EMSC Medical Guidelines Revised August 2014
Abdominal Pain (Non-Traumatic)
Treatment, Physical Exam, and Transport
1. Determine patients level of responsiveness using AVPU
2. Ensure airway patency
a. If airway not patent, perform head-tilt-chin-lift
b. To ensure patency after opening the airway, consider use of OPA or NPA if indications are met
3. Determine pulse oximetry and assess breathing
a. Use nasal cannula at 6 LPM if patient’s oxygen saturation is below 94%
b. Utilize other breathing devices PRN
4. Check circulation through capillary refill and ensure proper perfusion through checking for a radial pulse
a. Check skin signs and look for obvious bleeding
5. Visualize and palpate the entire abdomen and retroperitoneal area
a. Note any tenderness, masses, and/or rigidity, noting which quadrant they appear in
b. If shock is suspected, place patient in shock position
6. Take vital signs
a. Blood pressure, eyes, lung sounds, level of consciousness (Glasglow AND A&O), skin signs, respirations, pulse
7. Activate DPS Emergency and contact LAFD/the proper EMS agency
a. Call (213) 740 – 4321
b. Request ALS/BLS PRN
c. Provide exact location, age, sex, chief complaint, LOC, whether vitals are stable or not, any special information relevant to patient care
Verbal Assessment
1. Perform SAMPLE exam
2. Perform PQRST exam
3. Inquire about vomiting/nausea (and blood in the vomit)
4. If patient is female, inquire about her recent menstrual cycles/potential pregnancies
5. Inquire about food and fluid intake/possibility of food poisoning
6. Inquire about regularity of urination and bowel movements (and blood in the urine or stool)
Dos and Don’ts
· Do anticipate vomiting
· Do reassess vital signs every 5 minutes
· Do write a run report
· Don’t give the patient anything by the mouth (food or liquids)
Abdominal Pain (Traumatic)
Treatment, Physical Exam, and Transport
1. Determine patients level of responsiveness using AVPU
2. Ensure airway patency
a. If airway not patent, perform head-tilt-chin-lift (or modified jaw-thrust depending on injury mechanism)
b. To ensure patency after opening the airway, consider use of OPA or NPA if indications are met
3. Determine pulse oximetry and assess breathing
a. Use nasal cannula at 6 LPM if patient’s oxygen saturation is below 94%
b. Utilize other breathing devices PRN
4. Check circulation through capillary refill and ensure proper perfusion through checking for a radial pulse
a. Check skin signs and look for obvious bleeding (control bleeding if present)
5. Visualize and palpate the entire abdomen and retroperitoneal area
a. Note any tenderness, masses, and/or rigidity, noting which quadrant they appear in
b. Determine if there are any penetrating objects and stabilize accordingly if present
c. When patient presents with blunt trauma, take orthostatic blood pressure/pulse if patient presents with no signs of shock
d. If evisceration is present, cover with large, bulky dressing soaked in saline and tape down on all 4 sides; keep dressing wet throughout transport
e. If gunshot or knife injury is present, check for exit wounds (if wound involves thoracic area, treat it as a chest wound, see page 9)
f. If major blunt injury mechanism suspected, consider C-Spine
6. Take vital signs
a. Blood pressure, eyes, lung sounds, level of consciousness (Glasglow AND A&O), skin signs, respirations, pulse
7. Activate DPS Emergency and contact LAFD/the proper EMS agency
a. Call (213) 740 – 4321
b. Request ALS/BLS PRN
c. Provide exact location, age, sex, chief complaint, LOC, whether vitals are stable or not, any special information relevant to patient care
8. Perform rapid and detailed trauma assessments
a. Look for DCAPBTLS
Verbal Assessment
1. Inquire about injury mechanism
2. Perform SAMPLE exam
Dos and Don’ts
· Do anticipate vomiting
· Do reassess vital signs every 5 minutes
· Do write a run report
· Don’t give the patient anything by the mouth (food or liquids)
Allergic Reactions and Anaphylaxis
Treatment, Physical Exam, and Transport
1. Determine patients level of responsiveness using AVPU
2. Ensure airway patency
a. If airway not patent, perform head-tilt-chin-lift
b. To ensure patency after opening the airway, consider use of OPA or NPA if indications are met
3. Determine pulse oximetry and assess breathing
a. Check for associated SOB, obtain lung sounds, and note volume/anything abnormal
b. Use nasal cannula at 6 LPM if patient’s oxygen saturation is below 94%
c. Utilize other breathing devices PRN
4. Check circulation through capillary refill and ensure proper perfusion through checking for a radial pulse
a. Check skin signs and look for obvious bleeding (control bleeding if present)
