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2009-2010 Protocol Rollout. Protocols 2010 Edition. Philosophy Expectations Format Adult Reference Pages Adult Cardiac Adult General Pediatric Reference. Protocols 2010 Edition. Pediatric Cardiac Pediatric General Appendices. Philosophy. Goals

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2009-2010 Protocol Rollout

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protocols 2010 edition

Protocols 2010 Edition




Adult Reference Pages

Adult Cardiac

Adult General

Pediatric Reference

protocols 2010 edition1
Protocols 2010 Edition
  • Pediatric Cardiac
  • Pediatric General
  • Appendices
  • Goals
    • To establish minimum expectations for appropriate patient care
    • To relieve pain and suffering, improve patient outcomes and do no harm
    • To ensure a structure of accountability for operational medical directors, facilities, agencies and providers
  • Protocols are derived from a variety of sources
  • Final decision rests with the OMD committee
    • “In situations where an approved medical protocol conflicts with other recognized care standards, the medical provider shall adhere to the Tidewater EMS Regional Medical Protocol.”
  • Protocols are designed to be used in conjunction with each other- it is acceptable to use more than one protocol at a time.
  • Providers will maintain a working knowledge of the protocols
  • Each patient should have a thorough assessment performed
  • BLS providers should request ALS assistance if any deficiencies are found on the initial assessment
  • ALS providers may request additional ALS assistance for critical patients
  • Make early contact with receiving facilities
    • If providers are truly unable to make contact, they are permitted to perform LIFE SAVING PROCEDURES as standing orders
  • Flowcharts were getting too wordy and too hard to see in pocket guides
  • Split each protocol into two
    • Flowchart
    • Information page
  • Added a Warnings and Alerts section
    • The important stuff that will get you into trouble
reference pages
Reference Pages
  • Burn Chart
  • Dopamine drip chart
  • Magnesium sulfate drip chart
  • Epinephrine drip chart
  • Glascow Coma Scale
  • Adult Trauma Transport Criteria
  • Wong-Baker FACES pain rating scale
airway oxygenation ventilation
Airway / Oxygenation/ Ventilation
  • Enhanced providers may still use laryngoscope and Magill forceps to relieve airway obstruction
  • Indications for plural decompression (serious signs/symptoms of tension pneumothorax)
    • Respiratory distress with cyanosis
    • Loss of radial pulse (hypotension)
    • Decreased level of conciousness
airway oxygenation ventilation1
Airway / Oxygenation/ Ventilation
  • In the 2010 edition of the protocols, EMT-Intermediate will have standing orders for:
    • Plueral decompression
    • Nasal intubation
    • Post-intubation sedation
adult cardiac protocols
Adult Cardiac Protocols
  • No major Changes
  • Consistent with ACLS
  • Information added about cardiac arrest in dialysis patients
    • More detailed information in Dialysis/Renal Failure protocol
adult cardiac protocols1
Adult Cardiac Protocols
  • Adult Emergency Cardiac Care
  • Adult Asytole and Pulseless Electrical Activity
  • Adult Bradycardia
  • Adult Tachycardia – Narrow Complex
  • Adult Tachycardia – Wide Complex
adult cardiac protocols2
Adult Cardiac Protocols
  • Adult Ventricular Fibrillation and Pulseless Ventricular Tachycardia
  • ROSC (Return of Spontaneous Circulation)
    • Name changed from post resuscitation
    • Moving to the adult cardiac section
  • Termination of Resuscitation
termination of resuscitation
Termination of Resuscitation
  • Reworded to clarify
    • Allows EMS providers to stop resuscitation in cases where CPR started inappropriately
  • Once any ALS procedure is initiated, provider must contact medical control for an order to cease resuscitation efforts
allergic anaphylactic reaction
Allergic/Anaphylactic Reaction
  • In the 2010 edition, EMT-Intermediate may administer Solu-medrol on standing orders if patient is hemodynamically unstable or in respiratory distress
  • Epinephrine will be given IM instead of SQ with maximum dose of 0.5mg
  • Physician may order IV 1:10,000 epinephrine in severe cases
altered mental status
Altered Mental Status
  • Need to assess patient to determine cause of altered mental status
  • No more “coma cocktail”
breathing difficulty
Breathing Difficulty
  • Added Nitroglycerin Paste ONLY when using CPAP
    • Providers will apply one inch of paste to patient’s chest and cover with occlusive dressing
    • WEAR GLOVES when handling paste
    • Paste onset: at least 30 minutes so SL NTG should be given every 3-5 minutes
  • Morphine dose changed to 2 mg
    • Waiting 5 minutes between doses removed
  • Allows EMT-Intermediate and EMT-Paramedic to give up to 10 mg morphine on standing orders
  • Can call medical control for more if needed
cerebral vascular accident
Cerebral Vascular Accident
  • Minor changes to implement the hyper/hypoglycemia protocol if the blood sugar is <60 mg/dL or >500 mg/dL
chemical exposure
Chemical Exposure
  • New name for the poisoning protocol
  • Simplified from 6 pages into 1 page
  • Focuses on chemical exposures that can be treated by EMS providers
  • If it cannot be treated by EMS providers, decontaminate and transport while providing supportive care
chest pain ami
Chest Pain/AMI
  • Nitroglycerin paste added
    • Only if pain persists after 3 SL NTG and morphine
combative patient
Combative Patient
  • Added Ativan
    • Should be given with Haldol
  • In the 2010 edition EMT-Paramedics have standing orders for Haldol and Ativan
  • In the 2010 edition EMT-Intermediates and EMT-Paramedics may administer Benadryl on standing orders for dystonic reactions
dialysis renal failure
Dialysis/Renal Failure
  • New protocol
