Johnston Fire Department
2005 Patient Care Protocol
These protocols have been adapted from the Iowa Department of Public Health, Bureau of Emergency Medical Services; State of Iowa Protocols – 2002
Purpose
The purpose of these protocols is to assure safe and effective intervention during the out-of-hospital phase of patient care. In consideration of the unique resources, needs, population, and the geography of EMS systems in Iowa, individual medical directors may choose to enhance or omit portions of these protocols in accordance with Iowa Code, Chapter 147A. Medical directors are responsible to ensure the EMS personnel using these protocols have the training and skills required , and perform quality assurance activities to assure these protocols are used appropriately. On going review and update of theses protocols is necessary to keep pace with interventions known to be effective in out-of-hospital care.
Authority
According to Iowa Code, Chapter 147A, emergency medical personnel may only deliver emergency medical care under the direction of a physician medical director who is licensed to practice medicine in Iowa. The medical practice of out-of-hospital personnel is an extension of the medical director’s license.
Paramedics have authority to perform all the medications and procedures described in the protocols without contacting medical control for authorization. However, if you need to deviate in any way from the protocols, medical control must be contacted for authorization. In addition, report need not be given to a physician designee at the hospital concerning procedures or medications you have already provided. This report can be given to the dispatcher at the receiving hospital.
Along with the increased autonomy of allowing paramedics to perform by protocol only comes the additional responsibility of making wise treatment decisions. Paramedics must be able to defend their treatment, and their use of the protocol, if a treatment appears to be inappropriate or ill-advised on the patient arrival at the Emergency Department.
TABLE OF CONTENTS
Section 301 – Adult Patient Care Protocols
Introduction to Use of Protocols.301.01
Initial Protocols for all Patients301.02
Abdominal Pain301.03
Allergic Reaction and Acute Anaphylaxis 301.04
Altered Mental Status 301.05
Amputated Parts301.06
Apparent Death301.07
Asthma301.08
Burns Involving the Face and Respiratory Tract301.10
Burns.301.09
Cardiopulmonary Arrest301.11
Cerebrovascular Accident (CVA) - Brain Attack301.28
Chest Pain301.12
CHF / Pulmonary Edema301.13
Cold Emergencies301.14
DNR Protocol301.15
Fractures / Dislocations301.16
Heat Emergencies301.17
Hypertensive Crisis301.18
Obstetrical Emergencies301.19
Obstructed Airway301.20
Pain Management301.201
Patient Self-Medication301.21
Patient Prioritization Requirements301.22
Poisoning301.23
Psychiatric Emergencies301.24
Respiratory Distress301.25
Seizures301.26
Sexual Assault (alleged)301.27
Trauma 301.29
Unconscious Patient301.30
Section 302 - Advanced Procedures
12 Lead ECG Application302.01
AED Application and Use302.02
Air Medical Transport302.03
Assessment based Spinal Immobilization302.031
Assisted Administration of Patient Medication302.13
Basic Life Support – Adult302.04
Basic Life Support – Child302.05
Basic Life Support – Infant302.06
Chest Pain Checklist302.061
Combitube Placement 302.07
Elective Sedation - Adult 302.08
Endotracheal Intubation302.09
External Pacing302.10
Gastric Tube Placement302.14
Initiating Organ Donation302.141
Intraosseous Infusion302.11
Intravenous Cannulation302.12
Medication Assisted Intubation – Adult302.15
Nasotracheal Intubation302.16
Needle Cricothyrotomy.302.17
Needle Thoracostomy 302.18
Out of Hospital Trauma Triage Destination Decision Protocol302.181
Pertrach / Emergency Cricothyrotomy 302.19
Physical Restraints, Use of302.22
Rectal Valium Administration302.211
START (Simple and Rapid Treatment)302.212
Urinary Catheterization Procedure302.21
Ventilatory Assistance (manual)302.20
Use of Ventilator302.23
Section 303 - Pediatric Patient Care Protocols and Procedures
