Protocols

Question 1

EMT-B Standing Orders

Answer 1

Primary, secondary assessment
MCI Triage
VS, including BP HR RR LOC, pain lvl, skin signs, pupils, BS, SPO2
O2
BVM w/ O2
Oral glucose
CPR w/ & w/o LUCAS
Defibrillate via AED
TQ
Hemostatic dressing
Epi auto injector
Narcan
Duodote
Extrication
CPAP
Spinal immobilization
Extremity splints / traction splints

Assist with: NTG, Albuterol (mdi or neb), ASA, 12 lead placement, prepping IV fluid.

Can transport patients w/ NS / IV infusions, saline locks, mechanically restrained patients, pts w/ NG tube, gastrostomy tube, foley cath, or trach tube

Question 2

No treatment / eval &
Signing AMA

Answer 2

No tx / eval: No emergency medical or psychiatric condition, no injury or illness, transport not indicated nor requested, and legally capable of making decisions. If not legally capable of making decisions, their parent / guardian has done so. Complete a primary exam, secondary exam, and VS, pt communicates that they don’t want EMS services or transport, encouraged to f/u PRN, left in a safe situation.

AMA: Pt must be legally capable of making decisions; If not legally capable of making decisions, their parent / guardian has done so. Complete a primary exam, secondary exam, and VS, pt communicates that they don’t want EMS services or transport, must communicate to pt the potential risks/ consequences of refusal of care and offer alternative options for care / transport. Encouraged to call 911 again PRN. Consider legal detention via LEO.

Question 3

Cardiac Arrest

Answer 3

Start 5 cycles CPR

Consider passive ventilation for 6m if witnessed arrest
otherwise high-flow O2 by BVM w/ ETCO2

Try to elevate to 30 degrees semi-fowlers

~2min: Rhythm check, shock if appropriate. Note: Treat fine VF as PEA/ asystole; Do not shock unless coarse VF or pVT. For pVT / coarse VF, shock either per Zoll recc (120J, 150J, 200J) or max defib (200J, 200J, etc).

5 cycles CPR + IV/IO access

~4min: Rhythm check, shock if appropriate.

5 cycles CPR + Epi 1mg (0.1mg/mL)

~6min: Rhythm check, shock if appropriate.

5 cycles CPR. If indicated, amio 300mg or lido 1.0mg/kg

~8min: Rhythm check, shock if appropriate.

5 cycles CPR + Epi 1mg (0.1mg/mL)

~10min: Rhythm check, shock if appropriate

5 cycles CPR + sodium bicarb 50mL. If indicated. amio 150mg or lido 0.5mg/kg

~12min: Rhythm check, shock if appropriate

5 cycles + Epi 1mg (0.1mg/mL) + ETI

Etc.

After 20m, consider BH contact for pronouncement or transport. Must do so after 30m Nearest ERC unless confirmed STEMI

Note: Consider reversible causes, particularly in PEA (hypoxia, hypothermia, hypovolemia, hypoglycemia, hypokalemia, hyperkalemia, acidosis, tamponade, toxins, tension pneumo, coronary or pulmonary thrombosis, trauma) Can give 250mL NS boluses up to max of 1L unless rales, 250mL d10 for suspected hypoglycemia, NCD for tension pneumo, bicarb for acidosis, etc.

Question 4

ROSC

Answer 4

Ventilate and oxygenate via BVM / high flow
Assess for and correct hypoxia, hypovolemia, hypoglycemia, hypothermia
Perform a 12-lead. If STEMI, transmit to BH / CVRC
Consider advanced airway for apenic / resp. depression

Question 5

Cardiac CP

Answer 5

Monitor rhythm
Obtain 12-lead as soon as possible prior to leaving scene; make BH contact if acute MI suspected
ASA 324mg
SPO2, give O2 if <95%
NTG x 3
If pain unrelieved by 3 doses NTG and BP > 90, fentanyl 50mcg
For N/V and not suspected to be pregnant, zofran 4mg IV or 8mg ODT

Question 6

Symptomatic bradycardia (Adult)