  • EMT-Intermediates and EMT-Paramedics have standing orders for calcium chloride and sodium bicarbonate for dialysis patients in cardiac arrest
    • Physician order if not in arrest
    • ALWAYS FLUSH thoroughly (40ml) between calcium and sodium to prevent precipitation
dialysis renal failure1
Dialysis/Renal Failure
  • Also includes instructions for bleeding shunt/fistula
    • Firm fingertip pressure (may have to hold for 20+ minutes)
    • Pressure bandages do not work
    • Tourniquet above fistula site if life threatening bleed
drowning near drowning
Drowning/Near Drowning
  • ALL patients involved in a submersion incident should be encouraged to accept transport- they are at high risk for secondary drowning (development of life-threatening pulmonary edema)
  • NG/OG tubes are not appropriate for non-intubated patients
electrical lightning injuries
Electrical/Lightning Injuries
  • Not all lightning strike victims need to be transported to a Trauma Center
extraordinary measures
Extraordinary Measures
  • Not just for trauma anymore!
  • No other major changes
hyper hypoglycemia
  • New protocol
  • Emphasizes patient must be conscious and able to swallow to receive oral glucose
  • Thiamine ONLY if patient is known alcoholic or malnourished
  • 250 ml NS bolus for hyperglycemic patients- may repeat up to 1000 ml total
  • No major changes
nausea vomiting
  • New protocol
  • Zofran replacing Phenergan in the drug box
    • Dose is 4 mg slow IV push
    • EMT-Intermediates and EMT-Paramedics have standing orders
    • Should not be given with Amiodorone or Haldol
ob gyn pregnancy vaginal bleeding
OB/GYN Pregnancy/Vaginal Bleeding
  • Renamed since not all vaginal bleeding is related to pregnancy
  • Added transport guidelines for high-risk maternity patients
    • Not new- has been a part of appendix H for multiple years
    • May not apply to the rural agencies
ob gyn pregnancy pre eclampsia
OB/GYN Pregnancy/(Pre-) Eclampsia
  • Eclampsia may occur post delivery
  • The order in which medications are given has changed
    • Ativan given first to stop current seizure
    • Magnesium Sulfate given to prevent further seizures
pain management non cardiac
Pain Management / Non-Cardiac
  • Morphine dose changed to 2 mg
    • Removed the 5 minute wait time between doses
  • May implement Nausea/Vomiting protocol as needed
  • This is an agency specific protocol
  • Clarification of mixing sports drinks
    • Single serve taken at normal strength
    • Powdered dry mixes are mixed at half-strength, due to ice displacing the water
  • Changes made in an effort to be consistent with current NFPA guidelines
  • Hyperthermia protocol may be needed
  • Ativan is the first drug of choice for seizures
    • Dose is 2 MG IV/IM
  • Works best when given IV
  • Do not give Ativan rectally- use Valium instead
    • Not harmful just ineffective when given
  • IO is the ABSOLUTE last resort to give medications for seizures
shock non traumatic
  • New Protocol
  • Pressors for vasogenic or cardiogenic shock- Physician Order Only
    • Dopamine contraindicated for hypovolemic patients
  • Tourniquets are coming back
    • Not the same as IV tourniquets
    • Commercially available tourniquets (examples on next slide)
spinal immobilization
Spinal Immobilization
  • No longer in “Trauma” section
  • Medical patients may need spinal immobilization as well
  • Protocol as listed needed clarification in some areas
    • Age extreme patients
    • Unknown
      • If unable to explain how patient ended up on the floor, then IMMOBILIZE!
spinal immobilization reliable patient
Spinal Immobilization(Reliable Patient)
  • Calm
  • Cooperative
  • Not impaired by drugs, medications, alcohol or existing medical conditions
  • Awake, alert and oriented to person, place, time and event
  • Without any distracting injuries
spinal immobilization criteria
Spinal Immobilization Criteria
  • Signs and Symptoms of possible Spinal Cord Injury
    • Extreme pain or pressure in head, neck or back
    • Tingling or loss of sensation in hand, fingers, feet or toes
    • Partial or complete loss of control over any part of the body
    • Urinary or bowel urgency, incontinence or retention
    • Difficulty with balance and walking
spinal immobilization criteria1
Spinal Immobilization Criteria
  • Signs and Symptoms of possible Spinal Cord Injury continued
    • Abnormal band like sensations in the thorax- pain, pressure
    • Impaired breathing after injury
    • Unusual lumps on the head or spine
spinal immobilization criteria2
Spinal Immobilization Criteria
  • The EMS provider may conclude that a spinal cord injury is unlikely if they do not exhibit any S and S listed and meet the following criteria
    • Unaltered mental status
    • No neurological deficits
    • No intoxication from alcohol, drugs or medications
    • No other painful distracting injuries
spinal immobilization criteria3
Spinal Immobilization Criteria
  • Distracting injuries
  • Reliable patient
  • Special needs patients
  • Age extremes
    • Pediatrics
    • Geriatrics
      • Kyphosis
toxicological emergencies
Toxicological Emergencies
  • New name for overdose
  • Focuses on toxicological emergencies that EMS can treat
  • Does not cover every possible drug/medication
  • Narcan is used to treat respiratory depression
    • Not given just because pt is unconscious
trauma crush syndrome
Trauma: Crush Syndrome
  • No major changes
  • Remember this protocol exists and review it
  • Simplified
  • Removed morphine
  • May implement Pain Management: Non-Cardiac protocol as needed
  • Includes trauma transport criteria
vascular access
Vascular Access
  • Now includes adult IOs
  • Includes lidocaine dose/information for IOs
    • Standing order 20-40 mg for adults
    • Standing order for 0.5 mg/kg for pediatric
  • 14 gauge needle is for needle decompression only
  • Technician discretion for IV or Saline lock
    • IV is required for administration of D50
pediatric reference
Pediatric Reference