Allergic Reaction and Acute Anaphylaxis 303.01
Altered Mental Status 303.02
Apparent Death303.03
Burns Involving the Face and Respiratory Tract303.05
Burns303.04
Elective Sedation-Pediatric303.14
Pediatric Advanced Life Support 303.07
Pediatric Pain Management 303.06
Poisoning303.09
Respiratory Distress303.10
Seizures303.11
Suspected Child Abuse and Neglect303.12
Trauma303.13
Section 304 - Medication Protocols
Actidose304.00
Adenosine304.01
Albuterol304.02
Amiodarone304.03
Aspirin304.04
Atropine304.05
Atrovent304.053
Bretylium304.051
Calcium Gluconate304.06
Demerol304.061
Dextrose 50 %304.07
Diazepam304.08
Diphenhydramine / Benadryl304.09
Dopamine304.10
Epinephrine 1:10,000304.11
Epinephrine 1:1000304.12
Etomidate304.13
Furosemide304.14
Glucagon 304.15
Glucose Paste304.151
Lidocaine304.16
Magnesium Sulfate304.17
Morphine Sulfate304.18
Narcan / Naloxone304.19
Neo-Synephrine304.191
Nitroglycerin304.20
Nitrous Oxide304.22
Nubain304.225
Pitocin304.221
Procainamide304.21
Romazicon304.23
Sodium Bicarbonate304.24
Thiamine304.241
Tridil304.25
Vasopressin304.265
Verapamil304.251
Versed304.26
Section 305 - ACLS Algorithms
Asystole305.11
Stable VT or Frequent PVCs305.02
Bradycardia305.03
Comprehensive ECG305.05
Electrical Cardioversion 305.06
Hypothermia305.07
PEA305.08
Pulmonary Edema / Hypotension / Shock305.04
Tachycardia Overview305.01
Universal Algorhythm305.09
VF / Pulseless VT305.10
These protocols have been adapted from the Iowa Department of Public Health, Bureau of Emergency Medical Services; State of Iowa Protocols – 2002
Purpose
The purpose of these protocols is to assure safe and effective intervention during the out of-hospital phase of patient care. In consideration of the unique resources, needs, population, and the geography of EMS systems in Iowa, individual medical directors may choose to enhance or omit portions of these protocols in accordance with Iowa Code, Chapter 147A. Medical directors are responsible to ensure the EMS personnel using these protocols have the training and skills required, and perform quality assurance activities to assure these protocols are used appropriately. On going review and update of theses protocols is necessary to keep pace with interventions known to be effective in out-of-hospital care.
Authority
According to Iowa Code, Chapter 147A, emergency medical personnel may only deliver emergency medical care under the direction of a physician medical director who is licensed to practice medicine in Iowa. The medical practice of out-of-hospital personnel is an extension of the medical director’s license. Paramedics have authority to perform all the medications and procedures described in the protocols without contacting medical control for authorization. However, if you need to deviate in any way from the protocols, medical control must be contacted for authorization. In addition, report need not be given to a physician designee at the hospital concerning procedures or medications you have already provided. This report can be given to the dispatcher at the receiving hospital. Along with the increased autonomy of allowing paramedics to perform by protocol only comes the
additional responsibility of making wise treatment decisions. Paramedics must be able to defend their treatment, and their use of the protocol, if a treatment appears to be inappropriate or ill-advised on the patient arrival at the Emergency Department.
The following procedures will be carried out with ON-LINE Medical Control only:
- Medication Assisted Intubation
Service Program Name:
Johnston Fire Department
Service Authorization Level:
Provisional Paramedic /Transport
Service Medical Director:
Dr. Madison, DO
______
Medical Director’s Signature Date
Drug List
Drugs listed on this page are those referenced in the protocols. Medical directors may add, delete, and/or substitute drugs (such as Ativan for Valium) as appropriate for their service program. Additional drugs (such as those from current AHA/ACLS guidelines) may be determined by the service program medical director, based upon the unique EMS system factors.