Answer 6

Monitor rhythm
SPO2, give O2 if <95%IV / IO
Atropine 1mg IV/IO/IM q3m to a max total dose of 3mg
If 1st round of atropine has no effect, run concurrently with TCP
-Can give 5mg Versed IV / IN prior or during TCP if needed
If BP remains below 90, 250mL NS boluses
For furter, contact BH. BH may order push dose epi

Question 7

Narrow complex regular tachycardia

Answer 7

Monitor rhythm
SPO2, give O2 if <95%

For rates 100-150, consider a hypovolemic ST and trial NS bolus

Mildly symptomatic w/ rates >150…..
Consider a hypovolemic ST and trial NS bolus
Valsalva
Adenosine 12mg, repeated once after 3m

Severely symptomatic or BP < 90
Synch’d 100J shock, may repeat once @ max or Zoll (120, 150, 200J)

Question 8

Narrow-complex irregular tachycardia

Answer 8

Monitor rhythm
SPO2, give O2 if <95%
Consider 12 lead for CP, dyspnea
Consider hypovolemia and trial NS bolus

Question 9

Pulse-producing wide-complex tachycardia

Answer 9

Monitor rhythm
SPO2, give O2 if <95%
Stable or unstable? (Sys BP >90, no AMS, minimal or great CP)

If stable, transport ALS to nearest ERC

If unstable, 100J sync’d cardioversion
If rhythm persists, 150mg amio slow IV, allow 2 min to circulate
If rhythm persists, max dose (200J) cardioversion
If rhythm persists, 150mg amio slow IV, allow 2 min to circulate
If rhythm persists, max dose (200J) cardioversion

ALS escort to nearest ERC

Question 10

Burn victim (thermal, electrical, or chemical)

Answer 10

High flow O2 if indicated
Cooling measures if still symptomatic
For wheezing / suspected smoke inhalation: 5mg (6mL) albuterol via continuous neb
For pain: Morphine or fentanyl
BP < 90? 250mL NS boluses
Consider burn activation

Question 11

Abd pain

Answer 11

Airway
For dehydration, IV and 250mL boluses of NS
Zofran
Morphine or Fentanyl
Transport to nearest ERC (ALS if meds or NS given)

Question 12

Hyperglycemia

Answer 12

BLS if BG < 400 and no other complaints or comorbidity exists requiring ALS intervention or monitoring
ALS if BG > 250 w/ comorbidity or symptoms, or any BG > 400
Recommend ETCO2
For DKA: O2 6L via NC or NRB, monitor, IV, boluses of 250mL NS

Question 13

Allergic reactions

Answer 13

Simple rash, stable VS, no h/o anaphylaxis: SPO2, O2 PRN, transport

Angioedema: 0.5mg epi (1mg/mL) IM once, hold if any epi taken prior to arrival. High flow O2 via NRB or 6L NC. 50mg benadryl IM/IV once (hold if any taken prior to arrival). ALS to nearest ERC

Anaphylaxis (hypotension, wheezing, SPO2 <95, stridor, etc:
0.5mg epi (1mg/mL), repeated once after 5m (self auto-injection considered a first dose). 6L O2 via NC or mask. Establish IV/IO access, give 250mL NS boluses if hypotensive. If 5 minutes elapses with continued hypotension, respiratory distress, impending airway loss, then give the 2nd dose of epi and 50mg benadryl IM/IV once (hold if any taken prior to arrival)

Question 14

AMS

Answer 14

Protect airway (intubate PRN)
Consider SNRC
Monitor rhythm
SPO2, give O2 if <95%
For hypotension, give NS bolus
Consider hypoglycemia and treat appropriately
For respiratory depression, Narcan
Document response to each tx
ALS to nearest ERC

Question 15

CVA

Answer 15

Contact BH if SNRC criteria met (new onset pronator drift, extremity or facial paralysis / droop, asymmetric decreased grip strength OR sudden, severe HA, multiple emesis, neuro deficit, AMS, dia BP >100)

Ondanestron OK but otherwise nothing PO
Monitor rhythm
SPO2, give O2 if <95%
BG analysis, treat if <60
For hypotension, give NS bolus
Document last known well

Question 16

Behavioral / pysch

Answer 16

LEO, spit sock PRN
SPO2, give O2 if <95%
For hypotension, give NS bolus
BG analysis, treat if <60
For respiratory depression, BVM, O2 & Narcan
For excited delerium, 5mg Versed once

