ST. JOSEPH HEALTH CENTER
PRE-HOSPITAL CARE
&
PROCEDURES MANUAL
Updated January 5, 2005
PRE-HOSPITAL MEDICAL PROTOCOL FOR ALL UNITS
OPERATING UNDER THE MEDICAL AUTHORITY OF
ST. JOSEPH HEALTH CENTER
WARREN, OH 44484
MISSION STATEMENT: TO PROVIDE THE HIGHEST QUALITY PRE-HOSPITAL CARE TO THE CITIZENS OF TRUMBULL COUNTY AND SURROUNDING AREAS THROUGH SOUND MEDICAL DIRECTION, QUALITY EDUCATION, INNOVATION, AND CONTINUOUS PERFORMANCE IMPROVEMENT PROGRAMS
MEDICAL DIRECTOR, EMS
KATHRYN BULGRIN, D.O.
The contents of this document will be revised periodically as indicated by changing patient care and other medical standards. Revisions and modifications will be distributed to all pre-hospital units operating under medical authority of the Medical Director.
This pre-hospital medical protocol is for use ONLY by Emergency Medical Service squads operating under medical authority of St. Joseph Health Center and Dr. Kathryn Bulgrin, D.O.
MEDICAL AUTHORITY. Emergency Medical Technicians operating under this medical authority are required to follow this protocol unless an intervening physician licensed to practice medicine in the State of Ohio (M.D. or D.O.) accepts full responsibility for deviation from the provisions of this document and accompanies the patient to the receiving hospital. No squad or personnel of any particular squad is permitted to practice medicine beyond the scope of practice of their level of training as defined by the Department of Public Safety, Division of Emergency Medical Services, State of Ohio.
ALS ACTIVATION AND INTERCEPT. For any patient with serious illness and/or potentially life-threatening situations (chest pain/suspected myocardial infarction, respiratory distress, hypoglycemia, altered mental status, and/or other potentially life-threatening situations), all EMT-Basic and EMT-Intermediate units should immediately request assistance from the nearest ACLS (Paramedic) unit UNLESS the transport time is less than the rendezvous time with the Paramedic unit. EMT-Basic and EMT-Intermediate units' intervention on the patient's behalf should not exceed the scope of their practice and training.
All Emergency Medical Service units operating under the medical authority of St. Joseph Health Center are reminded that this protocol is for use in the pre-hospital setting only. This includes patient transports from:
Home to hospital
Accident scene to hospital
Extended care facility to hospital
Any other type of transport, i.e., inter-facility transport of critical care patients or inter-facility transport of any other type of patient is the responsibility of the sending facility, the respective physician, and the transporting agency. St. Joseph Health Center, including any of its signing physicians, WILL NOT accept liability or responsibility for these types of transports.
______
Kathryn Bulgrin, D.O.
HMHP St. Joseph Health Center
EMS Director
State of Ohio, County of Trumbull
Sworn to and subscribed to before me
On this _____ day of ______, 20 ___.
______
Notary Public
ST. JOSEPH HEALTH CENTER
EMERGENCY MEDICAL SERVICES
COLOR-CODED KEY TO PATIENT CARE GUIDELINES
All patient care algorithms are color coded to denote procedures which may be performed by each level of certification.
Ø EMT-Basics. EMT-Basics may perform any procedures in blue.
Ø EMT-Intermediate. EMT-Intermediates may perform all of the EMT-Basics procedures, as well as those color coded green.
Ø EMT-Paramedics. Paramedics may perform all of the EMT-Basic and EMT-Intermediate procedures, as well as those color coded red.
Any boxed procedures require on-line medical control direction
Higher levels of certification will perform lower level evaluations and procedures when interpreting the algorithms. No EMT is permitted to perform any procedures beyond his level of certification.
