EL DORADO COUNTY EMS AGENCY PREHOSPITAL PROTOCOLS Effective: July 1, 2017 EMS Agency Medical Director Reviewed: November 9, 2016 Revised: November 9, 2016 ALLERGIC REACTION/ANAPHYLAXIS ADULT BLS TREATMENT ABCs / ROUTINE MEDICAL CARE - Be prepared to support ventilation with appropriate airway adjuncts and circulation with external chest compressions. Administer oxygen at the appropriate flow rate, preferably high flow via non re-breather mask if patient has dyspnea. BLS Personnel: Allow patient to administer their own allergy medications as prescribed by their physician, see Field Policy: BLS Medication Administration. Place patient in position of comfort. If shock signs or symptoms begin, place patient in a supine position with legs elevated. NOTE: If allergen is a stinger, scrape it out of the patient’s skin (use a credit card or the dull side of a knife) to prevent the introduction of more venom; a cold pack may also be applied to the sting site to reduce swelling. PROTOCOL PROCEDURE: Flow of protocol presumes that condition is continuing, If the patient is distress, immediate rapid transport is preferred with treatment performed en route. OPTIONAL SKILLS EMT TREATMENT BENADRYL – 50 mg PO. Administer only if patient is alert and able to swallow. FOR PATIENTS WITH PROGRESSIVELY WORSENING SYMPTOMS: EPI-PEN AUTOINJECTOR - 0.3 mg IM. (0.3 mL 1;1,000) Repeat dose may be given in 10 minutes if ALS response is delayed and patient is not responding to treatment). ALS TREATMENT NORMAL SALINE – establish an IV/IO. give 1000 mL bolus(es) for hypotension. MR as needed. Start a second line if hypotension is present or if patient is severe. BENADRYL – 50 mg IV, IO, IM or PO. EPINEPHRINE 1:1,000 - 0.3 mg IM. Mid-anterolateral thigh is preferred. MR q 10 minutes. NEBULIZED BREATHING TREATMENT(S) (MAY BE GIVEN PRIOR TO IM EPI FOR BRONCHOSPASM): FOR WHEEZING: DUONEB (2.5 mg Albuterol and 0.5 Mg Atrovent in normal saline). Do not repeat Duoneb. If symptoms persist, give single dose of ALBUTEROL 2.5 mg in 3 mL normal saline. FOR STRIDOR: NEBULIZED EPINEPHRINE 1:1,000 – 5 mL (5 mg) via nebulizer given over 10 minutes. MR q 10 minutes. FOR SEVERE HYPOTENSION/AIRWAY COMPROMISE (IMPENDING ARREST): NORMAL SALINE – 2 IVs/IO wide open if hypotension present. INSERT ADVANCED AIWAY - If airway edema is present, intubate as soon as possible. CONTACT BASE STATION EPINEPHRINE 1:10,000 – 0.1 mg (diluted with NS or SW to 10 mL) slow IV push over 5 minutes. MR as needed. (Dose is equivalent to 1:100,000 after dilution). GLUCAGON – If no response to epinephrine, administer 2-4 mg IV/IO push or IM, q 5 minutes.
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EL DORADO COUNTY EMS AGENCY
PREHOSPITAL PROTOCOLS
Effective: July 1, 2017 EMS Agency Medical Director
Reviewed: November 9, 2016
Revised: November 9, 2016
ALLERGIC REACTION/ANAPHYLAXIS
ADULT
BLS TREATMENT
ABCs / ROUTINE MEDICAL CARE - Be prepared to support ventilation with appropriate
airway adjuncts and circulation with external chest compressions.
Administer oxygen at the appropriate flow rate, preferably high flow via non re-breather
mask if patient has dyspnea.
BLS Personnel: Allow patient to administer their own allergy medications as prescribed by their
physician, see Field Policy: BLS Medication Administration.
Place patient in position of comfort. If shock signs or symptoms begin, place patient in a supine
position with legs elevated.
NOTE: If allergen is a stinger, scrape it out of the patient’s skin (use a credit card or the dull side of
a knife) to prevent the introduction of more venom; a cold pack may also be applied to the sting
site to reduce swelling.
PROTOCOL PROCEDURE: Flow of protocol presumes that condition is continuing, If the patient is
distress, immediate rapid transport is preferred with treatment performed en route.
OPTIONAL SKILLS EMT TREATMENT
BENADRYL – 50 mg PO. Administer only if patient is alert and able to swallow.
FOR PATIENTS WITH PROGRESSIVELY WORSENING SYMPTOMS:
EPI-PEN AUTOINJECTOR - 0.3 mg IM. (0.3 mL 1;1,000) Repeat dose may be given in 10 minutes if ALS
response is delayed and patient is not responding to treatment).
ALS TREATMENT
NORMAL SALINE – establish an IV/IO. give 1000 mL bolus(es) for hypotension. MR as needed. Start a
second line if hypotension is present or if patient is severe.
BENADRYL – 50 mg IV, IO, IM or PO.
EPINEPHRINE 1:1,000 - 0.3 mg IM. Mid-anterolateral thigh is preferred. MR q 10 minutes.