FR, B, & I DRUG LIST
* Activated Charcoal (Actidose)
* Aspirin
* Glucose Paste
* Oxygen
** Hand Held Nebulizer
** Nitroglycerin
*** Epinephrine auto-injector
PARAMEDIC DRUG LIST
(Includes FR, B & I list)
Adenosine
Albuterol
Atropine
Benadryl
Dextrose
Dopamine
Epinephrine
Glucagon
Lasix
Lidocaine
Magnesium Sulfate
Morphine Sulfate
Narcan
Nitronox
Oxytocin
Procainamide
Romazicon
Sodium Bicarbonate
Thiamin
Valium
Verapamil
I.V. SOLUTIONS LIST
Normal Saline
ADDITIONAL DRUGS LIST
Additional drugs may be used by an approved service program, provided there is documented training of qualified personnel and there is a protocol approved by the service medical director.
Amiodarone
Atrovent (Ipratroium Bromide)
Calcium Gluconate
Etomidate
NeoSynephrine
Nitropaste
Nubain
Pitocin
Vasopressin
Versed
* Over the counter (All levels)
** Patient Assisted Medications (EMT-B and transitioned EMT-I)
*** Administered by EMT-B and EMT-I providers per protocol.
Scope of Practice
As outlined by the Iowa Code, the scope of practice for the different levels of certification is:
First Responder
- AED
- Oral airway suctioning
- Oral / nasopharyngeal airways
- Oxygen administration
- Esophageal / tracheal / double lumen airway
- Vitals, including blood pressure
- BCLS
- Bandaging
- Over the counter medications
- C-collar with manual stabilization
- Initiation of Organ Donation
EMT-Basic
- First Responder level skills, plus:
- Blood glucose testing / Glucometer
- Monitoring and maintenance of non-medicated IV
- Spinal immobilization (C-collar with manual stabilization, short board, long board
- Patient assisted meds (inhaler, nitro, epi-pen)
- MAST
- Extremity immobilization / splint
EMT-Intermediate
- First Responder skills & EMT-B skills, plus:
- Initiation of non-medicated IV
- EGTA
- Gastric tube insertion
EMT-Paramedic
- First Responder, EMT-B, & EMT-I skills, plus:
- Endotracheal intubation
- Pharmacological intervention
- Maintenance & monitoring of intravenous infusion of blood & blood products
- Tension pneumothorax decompression
- Cricothyrotomy and transtracheal insufflation
- Gastric tube insertion
- Nasogastric tube insertion
- Urinary catheterization
- Rotating tourniquets
- Intraosseous infusion
- Rhythm strip interpretation
- Obtaining 12-lead ECG
EMT-Paramedic Specialist
- First Responder, EMT-B, EMT-I and EMT-P skills, plus:
- Nasotracheal Intubation
- 12-lead ECG interpretation
- Assessment Based Spinal Immobilization
STANDARD OPERATING PROTOCOLS
301.02 PROTOCOLS FOR ALL PATIENTS
Scene Size-up
As you approach the scene, assure safety for yourself and the patient. Establish and follow
Incident Command.
BSI (Body Substance Isolation)
Prior to patient assessment, employ precaution to prevent contact with potentially infectious body fluids or materials.
Initial Assessment
Perform initially on every patient to form a general impression of needs and priorities
1. Assess mental status. Maintain spinal immobilization if needed.
Begin by speaking to the patient stating your name, tell the patient that you are an EMT and you are here to help.
2. Assess the patient’s airway status.
Responsive patient - assess adequacy of breathing.
Unresponsive patient - check for and maintain open airway
Position the patient according to age and size
Trauma patients or those with unknown nature of illness, the cervical spine should always be immobilized and the jaw thrust maneuver performed as indicated.
3. Assess the patient’s breathing.
If breathing is adequate and the patient is responsive, oxygen may be indicated.
All responsive patients breathing > 24 breaths per minute or < 8 breaths per minute should receive oxygen per AHA ACLS standards unless their condition warrants
otherwise.
If the patient is unresponsive and breathing is adequate, provide
oxygen per AHA ACLS standards unless patient condition warrants otherwise.