TABLE OF CONTENTS
I. ADULT PROTOCOLS
Abdominal Pain...... xx
Allergic Reactions...... xx
Altered Level of Consciousness...... xx
Anaphylactic Shock (See Shock)
Burns...... xx
Cardiac Emergencies...... xx
- Angina/Chest Pain...... xx
- Arrest...... xx
- Asystole...... xx
- PEA...... xx
- Ventricular Fibrillation...... xx
- Arrhythmias...... xx
- Bradycardia...... xx
- Tachycardias...... xx
Childbirth...... xx
Diabetic Emergencies...... xx
Eye Injuries...... xx
Glasgow Coma Scale / Revised Trauma Score...... xx
Heat Exposure...... xx
Hypertension Management ...... xx
Hypothermia / Frostbite...... xx
Near-Drowning / Drowning...... xx
Overdose / Poisoning...... xx
Respiratory Emergencies...... xx
- Airway Obstruction...... xx
- Asymmetric Breath Sounds...... xx
- Rales/Pulmonary Edema...... xx
- Wheezing...... xx
Seizures...... xx
Shock...... xx
- Anaphylactic...... xx
- Cardiogenic / Neurogenic / Septic / Hypovolemic...... xx
Stroke...... xx
Thrombolytic Screening Checklist...... xx
Trauma Arrest...... xx
Trauma Emergencies...... xx
Trauma Triage...... xx
II. PEDIATRIC PROTOCOLS
Altered Level of Consciousness...... xx
Arrhythmias ...... xx
- Bradycardia...... xx
- Narrow complex tachycardia...... xx
- Wide complex tachycardia...... xx
Cardiac Arrest...... xx
- Ventricular Fibrillation / Pulseless V-Tachycardia...... xx
- Asystole / PEA...... xx
Child Abuse / Neglect...... xx
Fluid and Drug Administration...... xx
Medications – Reference Dosages...... xx
Newborn Resuscitation...... xx
Respiratory Distress...... xx
- Upper Airway Obstruction...... xx
- Wheezing...... xx
Seizures...... xx
Shock...... xx
- Anaphylactic...... xx
- Cardiogenic / Neurogenic / Septic / Hypovolemic...... xx
Vital Signs – Normal...... xx
III. MEDICAL PROCEDURES
Automatic External Defibrillator (AED)...... xx
Airway and Breathing:...... xx
- Oxygen Therapy...... xx
- Pulse Oximetry...... xx
- Endotracheal Intubation...... xx
- Chest Decompression...... xx
- Cricothyrotomy...... xx
Alternative Medication Routes...... xx
Assisting with Medication Administration...... xx
C-Spine Immobilization...... xx
Conscious Sedation...... xx
External Pacemaker...... xx
Heimlich Maneuver...... xx
Interosseus Infusions...... xx
Intravenous Therapy...... xx
Pain Management...... xx
Patient Assessment...... xx
IV. PHARMACEUTICAL PROTOCOL
Activated Charcoal (Actidose)...... xx
Adenocard (adenosine)...... xx
Albuterol (Proventil / Ventolin)...... xx
Amiodarone (Cordarone)...... xx
Aspirin...... xx
Atropine Sulfate as Antidote for Poisonings...... xx
Atropine Sulfate as Cardiac Agent...... xx
Benadryl (diphenhydramine HCL)...... xx
Cordarone (amiodarone)...... xx
Dextrose 50% (D50) and 25% (D25)...... xx
Diazepam (Valium)...... xx
Diphenhydramine (Benadryl)...... xx
Dopamine HCL...... xx
Epinephrine (Adrenalin) (1:1000 and 1:10,000)...... xx
Furosemide (Lasix)...... xx
Glucagon...... xx
Isuprel ...... xx
Ketorolac (Toradol)...... xx
Lasix (Furosemide)...... xx
Lidocaine (Xylocaine) 2% and 1%...... xx
Magnesium Sulfate...... xx
Midazolam (Versed)...... xx
Morphine Sulfate...... xx
Narcan (Naloxone)...... xx
Nitroglycerin (Nitrostat)...... xx
Oxygen (O2)...... xx
Pediatric Medications – Common Dosages...... xx
Procainamide (Pronestyl)...... xx
Proventil (Albuterol / Ventolin)...... xx
Sodium Bicarbonate 8.4% & 4.2%...... xx
Solu-Medrol...... xx
Thiamin HCL (Vitamin B-1/Biamine)...... xx
Toradol (Ketorolac)...... xx
Valium (Diazepam)...... xx
Ventolin (Albuterol / Proventil)...... xx
Versed (midazolam) ...... xx
Xylocaine (Lidocaine)...... xx
V. ADMINISTRATIVE PROTOCOLS
Aeromedical Transport...... xx
Communications / When to Call Medical Control...... xx
Coroner Death Notification...... xx
Dead on Arrival (DOA)...... xx
Do Not Resuscitate (DNR) Guidelines & Forms...... xx
Drug Box Exchange Guidelines...... xx
Linen Replacement...... xx
Obtaining Individual Protocol...... xx
Patient Refusal or Withdrawal of Consent...... xx
Physician at the Scene...... xx
Restraint Policy...... xx
Termination of Resuscitation Efforts...... xx
Transfer Refusal...... xx
GENERAL PATIENT ASSESSMENT
1. ASSURE SCENE SAFETY
2. UNIVERSAL PRECAUTIONS SHALL BE OBSERVED TO PREVENT CONTACT
WITH BLOOD OR OTHER POTENTIALLY INFECTIOUS MATERIALS
3. INITIAL ASSESSMENT (Including ABCs)
This assessment is to discover and treat immediately life-threatening conditions.