NEBULIZED BREATHING TREATMENT(S) (MAY BE GIVEN PRIOR TO IM EPI FOR BRONCHOSPASM):
FOR WHEEZING: DUONEB (2.5 mg Albuterol and 0.5 Mg Atrovent in normal saline). Do not repeat
Duoneb. If symptoms persist, give single dose of ALBUTEROL 2.5 mg in 3 mL normal saline.
FOR STRIDOR: NEBULIZED EPINEPHRINE 1:1,000 – 5 mL (5 mg) via nebulizer given over 10 minutes.
MR q 10 minutes.
FOR SEVERE HYPOTENSION/AIRWAY COMPROMISE (IMPENDING ARREST):
NORMAL SALINE – 2 IVs/IO wide open if hypotension present.
INSERT ADVANCED AIWAY - If airway edema is present, intubate as soon as possible.
CONTACT BASE STATION
EPINEPHRINE 1:10,000 – 0.1 mg (diluted with NS or SW to 10 mL) slow IV push over 5 minutes. MR as
needed. (Dose is equivalent to 1:100,000 after dilution).
GLUCAGON – If no response to epinephrine, administer 2-4 mg IV/IO push or IM, q 5 minutes.
ALLERGIC REACTION/ANAPHYLAXIS CONTINUED
Reference: Routine Medical Care, BLS Medication Administration, Optional Skills
EMT, Benadryl, EpiPen & EpiPen Jr. Auto Injector, Epinephrine, Albuterol, Atrovent,
Glucagon, Pulseless Arrest
FOR ANAPHYLAXIS CAUSED CARDIAC ARREST: REFER TO ADULT PULSELESS ARREST PROTOCOL
CARDIAC MONITOR – Treat arrhythmias as needed.
NORMAL SALINE – 2 IVs/IO wide open with pressure bags. Aggressive volume expansion with a goal
of up to 4 liters.
For Dystonic (Extrapyramidal) reactions: Give BENADRYL 25 mg IV push or IM. (MR to Max. of 50 mg.)
ALLERGIC REACTION/ANAPHYLAXIS CONTINUED
Reference: Routine Medical Care, BLS Medication Administration, Optional Skills
EMT, Benadryl, EpiPen & EpiPen Jr. Auto Injector, Epinephrine, Albuterol, Atrovent,
Glucagon, Pulseless Arrest
PEDIATRIC
BLS TREATMENT
ABCs / ROUTINE MEDICAL CARE - Be prepared to support ventilation with appropriate
airway adjuncts and circulation with external chest compressions.
Administer oxygen at the appropriate flow rate, preferably high flow via non re-breather
mask if patient has dyspnea.
BLS Personnel: Allow patient to administer their own allergy medications as prescribed by their
physician, see Field Policy: BLS Medication Administration.
Place patient in position of comfort. If shock signs or symptoms begin, place patient in a supine
position with legs elevated.
NOTE: If allergen is a stinger, scrape it out of the patient’s skin (use a credit card or the dull side of
a knife) to prevent the introduction of more venom; a cold pack may also be applied to the sting
site to reduce swelling.
PROTOCOL PROCEDURE: Flow of protocol presumes that condition is continuing, If the patient is
distress, immediate rapid transport is preferred with treatment performed en route.
OPTIONAL SKILLS EMT TREATMENT
BENADRYL – 1 mg/kg (25 mg max) PO. Administer only if patient is alert and able to swallow.
FOR PATIENTS WITH PROGRESSIVELY WORSENING SYMPTOMS:
EPI-PEN JR AUTOINJECTOR (Only for pediatric patients weighing 15-30 kg (33-66 lbs): 0.15 mg IM.
(0.3 mL 1:2,000) Repeat dose may be given in 10 minutes if ALS response is delayed and patient is
not responding to treatment.
ALS TREATMENT
NORMAL SALINE – establish an IV/IO and give 20 mL/kg bolus(es) for hypotension, repeated as needed.
BENADRYL – 1 mg/kg (25 mg max) IV, IO, IM or PO.
EPINEPHRINE 1:1,000 - 0.01 mg/kg (Max. 0.3 mg) IM. MR q 10 minutes. Mid-anterolateral thigh is
preferred.
NEBULIZED BREATHING TREATMENT(S) (MAY BE GIVEN PRIOR TO EPI FOR BRONCHOSPASM):
FOR WHEEZING: DUONEB (2.5 Mg Albuterol and 0.5 Mg Atrovent in normal saline). Do not repeat
Duoneb. If symptoms persist, give single dose of ALBUTEROL 2.5 mg in 3 mL normal saline.
FOR STRIDOR: NEBULIZED EPINEPHRINE 1:1,000 – 0.5 mL/kg (Up to Max. single dose of 5 mL (5 mg)) via
nebulizer over 10 minutes. Dilute with NS to 5mL for patients 10 kgs or <. MR q 10 minutes until stridor
subsides * continuous monitoring.
FOR HYPOTENSION/AIRWAY COMPROMISE (IMPENDING ARREST):
NORMAL SALINE – 20 mL/kg boluses, repeated as needed.
INSERT ADVANCED AIWAY - If airway edema is present, intubate as soon as possible.
Consider starting CPR if unresponsive and no palpable BP.