5. Check for and write down signs of systemic allergic reaction (rash, itching, hives, SOB, generalized swelling, etc.)
6. Take vital signs
a. Blood pressure, eyes, lung sounds, level of consciousness (Glasglow AND A&O), skin signs, respirations, pulse
7. Activate DPS Emergency and contact LAFD/the proper EMS agency
a. Call (213) 740 – 4321
b. Request ALS/BLS PRN
c. Expedite transport if patient’s status is acute
d. Provide exact location, age, sex, chief complaint, LOC, whether vitals are stable or not, any special information relevant to patient care
e. Provide ALS with the suspected allergen if possible
8. Assist patient with prescribed medications
a. Epi-pen, if present, should be used on the upper outer thigh
b. Bronchodilator should be sprayed in the middle of an inhalation PRN
9. Position patient properly, minimize movement, and try to keep the patient calm
a. If patient is in shock, place in shock position
b. If patient has SOB but no signs of shock, place in Fowler’s position
c. If bite/sting/injection, lower below level of the heart
Verbal Assessment
1. Perform a SAMPLE exam
a. Inquire about allergies and whether the patient has been exposed to the allergen
b. Inquire about past experiences with this allergen
c. Inquire about an epi-pen
Dos and Don’ts
· Do minimize patient movement
· Do reassess vital signs every 5 minutes
· Do write a run report
· Do remove the allergen from patient if possible and non-invasive (brush off dust, flush off any liquids, etc.)
· Don’t give the patient anything by the mouth (food or liquids)
Altered Level of Consciousness
Treatment, Physical Exam, and Transport:
1. Determine patients level of responsiveness using AVPU
2. Ensure airway patency
a. If airway not patent, perform head-tilt-chin-lift
b. To ensure patency after opening the airway, consider use of OPA or NPA if indications are met
3. Determine pulse oximetry and assess breathing
a. Use nasal cannula at 6 LPM if patient’s oxygen saturation is below 94%
b. Utilize other breathing devices PRN
4. Position properly and consider C-Spine
a. Left lateral to protect airway if C-spine is deemed unnecessary
b. Consider C-spine if reason for the ALOC is unclear or traumatic
5. Check circulation through capillary refill and ensure proper perfusion through checking for a radial pulse
a. Check skin signs and look for obvious bleeding
6. Visualize and palpate the head
a. Note any DCAPBTLS and note the location
b. Look for Battle Signs, raccoon eyes, CSF from the nose or ears,
c. If shock is suspected, place patient in shock position
d. If trauma suspected, place in C-Spine
7. Take vital signs
a. Blood pressure, eyes, lung sounds, level of consciousness (Glasglow AND A&O), skin signs, respirations, pulse
8. Activate DPS Emergency and contact LAFD/the proper EMS agency
a. Call (213) 740 – 4321
b. Request ALS
c. Provide exact location, age, sex, chief complaint, LOC, whether vitals are stable or not, any special information relevant to patient care
9. Determine and treat the mechanism of ALOC if possible
Verbal Assessment:
1. Perform SAMPLE exam (with friend/family if necessary)
a. If performing SAMPLE with patient, be wary of responses
2. Perform PQRST exam PRN
a. If performing PQRST with patient, be wary of responses
Dos and Don’ts
· Do anticipate vomiting
· Do reassess vital signs every 5 minutes
· Do write a run report
· Don’t give the patient anything by the mouth (food or liquids)
Behavioral Emergencies
Treatment, Physical Exam, and Transport
1. Request DPS/LAPD backup
2. Determine patients level of responsiveness using AVPU
3. Ensure airway patency
a. If airway not patent, perform head-tilt-chin-lift
b. To ensure patency after opening the airway, consider use of OPA or NPA if indications are met
4. Determine pulse oximetry and assess breathing
a. Use nasal cannula at 6 LPM if patient’s oxygen saturation is below 94%
b. Utilize other breathing devices PRN
5. Activate DPS Emergency and contact LAFD/the proper EMS agency
a. Call (213) 740 – 4321
b. Request ALS
c. Provide exact location, age, sex, chief complaint, LOC, whether vitals are stable or not, any special information relevant to patient care
6. Make contact with someone who has knowledge of the patients history before making contact with patient if possible
7. Attempt to take vital signs
8. Use restraints only if necessary to protect self, partner, or public from the patient
a. Never restrain the patient prone
b. 4 rescuers works well for restraining patients
c. Apply restraints to wrists and ankles (with a sheet across the midsection PRN)
Verbal Assessment
· Always maintain conversation with the patient
· Attempt to perform a SAMPLE exam
· If the patient is under conservatorship or 72-hour hold, and should the patient refuse transport, advise the patient that the doctor or police officer has made the final decision to transport. It is now the patient's decision to go quietly, without restraints, or force you to "tie" him/her down to the gurney and transport against his/her will.
o Note: Many times, given this decision, the patient will decide to be transported quietly, without force. A police officer must accompany all restrained patients and should at the minimum follow all EMS 5150 transports.