a) Airway
- Open airway if needed
- Medical – head tilt chin lift
- Trauma – jaw thrust
- Look for airway obstructions: vomit, bleeding, facial trauma, etc.
- Identify and correct any existing or potential airway obstruction or problems
- Consider oxygen therapy at this time
- Consider Oropharyngeal Airway (OPA) or Nasopharyngeal Airway (NPA)
b) Breathing
- Check adequacy of ventilation – should be done by quickly observing chest rise/fall, approximate rate and listening to patient talk
- Expose chest and observe chest wall movement
- Consider oxygen therapy at this time
c) Circulation
- Palpate for pulse
- Radial pulse not present indicates systolic blood pressure < 80 mmHg
- Carotid pulse not present indicates systolic blood pressure < 60 mmHg
- Note skin temperature, color, and condition
- Note capillary refill in children
- Identify and treat life-threatening conditions or injuries and control bleeding, as needed
d) Disability:
Determine Level of Consciousness by:
- A – Alert
- V – Responds to Voice
- P – Responds to Pain
- U – Unresponsive
- Check pupils for size and reaction time
Form a General Impression of the Patient (age, sex, injury or illness, and immediate
environment)
4. FOCUSED HISTORY AND PHYSICAL EXAM
This section will identify any additional injuries or conditions that may also be life threatening.
Re-evaluate the mechanism of injury (trauma) or nature of illness (medical).
a) Trauma patients with significant mechanism of injury should be assessed as follows:
- Rapid head-to-toe assessment (inspect, palpate, and auscultate)
- Assess baseline vital signs to include:
a. Respirations
b. Pulse
c. Skin color, temperature, and condition
d. Pupils
e. Blood pressure
- Obtain SAMPLE History
Signs and Symptoms
Allergies
Medications (prescribed and over-the-counter)
Pertinent past medical history
Last oral intake
Events prior to injury
- Provide interventions (bandaging, splinting, boarding)
b) Trauma patients without significant mechanism of injury should be assessed as follows:
- Focused assessment (focuses primarily on injury site, rather than head to toe)
- Assess baseline vital signs (as listed above)
- Obtain SAMPLE history (as listed above)
c) Medical patients who are unresponsive should be assessed as follows:
- Rapid head-to-toe assessment
- Assess baseline vital signs (as listed above)
- Obtain SAMPLE history (as listed above)
d) Medical patients who are responsive should be assessed as follows:
- Assess patient's complaints (OPQRST)::
Onset (When and how did the symptoms begin?)
Provocation (What makes the symptoms worse?)
Quality (How would you describe the pain?)
Radiation (Where do you feel the pain?)
Severity (How bad is the pain?)
Time (How long have you had the symptoms?)
- Obtain a SAMPLE history (see above)
- Focused assessment (Assessment of specific complaint areas unless general "I don't feel well," which would require head-to-toe exam)
- Assess baseline vital signs
5. ONGOING ASSESSMENT
Reassess interventions.
I. ADULT PROTOCOLS
ABDOMINAL PAIN
EMT-Basic: 1. Confirm ALS en route, as indicated.