If the breathing is inadequate, assist the patient’s breathing and
If in distress, administer oxygen per AHA ACLS standards unless patient condition warrants otherwise. Use ventilatory adjuncts as needed.
If utilizing pulse oximetry, titrate oxygen delivery to keep oxygen saturation greater than 90 percent.
Assess the patient’s circulation.
Check for pulse. If absent begin CPR.
Check for major bleeding. If present, control.
Check perfusion by evaluating skin color and temperature.
STANDARD OPERATING PROTOCOLS
301.02 PROTOCOLS FOR ALL PATIENTS
Determine Life Threatening Illness/Injury
1. If life threatening condition is found, treat immediately.
2. Assess nature of illness or mechanism of injury.
Identify Priority Patients
1. Consider:
Poor general impression
unresponsive patients -no gag or cough
Difficulty breathing
Responsive / not following commands
Shock (hypoperfusion)
Complicated childbirth
Uncontrolled bleeding
Severe pain anywhere
Chest pain with BP<100 systolic or suspected AMI
2. Trauma Patients
Follow the Out-Hospital Trauma Triage Destination Decision Protocol for the identification of time critical injuries, method of transport and trauma facility resources necessary for treatment of those injuries.
Conduct appropriate history and physical examination
Treatment
1. Follow specific protocol(s) and standing orders approved by service medical director.
2. IV’s should be started in route to the hospital, except where there is an unavoidable delay (i.e. extrication). If paramedic level intervention for an unstable patient requires IV access, the IV should be started as soon as feasible.
1. Venous access can be achieved using either:
Saline lock used only on patients who have stable vital signs and do not require, volume replacement.
Normal Saline for IV fluid administration or volume replacement.
STANDARD OPERATING PROTOCOLS
301.02 PROTOCOLS FOR ALL PATIENTS
2. IV fluid administration is at the following rates:
TKO - slow drip for patients that may need IV medications or fluid
bolus.
Fluid Challenge - rapid 250-500cc bolus.
3. Medication administration - Before administration of a drug you must ask yourself the following questions as you select the medication and confirm that it is not
expired.
Do I have the right patient?
Is this the right medication?
Is this the right dose?
Am I giving this medication by the right route of administration?
Transporting / Tiering
Patients should be transported as soon as possible to appropriate medical facility. Immediate transport with treatment en route is recommended for patients with significant trauma or unstable airways.
Tier with an appropriate service if assistance or level of care needs exist and can be met timely through tiered response.
Communications
A brief radio report including what type of patient and which protocol is being followed at least 5 minutes prior to arriving at the hospital.
A verbal report should be given to the nurse who receives the patient when care is transferred.
A written run report should be completed as soon as possible and a copy provided to the receiving facility to assure the continuity of patient care.
Other
Notify dispatch when assignment is complete. Clean, restock, and check over vehicle and equipment for next assignment.
Consider having a critical incident stress debriefing (CISD) anytime rescuers and health care providers have been involved in a major incident, or one which produces adverse reaction.
You may need to use more than one protocol for any single patient.
STANDARD OPERATING PROTOCOLS
301.03 ABDOMINAL PAIN
Basic Treatment Guidelines
1. Follow initial protocols for all patients
2. General abdominal pain treatment:
If medical emergency, refer to appropriate protocol.
If trauma emergency, refer to appropriate protocol.
Administer oxygen per AHA ACLS standards unless patient condition warrants otherwise.
Keep the patient lying still.
Transport in a position of comfort.
Be alert for vomiting.
Keep the patient NPO.
Advanced Treatment Guidelines
1. If patient condition warrants, establish IV access, infuse as patient condition indicates.
2. Consider cardiac monitoring if condition warrants.
3. If history of kidney stones with similar pain / symptoms. Administer MORPHINE SULFATE 1-5 mg IVP for initial dose and then 2mg increments for pain control until one of the following is present:
Relief of pain
Hypotension develops
Respiratory depression occurs
CNS depression occurs
10mg total has been administered
4. Be alert for pulsating masses. If present be, highly suspicious of abdominal aortic aneurysm (AAA). Monitor peripheral pulses and BP. Establish large bore IV’s.