CONTACT BASE STATION
ALLERGIC REACTION/ANAPHYLAXIS CONTINUED
Reference: Routine Medical Care, BLS Medication Administration, Optional Skills
EMT, Benadryl, EpiPen & EpiPen Jr. Auto Injector, Epinephrine, Albuterol, Atrovent,
Glucagon, Pulseless Arrest
EPINEPHRINE 1:10,000 – 0.01 mg/kg (diluted with NS or SW to 10 mL) slow IV push over 5 minutes. MR
as needed. (Dose is equivalent to 1:100,000 after dilution).
GLUCAGON – If no response to epinephrine, administer 0.1mg/kg IV/IO push or IM, q 5 minutes.
FOR ANAPHYLAXIS CAUSED CARDIAC ARREST: REFER TO PEDIATRIC PULSELESS ARREST PROTOCOL
CARDIAC MONITOR – Treat arrhythmias as needed.
For Dystonic (Extrapyramidal) reactions: Give BENADRYL 1 mg/kg IV push or IM. (Max. of 25 mg.)
ALLERGIC REACTION/ANAPHYLAXIS CONTINUED
Reference: Routine Medical Care, BLS Medication Administration, Optional Skills
EMT, Benadryl, EpiPen & EpiPen Jr. Auto Injector, Epinephrine, Albuterol, Atrovent,
Glucagon, Pulseless Arrest
EL DORADO COUNTY EMS AGENCY
PREHOSPITAL PROTOCOLS
Effective: July 1, 2017 EMS Agency Medical Director
Reviewed: February 8, 2017
Revised: February 8, 2017
ALTERED LEVEL OF CONSCIOUSNESS
ADULT
BLS TREATMENT
ABCs / ROUTINE MEDICAL CARE - administer oxygen at appropriate flow rate. Be
prepared to support ventilation with appropriate airway adjuncts.
If hypoglycemia is suspected in a conscious, known diabetic who is able to follow
simple commands, give the patient 15 grams of prepared oral dextrose solution (may
repeat in 10 minutes) or encourage drinking/eating a sugar-containing beverage or
food.
PROTOCOL PROCEDURE: Flow of protocol presumes that condition is continuing. Consider
etiology: shock, toxic exposure, insulin shock, seizure, or head trauma. If patient is in
distress, immediate, rapid transport is preferred with treatment performed en route.
ALS TREATMENT NORMAL SALINE – establish IV/IO.
BLOOD SAMPLE/GLUCOSE LEVEL ASSESSMENT - obtain blood sample via finger stick or
venipuncture. Rule out diabetic emergency. Consider confirming test results with second
glucose check with blood from a different site (and different meter, if available) if reading is
abnormal or the patient’s presentation doesn’t match the test results.
For symptomatic HYPOGLYCEMIA (b.s. < 60 mg/dL):
DEXTROSE - Administer 100cc of a 250cc bag of Dextrose 10% (10g), May repeat to a max of
50g. After each 10g (100cc) bolus check BG, LOC and patency of line. .
GLUCAGON - if no IV access, give 1 mg IM/IN.
Recheck blood glucose 5 minutes after administration of dextrose or glucagon.
For RESPIRATORY DEPRESSION:
NARCAN*:
IV: 0.5 mg in 1 minute increments slow IV push, titrated to effect (Max. 2 mg).
IN: 0.5 mg. May repeat in 5 minutes if no response (Max. 1 mL per nostril).
IM: 1 mg if unable to establish IV. May repeat in 5 minutes if no response.
ET: 1 mg diluted to 5-10 mL. May repeat in 5 minutes if no response.
*The goal of Narcan administration is to improve respiratory drive, NOT to return patient to
their full mental capacity.
*If no response to normal doses or if patient is in extremis, administer 2 mg IV/IM/IO/ET/IN
ALTERED LEVEL OF CONSCIOUSNESS CONTINUED
References: Formulary Dextrose, Narcan, Glucagon
Routine Medical Care
q 5 minutes.
CONTACT BASE STATION
ALTERED LEVEL OF CONSCIOUSNESS CONTINUED
References: Formulary Dextrose, Narcan, Glucagon
Routine Medical Care
PEDIATRIC
BLS TREATMENT
ABCs / ROUTINE MEDICAL CARE - administer oxygen at appropriate flow rate. Be prepared to
support ventilation with appropriate airway adjuncts.
If hypoglycemia is suspected in a conscious, known diabetic who is able to follow simple
commands, give the patient 15 grams of a prepared oral dextrose solution (may repeat
in 10 minutes) or encourage drinking/eating a sugar-containing beverage or food.
PROTOCOL PROCEDURE: Flow of protocol presumes that condition is continuing. Consider
etiology: shock, toxic exposure, insulin shock, seizure, or head trauma. If patient is in
distress, immediate, rapid transport is preferred with treatment performed en route.
ALS TREATMENT
NORMAL SALINE – establish IV/IO.
BLOOD SAMPLE/GLUCOSE LEVEL ASSESSMENT - obtain blood sample via finger stick or
venipuncture. Rule out diabetic emergency. Consider confirming test results with second
glucose check with blood from a different site (and different meter, if available) if reading is
abnormal or the patient’s presentation doesn’t match the test results.