Dos and Don’ts
· Do be vigilant at all times of changing behavior patterns in the patient
· Do document everything as thoroughly as possible
· Do request DPS/LAPD assistance if situation could be deemed unsafe
· Don’t do anything to aggravate the patient
· Don’t place yourself, your partner, or the public in any danger
Additional Notes
· Approach will vary based on the circumstances of the call and the patient
· NEVER put yourself in danger
· Secondary assessment can be waived if it could aggravate the patient
· Document as thoroughly as possible
Burns
Treatment, Physical Exam, and Transport
1. Determine patients level of responsiveness using AVPU
2. Ensure airway patency
a. If airway not patent, perform head-tilt-chin-lift
b. To ensure patency after opening the airway, consider use of OPA or NPA if indications are met
3. Determine pulse oximetry and assess breathing
a. Use nasal cannula at 6 LPM if patient’s oxygen saturation is below 94%
b. Assess lung sounds and note volume and any irregularities
c. If singed nasal hairs, facial burns, or soot around mouth, consider ventilation
d. Utilize other breathing devices PRN
4. Check circulation through capillary refill and ensure proper perfusion through checking for a radial pulse
a. Check skin signs and look for obvious bleeding
5. Treat the burn(s) itself
a. Remove constrictive clothing or jewelry
b. Flush burns initially with saline to stop the burning
c. Estimate size of burn using rule of nines or rule of palm
d. Place burn dressings over burn, and then cover with dry, sterile gauze
e. If dry chemical burn, brush off and then flush with lots of water/saline
f. If liquid chemical burn, flush with lots of water/saline
6. Treat any complications from the burns
a. If electrical burn, consider possible cardiac arrhythmia
b. If explosion, look for associated traumatic injuries
7. Take vital signs
a. Blood pressure, eyes, lung sounds, level of consciousness (Glasglow AND A&O), skin signs, respirations, pulse
8. Activate DPS Emergency and contact LAFD/the proper EMS agency
a. Call (213) 740 – 4321
b. Request ALS/BLS PRN
c. Provide exact location, age, sex, chief complaint, LOC, whether vitals are stable or not, any special information relevant to patient care
d. All electrical burns should be transported
Verbal Assessment
1. Perform a SAMPLE exam
2. Determine circumstances surrounding the burn to treat the burn properly
3. Determine if any treatment was instituted prior to EMS arrival
Dos and Don’ts
· Do stop the burning by flushing it with saline
· Do write a run report
· Do seriously consider transporting every patient
· Do monitor respiratory status vigilantly
· Don’t break blisters, remove tar, apply ice water/tape/ointment, or remove stuck clothing
Cardiac Arrest
Treatment, Physical Exam, and Transport
1. Determine patients level of responsiveness using AVPU
2. If unresponsive to verbal and painful stimuli, check for a carotid pulse
3. If carotid pulse not present, begin compressions immediately @ rate of >100 per minute
4. Have partner apply Automated External Defibrillator (AED) while compressions are being performed
5. Activate DPS Emergency and contact LAFD/the proper EMS agency
a. Call (213) 740 – 4321
b. Request ALS assistance
c. Provide exact location, age, sex, chief complaint, LOC, whether vitals are stable or not, any special information relevant to patient care
6. Follow the prompts from the AED
7. If shock is administered, begin a new round of CPR immediately, following the AHA compression to breath ratio
8. Ventilate using a BVM with high flow, 100% oxygen using 2-person ventilating techniques
a. Use an OPA/NPA, unless contraindicated
b. Use suctioning PRN
9. Control bleeding PRN
10. Continue CPR until spontaneous restoration of pulse
In event of spontaneous restoration of pulse
1. Assess for spontaneous respirations
a. If no spontaneous respirations, ventilate @ AHA ratios for rescue breathing
b. If spontaneous respirations present, administer high flow oxygen
2. Place patient in shock position
3. Obtain a set of vitals and reassess every 5 minutes
Verbal Assessment
· Determine events preceding cardiac arrest
· Determine how long the patient has been down
· Determine if CPR was instituted prior to arrival
· Determine if DNR is present
· Determine medical history (if possible)
Dos and Don’ts
· Do perform CPR as long as necessary to have spontaneous restoration of pulse or until reaching the nearest emergency paramedic receiving facility
· Do expedite transport
Chest Pain
Treatment, Physical Exam, and Transport
1. Determine patients level of responsiveness using AVPU
2. Ensure airway patency
a. If airway not patent, perform head-tilt-chin-lift
b. To ensure patency after opening the airway, consider use of OPA or NPA if indications are met
3. Determine pulse oximetry and assess breathing
a. Use nasal cannula at 6 LPM if patient’s oxygen saturation is below 94%
b. Apply high flow oxygen if patient is experiencing SOB
c. Obtain lung sounds and note volume and any irregularities
4. Check circulation through capillary refill and ensure proper perfusion through checking for a radial pulse
a. Check skin signs and look for obvious bleeding
5. Visualize and palpate the chest
a. Note any DCAPBTLS
b. Look for JVD and pedal edema
c. Be specific when determining whether pain is cardiac, pleuritic, or muscular
6. Take vital signs
a. Blood pressure, eyes, lung sounds, level of consciousness (Glasglow AND A&O), skin signs, respirations, pulse