5. Consider NITROUSOXIDE self administered for pain.
Possible Related Protocols
Hypotension
Hypovolemia
Pain management
STANDARD OPERATING PROTOCOLS
301.04 ALLERGIC REACTION AND ACUTE ANAPHYLAXIS
Basic Treatment Guidelines
1. Follow initial protocols for all patients.
2. Administer oxygen per AHA ACLS standards unless patient condition warrants otherwise.
3. Treat for shock / hypoperfusion if present.
4. If patient is unconscious and pulseless, proceed with cardiac arrest protocol.
Advanced Treatment Guidelines
1. Establish IV access, infuse as patient condition indicates.
2. Monitor ECG and treat dysrhythmias.
3. If reaction is not life threatening, consider administration of :
1. EPINEPHRINE 0.3-0.5mg of 1:1000 solution subcutaneously. If treating a bite or sting, inject proximal to the site when possible as needed every 5-10 minutes up to 3 doses. Use caution in patients with coronary artery disease.
2. BENADRYL 25-50mg IM or slow IV push.
4. If reaction is severe and life threatening, consider administration of EPINEPHRINE 0.5-1.0mg of 1:10,000 solution slow IV push.
5. Consider ALBUTEROL 2.5mg in 3.0cc NS by nebulizer for wheezing.
- ATROVENT (Iptratropium Bromide) 0.5 mg/2.5 mL NS may be added to the ALBUTEROL and delivered simultaneously. *ATROVENT is a one time only administration. The ALBUTEROL may be repeated
STANDARD OPERATING PROTOCOLS
301.05 ALTERED MENTAL STATUS
Basic Treatment Guidelines
1. Follow initial protocols for all patients
2. General altered mental status treatment:
1. Consider all possible causes including head trauma
2. Administer oxygen per AHA ACLS standards unless patient condition warrants otherwise.
3. Utilize appropriate airway management.
4. Administer oral glucose if patient is able to swallow.
5. Be alert for combativeness.
6. Transport in position of comfort
Advanced Treatment Guidelines
1. Appropriate airway management
2. Cardiac monitoring
3. Establish IV access, infuse as patient condition indicates.
4. Obtain blood sugar level.
5. If blood sugar < 60mg/dl, administer 25G 50% DEXTROSE IV and observe for changes. If unable to establish IV access, administer 1mg GLUCAGON IM.
6. If symptoms suggest hypoglycemia, administer 12.5G DEXTROSE IV even if BS > 60mg/dl.
7. If unknown history of events or history of drug abuse, administer 1-2 mg NARCAN IV and observe for response. May repeat if necessary.
8. Consider THIAMIN 100mg IV/IM for patients who are malnourished, history of alcoholism, or long transport time.
Possible Related Protocols
Hypoglycemia
Hyperglycemia
Overdose
Unconscious patient
CVA/Brain Attack
STANDARD OPERATING PROTOCOLS
301.06 AMPUTATED PARTS
Basic Treatment Guidelines
1. Follow initial protocols for all patients
2. General amputated parts treatment:
Control bleeding.
Treat for shock.
Administer oxygen per AHA ACLS standards unless patient condition warrants otherwise.
Follow trauma protocol as indicated.
Care of Amputated Part
Rinse part gently with normal saline to remove loose debris; do not scrub.
Wrap amputated part in saline moistened gauze and transport with the patient.
Place wrapped part in plastic bag and seal (do not immerse part in water/saline). Label with name, date and time.
For long transport, wrap amputated part as indicated above, and keep cool. Place in cooler with cool pack or ice, but NOT in direct contact with ice.
Advanced Treatment Guidelines
1. Establish IV access, infuse as patient condition indicates.
2. Treat for shock if appropriate.
3. Treat for pain if appropriate.
Possible Related Protocols
Hypovolemia
Pain management
STANDARD OPERATING PROTOCOLS
301.07 APPARENT DEATH
Basic Treatment Guidelines
1. Follow initial protocols for all patients
2. Make determination of apparent death. Patient will meet the following criteria;