Hypoglycemia in pediatrics is defined as:
Neonate < 1 month: (b.s. < 50 mg/dL)
Infant/child >1 month: (b.s. < 60 mg/dL)
For HYPOGLYCEMIA:
DEXTROSE:
Less than 1m/o: D10W
2 mL/kg IV/IO may repeat every 5 min until b.s. is at a normal limit.
Greater than 1m/o: D10W
5 mL/kg IV/IO may repeat every 5 min until b.s. is at a normal limit.
GLUCAGON - if no IV access, give 0.1 mg/kg IM/IN (Max. 1 mg).
Recheck blood glucose 5 minutes after administration of dextrose or glucagon.
For RESPIRATORY DEPRESSION:
NARCAN - 0.1 mg/kg IV/IN/IO/IM titrated to effect (Max. 2 mg). May repeat initial dose, if
no response, within 5 minutes. (Maximum IN dose of 1 mL per nostril; If no response to
normal doses contact base station). Avoid use in neonates
CONTACT BASE STATION
EL DORADO COUNTY EMS AGENCY
PREHOSPITAL PROTOCOLS Effective: January 2012
Reviewed: July 2013 EMS Agency Medical Director Revised: July 1, 2016
Scope: ALS – Adult/Pediatric
BRADYCARDIA
Consider 2nd IV or IO if difficult access.
Consider 250 mL Fluid Bolus
Give Atropine IV/IO: 0.5 mg q 3-5 min (Max 3 mg)
Adolescents: 1mg IV/IO (Max. Single dose)
Max total dose 2mg IV/IO
If Atropine is ineffective or if delay in IV/IO
Begin TCP at 80 bpm
Do not delay if high degree block is present
Consider pain Management
Fentanyl 50mcg slow IV/IO over 2 min
Withhold if Systolic BP < 100 mm Hg
ADULT ALGORITHM
ABCs / ROUTINE MEDICAL CARE - Be prepared to support ventilation with appropriate
airway adjuncts and circulation with external chest compressions.
Administer oxygen if indicated at the appropriate flow rate.
Place patient in position of comfort.
Obtain and transmit 12 lead EKG (Do not delay therapy).
PROTOCOL PROCEDURE: Flow of protocol presumes that bradycardia is continuing. If
response or condition changes, see appropriate protocol. If at any time a stable
patient becomes unstable, go to the unstable section of this protocol. If patient is in
severe distress, immediate, rapid transport is preferred with treatment performed
enroute.
STABLE HR < 50; SBP > 100; GCS >14;
NO SEVERE CHEST PAIN/DYSPNEA
Cardiac Monitor
Establish IV
Moved to unstable section if
condition deteriorates
UNSTABLE HR < 50; SBP <100; GCS <14;
SEVERE CHEST PAIN/DYSPNEA
References: Prehospital Formulary, Transcutaneous Pacing Procedure,12 Lead EKG Procedure
CONTACT BASE
Dopamine infusion may be ordered for hypotension.
2-10 µg/kg/min IV/IO.
Titrate to patient response. Taper slowly
BRADYCARDIA CONTINUED
ABCs / ROUTINE MEDICAL CARE - Be prepared to support ventilation with
appropriate airway adjuncts and circulation with external chest compressions.
Begin ventilation with BVM if HR < 60; if no improvement in 1 minute begin CPR.
Administer oxygen if indicated at the appropriate flow rate.
Place patient in position of comfort.
Obtain and transmit 12 lead EKG (Do not delay therapy).
PROTOCOL PROCEDURE: Flow of protocol presumes that bradycardia is continuing. If
response or condition changes, see appropriate protocol. If at any time a stable
patient becomes unstable, go to the unstable section of this protocol. If patient is in
severe distress, immediate, rapid transport is preferred with treatment performed
enroute.
STABLE NO HYPOTENSION, NO DELAYED CRT,
NO SEVERE CHEST PAIN/DYSPNEA
Cardiac Monitor
Establish IV
Moved to unstable section if condition
deteriorates
UNSTABLE ALOC, HYPOTENSION, DELAYED CRT,
SEVERE CHEST PAIN/DYSPNEA
References: Prehospital Formulary, Transcutaneous Pacing Procedure,12 Lead EKG Procedure
PEDIATRIC ALGORITHM
If HR < 60 Perform CPR
Consider 2nd IV or IO if difficult access.
Give Epinephrine 0.01 mg/kg IV/IO
1:10,000 = 0.1 mL/kg
Repeat every 3 – 5 min.
If increased vagal tone or primary AV block:
Give Atropine 0.02 mg/kg IV/IO May repeat dose once in 5 min.
Minimum dose 0.1mg. Max. total dose of 1 mg.
Consider TCP at 80 bpm
Do Not delay if high degree block is present Consider pain management if BP adequate
Fentanyl 50mcg slow IV/IO over 2 min
Treat underlying causes
Contact Base
EL DORADO COUNTY EMS AGENCY
PREHOSPITAL PROTOCOL
Effective: July 1, 2017 EMS Agency Medical Director
Reviewed: February 8, 2017
BRIEF RESOLVED UNEXPLAINED EVENT General Info:
A Brief Resolved Unexplained Event was formerly known as “An Apparent Life Threatening Event”.