2. Administer oxygen 2 liters nasal cannula or higher
concentrations as indicated with shock or respiratory
distress
3. Apply pulse oximeter (if available)
4. Obtain relevant history (Onset, Provokes, Quality, Radiation,
Severity, Time, Interventions, Associated Symptoms,
Allergies, Medications, Past Med/Surg History, Last Meal)
5. Perform complete assessment
6. Check blood sugar level (if < 80 or > 400,
refer to Diabetic Emergency Protocol)
7. Place patient in position of comfort
8. Give nothing by mouth
EMT-Intermed: 9. Reassess patient
10.Obtain IV access – normal saline at TKO
11. 250-500 cc bolus IV normal saline for hypotension (may
repeat bolus x 2 as needed for hypotension)
EMT-Paramedic: 12. Reassess patient
13. Apply cardiac monitor and treat per ACLS protocol
ALLERGIC REACTIONS
Mild Reaction: Rash, Itching, and/or Swelling
Moderate Reaction: Wheezing and/or Lightheadedness
Severe Reaction (Anaphylaxis): Respiratory Distress, Hypotension, and/or Decreased Responsiveness
EMT-Basic: 1. Confirm ALS en route, as indicated.
2. Administer oxygen 2 liters nasal cannula or higher
concentrations as indicated with shock or respiratory
distress
3. Apply pulse oximeter (if available)
4. Obtain relevant history (Onset, Possible Exposures/New
Medications, Allergies, Associated Symptoms, Interventions,
Past Medical History)
5. Perform complete assessment
6. Assist patient in administering their own EPI-pen and/or
albuterol MDI as indicated by symptoms or history
7. Place patient in position of comfort
EMT-Intermed: 8. Reassess patient (monitor airway & respiratory status closely)
9. Obtain IV access – normal saline at TKO
10. 250-500 cc bolus IV normal saline for hypotension (may
repeat bolus x 2 as needed for hypotension)
11. Benadryl 25-50 mg IM or 25 mg IV slow over 3 minutes
12. Albuterol aerosol 2.5 mg prn for wheezing (may repeat x 2)
13. Epinephrine (1:1000) 0.3 mg SQ for severe
reactions/anaphylaxis
14. Intubate as indicated (Certified EMT-I only)
EMT-Paramedic: 15. Reassess patient (monitor airway & respiratory status closely)
16. Consider Solu-Medrol 125 mg IV
17. Apply cardiac monitor and treat per ACLS protocol
18. Intubate as indicated
19. Dopamine 5 mcg/kg/min titrated up to 20 mcg/kg/min in
symptomatic patient with SBP < 90 mmHg
ALTERED LEVEL OF CONSCIOUSNESS
EMT-Basic: 1. Confirm ALS en route.
2. Secure airway and consider cervical spine injury
3. Administer 100% oxygen by NRB mask (assist ventilation
with BVM with oral or nasal airway if indicated)
4. Apply pulse oximeter (if available)
5. Obtain relevant history (Onset, Circumstances, Past Medical
History-DM, Seizure, Drug Abuse, Head Injury, Medications,
Recent Illness, Associated Symptoms, and Allergies)
6. Thrombolytic Screening (for stroke patients)
7. Perform complete assessment
8. Document Glasgow Coma Scale
9. Check blood glucose of diabetic patients (If < 80 and patient
alert, give oral glucose 1 tube)
10. Place patient in position of comfort
EMT-Intermed: 11. Reassess patient
12. Obtain IV access – normal saline at TKO
13. D50 1 amp IV if blood sugar < 80 or not obtainable (or
Glucagon 1 mg IM)
14. 250-500 cc bolus IV normal saline for hypotension (may
repeat bolus x 2 as needed for hypotension)
15. Intubate as indicated (Certified EMT-I only)
EMT-Paramedic: 16. Reassess patient (manage airway)
17. Apply cardiac monitor and treat per ACLS protocol
18. Narcan 0.5-2 mg IV/ET for decreased responsiveness,
respiratory depression, or suspicion of narcotic overdose
(consider patient restraint prior to administration). May repeat
dose
19. Consider thiamine 100 mg IV/IM (especially with alcohol
history)
20. Intubate patient if indicated for airway protection/
ventilation (if no response to Narcan and/or D50)
ANAPHYLACTIC SHOCK
EMT-Basic: 1. Confirm ALS en route.
2. Administer oxygen 100% NRB mask (prepare to assist
ventilation)
3. Apply pulse oximeter (if available)
4. Obtain relevant history (Onset, Possible Exposures/New
Medications, Allergies, Associated Symptoms, Interventions,
Past Medical History)
5. Perform complete assessment
6. Assist patient in administering their own EPI-pen as
indicated
7. Place patient in position of comfort