Charts for normal vital signs by age

Charts for average weight, ETT size


Burn Chart

Wong Baker FACES pain rating scale

Pediatric Trauma Transport Criteria

pediatric trauma transport criteria
Pediatric Trauma Transport Criteria

No major changes

Remember CHKD is not a trauma center

When in doubt, contact either CHKD or SNGH for transport decision

asystole pea

No atropine

“A BLS airway is an adequate airway. A brief attempt at an advanced airway by an experienced provider is appropriate.”


Compressions if HR <60 with poor perfusion despite oxygenation and ventilation

Epinephrine is the drug of choice for pediatric bradycardia


No guidelines in PALS or PEPP

OMDs agree rate of 100 is reasonable

pediatric tachycardia narrow complex
Pediatric Tachycardia- Narrow Complex

Assessment is key

Distinguish ST vs SVT

Stable SVT

Adenosine by physician order only

Try vagal maneuvers first

Ice to face

Blow on thumb

Arm on abdomen

No ocular pressure or carotid massage

pediatric tachycardia narrow complex1
Pediatric Tachycardia- Narrow Complex

Unstable SVT

Cardiovert ASAP

Vagal Maneuvers are appropriate prior to the administration of adenosine

Adenosine is a physician order

v fib pulseless v tach
V-Fib/Pulseless V-Tach


Pediatric AEDs preferred for children 1-8

No recommendation for/against using AEDs on infants

Pads should not touch- use pediatric pads or front-back placement

Pediatric pads may or may not attenuate- check with manufacturer

pediatric airway oxygenation ventilation
Pediatric Airway/Oxygenation/Ventilation

New protocol

Includes parts of pediatric airway obstruction

No nasal intubations

Enhanced are still allowed to use laryngoscope and Magill forceps for obstruction

BLS airway

pediatric allergic anaphylactic reaction
Pediatric Allergic/Anaphylactic Reaction