An ALTE is an episode that is frightening to the observer (may think infant has died) and
involves some combination of:
1. Apnea
2. Color change
3. Marked change in muscle tone. (Limpness, loss of tone)
4. Choking or gagging
Usually occurs in infants <12 months old. However, any child < 2 years old who exhibits
symptoms of apnea may be considered an ALTE
50% have a possible identifiable etiology (e.g., abuse, SIDS, swallowing dysfunction, infection,
ABCs / ROUTINE MEDICAL CARE –be prepared to support ventilation with appropriate airway
adjuncts.
FULL SPINAL PRECAUTIONS, if indicated.
Administer high flow oxygen via non re-breather mask.
Splint the effected limb(s) at heart level.
Maintain body temperature.
PROTOCOL PROCEDURE: Flow of protocol presumes patient has had a full extremity (or more)
crushed, pinned, or otherwise immobile with severely impaired circulation for at least two (2) hours.
It is advisable in these situations for BLS personnel to wait for ALS personnel before attempting
extrication. Early notification to the hospital is essential for proper triage and a notification of
surgical personnel.
ALS TREATMENT
PRE-EXTRICATION:
CONSIDER AIR AMBULANCE RESPONSE TO SCENE
EKG- Apply and continuously monitor patient’s cardiac rhythm.
NORMAL SALINE - Establish 2 large bore IVs via blood administration or macro drip tubing. Use IO if
unable to establish IV. Give 20 mL/kg IV/IO bolus, prior to release of compression. If patient is in shock
or is compensating for impending shock, refer to SHOCK protocol.
PAIN MANAGEMENT – As appropriate, refer to Formulary.
IMMEDIATELY BEFORE EXTRICATION (IF POSSIBLE):
ALBUTEROL - 5.0 mg in 6 ml NS via nebulizer. Run continuously before and after extrication.
SODIUM BICARBONATE – 1 mEq/kg up to 100 mEq IVP/IO (Flush line with NS before and after
administration).
POST –EXTRICATION:
RAPID TRANSPORT - As soon as possible.
CALCIUM CHLORIDE – If suspected hyperkalemia (Compression >4 hrs and: absent P waves, Peaked T
waves, and/or prolonged QRS) give 1 gm IV/IO slowly over 5 minutes. Repeat at same dose if
symptoms persist. (Flush line with NS before and after administration).
NOTE: Do not run Sodium Bicarbonate and Calcium Chloride concurrently. Either flush the line well or
use a separate line.
CRUSH SYNDROME CONTINUED
PEDIATRIC
BLS TREATMENT
ABCs / ROUTINE MEDICAL CARE – Be prepared to support ventilation with appropriate airway
adjuncts.
FULL SPINAL PRECAUTIONS, if indicated.
Administer high flow oxygen via non re-breather mask.
Splint the effected limb(s) at heart level.
Maintain body temperature.
PROTOCOL PROCEDURE: Flow of protocol presumes patient has had their lower
extremities/pelvis/torso crushed, pinned, or otherwise immobile with severely impaired circulation
for at least two (2) hours. It is advisable in these situations for BLS personnel to wait for ALS personnel
before attempting extrication. Early notification to the hospital is essential for proper triage and
notification of surgical personnel.
ALS TREATMENT
PRE-EXTRICATION:
CONSIDER AIR AMBULANCE RESPONSE TO SCENE
NORMAL SALINE – Establish IV or IO. Refer to shock protocol if patient is in shock.
PAIN MANAGEMENT – As appropriate, refer to Formulary.
CONTACT BASE STATION- For treatment determination and for early notification of destination and
surgical personnel.
FLUID BOLUSES (May be ordered) – Give initial bolus of 20 mL/kg. If suspected history of volume loss
and no improvement with initial bolus give additional fluid boluses at 20 mL/kg to a Max. of 60 mL/kg.
IMMEDIATELY BEFORE EXTRICATION (IF POSSIBLE):
ALBUTEROL* - 5.0 mg in 6 ml NS via nebulizer. Run continuously before and after extrication.
SODIUM BICARBONATE – 1 mEq/kg up to 100 mEq IVP/IO (Flush line with NS before and after
administration).
POST –EXTRICATION:
RAPID TRANSPORT - As soon as possible.
BASE PHYSICIAN ORDER ONLY– If suspected hyperkalemia (Compression >4 hrs and: absent P waves,
Peaked T waves, and/or prolonged QRS) CALCIUM CHLORIDE 20 mg/kg IV/IO push over 1 minute
may be ordered. Repeat at same dose if symptoms persist. (Flush line with NS before and after
administration).
NOTES:
* Use 2.5 mg of Albuterol in 3 mL of NS/SW if patient is < 2 years old.
Do not run Sodium Bicarbonate and Calcium Chloride Concurrently. Either flush the line well or use a
separate line.
