelines

TRAUMA ARREST

EMT-B EMT-I PARAMEDIC

VENTILATE PT. PROVIDE INITIATE CPR

WITH C-SPINE SUCTION / 100 % O2

CONTROL ORAL or NASAL AIRWAY

CONTROL APPLY PASG CONTACT MEDICAL

BLEEDING CONTROL

OROTRACHEAL INTUBATION

MONITOR ET CO2

CONSIDER

SURGICAL CRICOTHYROTOMY

FOR

APNEA OR OBSTRUCTION

RAPID

TRANSPORT

APPLY MONITOR SALINE IV x 2 - ENROUTE TO HOSPITAL

CHECK RHYTHM DO NOT DELAY TRANSPORT

TREAT

ARRHYTHMIAS

1. Consider transport of the victim to the nearest facility that has Sexual Assault Nurse Examiner (SANE) capabilities. Transport to nearest facility if significant injuries or patient instability is present.
2. Care of the victim

1. Give emotional support-remember the victim may not want to be touched.
2. Evaluate patient’s general appearance and relevant history of condition.
3. Check for associated injuries including cuts, abrasions, bruises, and fractures.
4. Be alert for signs of internal hemorrhage:

1. If severe hemorrhage is noted, remove any clothing (place in paper bag or wrap in clean sheet and transport with patient to hospital) and apply direct pressure with 4x4’s.
2. Establish large bore IV access and follow trauma protocols.

1. Preserving evidence

1. Evidence may include blood stains, semen, bite marks, finger imprints, fibers, plant material, etc.
2. Crime scene management

i. Segregate materials used to treat victim.

ii. Bag used dressings and label as evidence.

iii. Do not use phones or bathrooms.

iv. Do not turn off lights, TV’s or radios.

v. If furniture must be moved, note location or photograph prior to moving.

3. To preserve potential evidence

1. Do not allow the patient to drink, brush teeth, or rinse mouth.
2. Do not allow the victim to change clothes.
3. Do not allow the victim to wash face, hands or genital area.
4. Prevent the victim from urinating or defecating if possible.

1. Place the victim on a clean sheet on the cot
2. Any clothing with victim or removed from victim should be placed in individual paper bags. If paper bags not available, place folded (not wadded) in clean sheet or pillowcase. Mark the bag with victim’s name, date, time and your name (proper chain of evidence procedure).
3. When care is transferred to ED staff, fold the cot sheet on itself to contain any fibers, particles, or other evidence that may have fallen from the victim. Give sheet to the ED staff and document such in the run report.

1. Documentation-BECOMES IMPORTANT EVIDENCE

1. Document specific description of how and where the victim was found.
2. Document statements that are made by the victim as quotes.
3. Document the emotional status of the victim.
4. Document what clothing the victim was wearing when found.

1. Rules for preserving evidence

1. Observe universal precautions.
2. Do not ball up clothing. Fold clothing inward to itself and place items in separate paper bags.
3. If paper bags are not available, clothing items may be wrapped in clean sheets or pillowcases.
4. Do not shake clothing.
5. If clothing must be cut off, avoid cutting through stains or wound defects.
6. Write the contents on the outside of the package with the date, time and your name.