New Protocol

Similar to the adult protocol

Administer epinephrine IM (preferred method), not SQ

Physician may order epinephrine IV in severe anaphylaxis

IV epinephrine should be 1:10,000 not 1:1,000

Solumedrol is not routinely indicated for pediatrics- online medical control may order

pediatric altered mental status
Pediatric Altered Mental Status

Focus is on assessment to determine a likely cause of the altered mental status

CVA (stroke) is possible in children with sickle cell disease

pediatric breathing difficulty
Pediatric Breathing Difficulty

New name for Pediatric Respiratory Distress

Includes treatment for croup, epiglottitis (from the old Pediatric Airway Obstruction protocol)

pediatric breathing difficulty1
Pediatric Breathing Difficulty


If patient has stridor, drooling and forward posture, let him/her maintain position of comfort and maintain own airway


Nebulized epinephrine

Not a new treatment but providers forget it is there

pediatric burns
Pediatric Burns

New Protocol

Mirrors the Adult Burns Protocol

Key Point: CHKD can handle burn patients as long as there is no airway involvement

If you need guidance for destination contact SNGH or CHKD

care of the newly born
Care of the Newly Born

Umbilical vein cannulation should not be routinely used

Check blood sugar if premature, distressed or mom is a diabetic

Do not give Narcan to newborns, even if mom is a narcotics user

Can precipitate withdrawal seizures

Respiratory depression is easier to handle than the seizures

care of the newly born1
Care of the Newly Born

Keep them warm

Mottling, acrocyanosis (blue hands/feet) are both signs of hypothermia in newborns

pediatric hyper hypoglycemia
Pediatric Hyper/Hypoglycemia

New protocol

Includes instructions on how to mix D10 and D25

Hypoglycemia is life-threatening in children and must be corrected ASAP

Dextrose can be administered rectally with a physician order

pediatric hyper hypoglycemia1
Pediatric Hyper/Hypoglycemia


Bolus only if assessment reveals signs of dehydration

Dry mucous membranes


pediatric nausea vomiting
Pediatric Nausea/Vomiting

New protocol


Pediatric dose: 0.15 mg/kg IV

May be repeated once after 20 minutes (standing order)

Maximum dose is 8 mg

Higher than the adult dose because children have a faster metabolism

pediatric pain management
Pediatric Pain Management

Should be considered for patients with:


Sickle cell crisis



Can be used for other painful conditions with a physician order

Not usually appropriate for abdominal pain

pediatric pain management1
Pediatric Pain Management

Use Wong-Baker FACES pain rating scale with younger children


Dose 0.1 mg/kg

Standing order only for isolated extremity injuries

Implement Pediatric Nausea/Vomiting protocol as needed

pediatric seizures
Pediatric Seizures

Rectal Valium (diazepam)

O.4 mg/kg (rectal dose)

Ativan (lorazepam)

Pediatric dose: 0.1 mg/kg maximum 2 mg

SLOW IV administration- risk of apnea if pushed too quickly

DO NOT administer rectally- not harmful but is ineffective

pediatric seizures1
Pediatric Seizures

Patients must be on cardiac, SpO2 monitors when benzodiazepines are administered

Order of treatment

Rectal Valium first for younger children and/or difficult IV

Ativan IV for older children and/or easier IV

Ativan also may be given IM

Do not start an IO just to give an anti-epileptic

  • The Appendix section contains the following:
    • A. Related Policies and Procedures
    • B. Regional Drug and IV Box Policy
    • C. Special Resources
    • D. Patient Restraint
    • E. DDNR
    • F. Policy for Ambulance Restocking
    • G. Tidewater Regional Ambulance Diversion Policy
  • F. Policy for Ambulance Restocking
  • G. Tidewater Regional Ambulance Diversion Policy
  • H. Ambulance Patient Destination Policy
  • I. Tidewater Regional Trauma Plan
  • J. Specialty Protocols
  • K. Medications
  • CBRNE- Biological
  • CBRNE- Blistering Agents
  • CBRNE- Cyanide
  • CBRNE- Choking Agent
  • CBRNE- Nerve Agents
    • Adult
    • Pediatric
CBRNE- Nuclear
  • CBRNE- Riot Control Agents
new medications
New Medications
  • Ativan (Lorazepam)
    • A potent benzodiazepine anticonvulsant for seizures and seizures proximal to chemical exposure
    • Seizures, Chemical Exposure, Combative Patient
new medications1
New Medications
  • Nitroglycerin TD paste
    • A potent vasodilator for decreased oxygen demand in chest pain, and fluid shifting in CHF
    • Chest Pain, AMI, ACS, Breathing Difficulty (CHF)
new medications2
New Medications
  • Zofran (Ondansetron)
    • A seratonin antagonist antiemetic for nausea and vomiting
    • Nausea/Vomiting