EL DORADO COUNTY EMS AGENCY
PREHOSPITAL PROTOCOLS
Effective: July 1, 2017 EMS Agency Medical Director
Reviewed: February 8, 2017
DROWNING
ADULT/PEDIATRIC
BLS TREATMENT
ABCs / ROUTINE MEDICAL CARE - administer oxygen at appropriate flow rate. Be prepared to
support ventilation with appropriate airway adjuncts.
IF THE PATIENT IS IN CARDIOPULMONARY ARREST, SEE PULSELESS ARREST PROTOCOL.
FULL SPINAL PRECAUTIONS - if there is a suspected diving injury, in the setting of other trauma
or if there are signs of intoxication.
ADULTS ONLY: CPAP (If trained and equipped) - start with valve at 7.5 cm setting and 100% O2
flow rate. Titrate to patient’s condition. If patient’s respiratory status does not improve, change
valve setting to 10.0 cm. Be prepared to support ventilations with appropriate airway adjuncts.
Monitor and record vital signs every 5 minutes. Be prepared for possible hypotension. If
hypotension develops, decrease valve setting.
PROTOCOL PROCEDURE: Flow of protocol presumes that the patient’s condition is continuing. If
patient is in severe distress, immediate, rapid transport is preferred with treatment performed en
route.
All patients should have wet clothing removed and be covered with warm blankets to prevent
further heat loss.
All patients should be transported for evaluation, no matter how stable they present.
Begin resuscitation in all patients with <90 minute submersion time (deviations to this time frame
will be at the discretion of the base station).
For patients submerged in cold water, refer to “COLD EXPOSURE” protocol.
ALS TREATMENT
NORMAL SALINE - establish IV/IO, set rate as per patient’s condition.
BLOOD SAMPLE/GLUCOSE LEVEL ASSESSMENT - obtain blood sample via venipuncture. Rule out
diabetic emergency.
REFER TO ALTERED LEVEL OF CONSCIOUSNESS OR SEIZURE PROTOCOLS AS APPROPRIATE.
CONTACT BASE STATION
EL DORADO COUNTY EMS AGENCY
PREHOSPITAL PROTOCOLS
Effective: July 1, 2017 EMS Agency Medical Director
Reviewed: December 14, 2016
Revised: December14, 2016 GENERAL TRAUMA
ADULT/PEDIATRIC
BLS TREATMENT
ABCs / ROUTINE MEDICAL CARE – Be prepared to support ventilation with appropriate airway
adjuncts.
CONTROL BLEEDING:
For Uncontrolled Extremity Bleeding:
1) Apply direct pressure/pressure bandage. Use hemostatic agent*, if still not controlled:
2) Apply approved tourniquet device:
Apply 2-3” proximal to wound
Tighten until control of bleeding
Document time and presence/absence of distal pulses
If bystanders or first responders placed non-approved or improperly placed tourniquet, assess
need for tourniquet and re-apply an approved tourniquet if necessary.
For bleeding to head, neck, pelvis, or for penetrating trauma to extremities:
Pack wound with an approved hemostatic gauze until external bleeding is controlled (be
aware that internal hemorrhage may still occur).
SMR*/FULL SPINAL PRECAUTIONS - if indicated.
ADMINISTER OXYGEN - at the appropriate flow rate, preferably high flow via non re-breather
mask for any major trauma.
Attempt to have patient packaged prior to the medic unit’s arrival, if possible.
PROTOCOL PROCEDURE Flow of protocol presumes patient has, or has the potential for, a
significant traumatic injury. Rapid transport with IV(s) established en route is a standard.
Consider air ambulance response for rapid transport from rural areas. Amputations not
meeting critical trauma criteria should be transported to the closest appropriate hospital. Early notification to the hospital is essential for proper triage and notification of surgical
personnel.
SPECIFIC TRAUMATIC INJURIES:
EXTREMITY INJURIES:
Splint extremity in position found. Return extremity to anatomical position only if distal
pulse is absent. After splinting, check distal pulse frequently. Apply Traction splint to
isolated mid-shaft femur fracture. Clean exposed bone ends prior to applying traction
splint to open fractures. Apply pelvic binder device (KED or bed sheet) for suspected
open-book pelvic fractures.
AMPUTATIONS/AVULSIONS:
Place amputated/avulsed part in a dry, sterile, and watertight container/bag. Place the
sealed container/bag in ice water and transport with the patient.
GENERAL TRAUMA CONTINUED
FLAIL CHEST:
Closely monitor patient’s airway, breathing, and consider CPAP.
OPEN CHEST WOUNDS:
Cover (do not pack) the wound with occlusive dressing.”(Asherman Chest Seal)”
Continuously evaluate for the development of tension pneumothorax. If the patient’s
condition worsens after the application of occlusive dressing, remove dressing
momentarily during forceful exhalation. Evaluate patient, then re-apply by securing the
dressing on three sides only (dressing acts as a one-way-valve allowing air to escape, but
not enter the chest). Closely monitor patient’s airway and breathing.
OPEN NECK WOUNDS:
Cover wound with an occlusive dressing and apply direct pressure. If uncontrolled
hemorrhage occurs, pack wound with hemostatic gauze before covering wound with
occlusive dressing. Closely monitor patient’s airway and breathing.
IMPALED OBJECTS:
Do not remove object unless it interferes with CPR or upper airway. Stabilize object in
place.
ABDOMINAL EVISCERATIONS:
Cover injury with a sterile saline-soaked dressing. Cover saline-soaked dressing with an
occlusive dressing.
ALS TREATMENT
CONTACT BASE STATION- preferably while en route to the scene for early notification of
destination and surgical personnel.
RAPID TRANSPORT - as soon as possible with ALS procedures performed en route. Ideally, scene
times for critical trauma should not exceed 10 minutes.
NORMAL SALINE - establish 2 large bore IVs via blood administration or macro drip tubing. Use IO
if unable to establish IV. If patient is in shock, or is compensating for impending shock, refer to
SHOCK protocol.
CONSIDER PAIN MANAGEMENT – refer to formulary for pain control options for those
hemodynamically stable patients who are in moderate to severe pain.
FOR TRAUMATIC ARREST - Treat as per Pulseless Arrest Protocol. Consider immediate bilateral
needle chest decompression and aggressive fluid expansion with pressure infusers.
EL DORADO COUNTY EMS AGENCY
PREHOSPITAL PROTOCOLS
Effective: July 2008
Reviewed: July 2009, February 2010 EMS Agency Medical Director
Revised: July 1, 2016
Scope: BLS/ALS – Adult/Pediatric
HEAD TRAUMA
ADULT
BLS TREATMENT
ABCs / ROUTINE MEDICAL CARE :
Be prepared to support ventilation with appropriate airway adjuncts.
Administer oxygen if indicated at an appropriate flow rate
Spinal Precautions as indicated.
For eye injuries consider covering both eyes to prevent further trauma of injured eye.
Consider possible non-traumatic etiology of ALOC: shock, toxic exposure, insulin shock, or
seizures. Refer to appropriate protocol.
PROTOCOL PROCEDURE: Flow of protocol presumes patient has, or has the potential for, a
significant head injury. Rapid transport with IV(s) established en route is a standard. Early
notification to the hospital is essential for proper triage and notification of surgical personnel.
ALS TREATMENT
CONTACT BASE STATION - Early notification of destination and surgical personnel.
RAPID TRANSPORT - ASAP - Ideally, scene times for critical trauma should not exceed 10 minutes.
NORMAL SALINE - Establish 2 large bore IVs via macro drip tubing. Place IO if unable to establish IV.
If patient is in shock or is compensating for impending shock, refer to SHOCK protocol.
Hypotensive patients with head injuries should have IV fluid resuscitation to maintain appropriate
systolic BP.
BLOOD SAMPLE/GLUCOSE LEVEL ASSESSMENT - Obtain blood sample via venipuncture. Rule out
diabetic emergency. Use caution when administering Dextrose/Glucagon to head injured patients,
consider contacting base station if blood sugar is borderline or patient is not a known diabetic.
REFER TO ALTERED LEVEL OF CONSCIOUSNESS OR SEIZURE PROTOCOLS AS APPROPRIATE.
LIDOCAINE 2%* (PRE-INTUBATION ONLY) - 1.5 mg/kg IV push (Max. total dose 100 mg).
Administer 2 minutes prior to intubation attempt when feasible, to blunt increased ICP.
AVOID HYPERVENTILATION OF HEAD INJURED VICTIMS.
HEAD TRAUMA CONTINUED
PEDIATRIC
BLS TREATMENT
ABCs / ROUTINE MEDICAL CARE :
Be prepared to support ventilation with appropriate airway adjuncts.
Administer oxygen if indicated at an appropriate flow rate
Spinal Precautions as indicated.
For eye injuries consider covering both eyes to prevent further trauma of injured eye.
Consider possible non-traumatic etiology of ALOC: shock, toxic exposure, insulin shock, or
seizures. Refer to appropriate protocol.
PROTOCOL PROCEDURE: Flow of protocol presumes patient has, or has the potential for, a significant
head injury. Rapid transport with IV(s) established en route is a standard. Early notification to the
hospital is essential for proper triage and notification of surgical personnel.
ALS TREATMENT
CONTACT BASE STATION – Early notification of destination and surgical personnel.
RAPID TRANSPORT – ASAP, Ideally, scene times for critical trauma should not exceed 10 minutes.
NORMAL SALINE – Establish 2 large bore IVs via macro drip tubing. Place IO if unable to establish IV.
If patient is in shock or is compensating for impending shock, refer to SHOCK protocol.
Hypotensive patients with head injuries should have IV fluid resuscitation to maintain appropriate
systolic BP. [70 + (2 x age in Yrs)]
BLOOD SAMPLE/GLUCOSE LEVEL ASSESSMENT - Obtain blood sample via venipuncture. Rule out
diabetic emergency. Use caution when administering Dextrose/Glucagon to head injured patients,
consider contacting base station if blood sugar is borderline or patient is not a known diabetic.
REFER TO ALTERED LEVEL OF CONSCIOUSNESS OR SEIZURE PROTOCOLS AS APPROPRIATE.
SODIUM BICARBONATE - administer 1 mEq/kg IV/IO push for cardiac toxicity. May require
second dose and aggressive fluid resuscitation. The goal is correction of QRS widening and
cardiac stability.
FOR BETA BLOCKER OVERDOSE:
GLUCAGON - administer 0.1 mg/kg IV/IO/IN push or IM.
FOR CALCIUM CHANNEL BLOCKER OVERDOSE:
CALCIUM CHLORIDE – administer 20mg/kg (0.2 mL/kg) of a 10% solution slow IV/IO push.
Calcium Chloride is contraindicated in patients taking digitalis-based medications
EL DORADO COUNTY EMS AGENCY
PREHOSPITAL PROTOCOLS
Effective: July 1, 2014
Reviewed: May 2014
Revised: July 1, 2016 EMS Agency Medical Director
Scope: BLS/ALS – Adult/Pediatric
PULSELESS ARREST
BLS TREATMENT
1. Ensure scene safety and confirm unresponsiveness.
2. Simultaneously check for pulse and no breathing or only gasping for no more than 10 seconds.
3. Start CPR as per current guidelines. Support ventilation with appropriate airway adjuncts.
4. Prior to defibrillation: Ensure skin is clean and dry. Remove metal necklaces and underwire bras. Check the person for implanted medical devices or piercings, place pads at least 1 inch away
from implanted devices or piercings.
5. Unwitnessed arrest:
CPR should be initiated while the AED/defibrillator equipment is being retrieved and applied.
Defibrillation, if indicated, should be attempted as soon as the device is ready for use. If no shock
advised continue CPR.
Witnessed arrest:
Attach AED/defibrillator to patient. If shock advised, deliver shock and immediately follow shock,
and each subsequent shock, with 2 minutes of CPR (5 cycles of 30:2) starting with compressions.
If no shock advised continue CPR.
Pediatric Note: If an AED with an attenuator is not available, an AED with standard electrodes
may be used. Attach pads in anterior/posterior position.
6. If patient is hypothermic limit shocks to one (1) only, refer to COLD EXPOSURES protocol.
7. Continue CPR and follow AED instructions until ROSC achieved and/or care is transferred to ALS
personnel.
8. Establish airway with King Tube Device (EXPANDED SCOPE EMTS).
Return of Spontaneous Circulation (ROSC):
1. If patient is resuscitated and has:
Effective spontaneous respirations: Apply high flow oxygen, place patient in left lateral
recumbent position and be prepared to suction airway.
Ineffective or absent respirations: Assist/provide ventilations, do not over-ventilate the patient.
Administer 10 ventilations per minute and be prepared to suction airway.
2. Re-assess the patient’s vital signs and effectiveness of ventilations frequently.
PROTOCOL PROCEDURE:
Flow of protocol presumes pulseless arrest is continuing. Effective CPR with a minimum of
interruptions should be the primary objective. Consider possible cause (H’s and T’s) and treat
accordingly. If correctable cause is suspected or condition changes refer to appropriate
protocol.
PULSELESS ARREST CONTINUED
Consider Sodium Bicarbonate 1mEq/kg for known dialysis patient, arrest >20 minutes, or suspected
tricyclic OD
Consider Gastric Tube upon establishing an advanced airway
Resuscitate on scene a minimum of 20 minutes or until there is return of spontaneous circulation
(ROSC), consider pronouncement if resuscitation is not successful or transport per base station order.
See Determination of Death Policy
If ROSC achieved, consider Therapeutic Hypothermia if inclusion criteria are met. See Procedure
ADULT ALS ALGORITHM
During CPR:
Push hard and fast 100-120/min)
Press at least 2-2.4” deep while Ensuring full
chest recoil
1 cycle of CPR: 30:2, minimize interruptions
Avoid hyperventilation
Ventilate at 10 breaths per minute without
compression pauses when an advanced
airway is in place
Rotate compressors every two minutes
Check rhythm every 2 minutes
Consider possible correctable causes H’s and T’s:
- Hypovolemia
- Hypoxia
- Hydrogen ion (acidosis)
- Hypo-/hyperkalemia
- Hypoglycemia
- Hypothermia
- Toxins
- Tamponade, cardiac
- Tension pneumothorax
- Thrombosis (coronary or pulmonary)
- Trauma
ASYSTOLE/PEA
PULSELESS VT/VF
1) Do 5 cycles of CPR between
each procedure.
2) Establish IV/IO.
3) Give Epinephrine IV/IO: 1 mg
1:10,000 May repeat q 3-5 min.
4) Insert advanced airway.
5) If no IV/or IO give Epinephrine
via ET: 2 mg 1:1,000 dilute in 5-10
mL NS or SW followed by 5
normal ventilations. May repeat
q 3-5 min.
6) Consider Sodium Bicarbonate
1mEq/kg for known dialysis
patient, arrest >20 minutes, or
suspected tricyclic OD.
1) Check rhythm. If indicated give 1 shock*, then immediately
resume CPR. Deliver shocks every 2 minutes if VF/VT continues.
2) Do 5 cycles of CPR between each procedure.
3) Establish IV/IO.
4) Give Epinephrine 1 mg 1:10,000 IV/IO. May repeat q 3-5 min.
5) Give Amiodarone: 300 mg Slow IV/IO push over 1-2 minutes.
6) Consider Magnesium Sulfate 2 Gm IV/IO diluted in 10 mL NS or