Question 17

Respiratory distress

Answer 17

SPO2, give O2 if <95% (or 2L via NC for COPD not in severe distress)
For bilateral basilar rales: NTG, CPAP, 12-lead
Stable stridor: Position of comfort, ALS to nearest ERC
Wheezing: Albuterol neb, CPAP, ALS to nearest ERC

Question 18

SZ

Answer 18

Protect airway (position on side and suction)
10mg Versed IM (or 5mg IV/IN/IO repeated once after 3m)
SPO2, give O2 if <95%
Utilize BVM for ETCO2 > 50
BG analysis, treat if <60
ALS to nearest ERC

Question 19

Shock (symptomatic hypotension)

Answer 19

Monitor rhythm; 12 lead to r/o MI
SPO2, give O2 if <95%
IV Access; For hypotension, give NS bolus
Contact BH if not responding to NS or rales present
ALS transport

Question 20

Substance OD

Answer 20

Protect airway (position on side and suction)
BVM if needed (intubate if time permits)
SPO2, give O2 if <95%
BG analysis, treat if <60
For hypotension, give NS bolus
Opiate OD suspected: Narcan
Stimulant OD suspected: Midazolam 5mg IM/IV once if needed
Monitor for and treat hyperthermia
For N/V (and not pregnant): Zofran 8mg ODT or 4mg IV
For OP poisoning: atropine 2mg repeated once PRN
Cyanide? High flow O2, cardiac monitor, hydroxocobalamine
Wheezing? Albuterol neb, CPAP
Dystonia? Benadryl

Question 21

Sepsis

Answer 21

Suspect infection - cough, h/o UTI, skin infection, immune weakness
GCS<13? SBP<100? RR>22?

Tx:
Monitor rhythm
SPO2, give O2 if <95%
IV Access; For hypotension, give NS boluses
Call BH for no improvement
ALS to nearest ERC with sepsis alert

Question 22

N/V

Answer 22

Protect the airway, suction as needed
For hypotension, IV access and NS boluses
Zofran 8mg ODT or 4mg IV repeated once after ~3m

Question 23

ETI Sedation

Answer 23

5mg midazolam once if SBP > 90
(trial 250mL NS bolus if SBP < 90)

Question 24

Trauma Triage Criteria

Answer 24

Falls (>15’ in adult, >10’ in child, fall from galloping horse)

MVCs (1’ intrusion into where seated or any 1.5’ intrusion, partial or complete ejection, death of another passenger)

Diving accidents w/ suspected spinal cord injury

Hangings

Auto vs. pedestrian or biker >20mph or when thrown

Motorbike crash > 20mph

Any unmanageable airway]

Traumatic cardiopulmonary arrest

Cleanly cut amputations to the thumb prox. to IP, multiple fingers prox. to mid-phalanx, hand, UE, penis. Possibly leg per BH

Question 25

Trauma Standing Orders

Answer 25

SPO2, give O2 if <95%
Wheezing? Albuterol neb
Bleeding? Pressure, hemostatic, TQ
For hypotension, IV access and NS boluses
Eye injury? cove the injured eye, elevate the head, morphine or fentanyl for pain
For N/V (and not pregnant): Zofran 8mg ODT or 4mg IV
Extremity trauma? Splint, cold packs, morphine or fentanyl
Stabilize impaled objects in place when possible, pain meds
Avulsion? return tissue to proper place and secure with NS sterile dressing
Amputation? rinse off with sterile saline, wrap in NS sterile gauze

Question 26

Crush injury

Answer 26

BVM if needed
SPO2, give O2 if <95%
IV/IO access, give 250mL NS prior to release of compression force
Continue NS as a wide open infusion for hypovolemia
Albuterol neb
if extrication > 1 hour: 50mL sodium bicarbonate
Morphine or fentanyl for pain
Release compression & extricate patient
Manage bleeding, splinting
Transport

Question 27

Symptomatic bradycardia (ped)

Answer 27

Ensure patent airway
Assist breathing if needed; BVM or O2
Monitor rhythm
IV/IO access
Epinephrine 0.01mg/kg (0.1mg/mL solution)
BH contact
Atropine 0.2mg/kg (min 0.1mg, max 0.5mg), may repeat once
3 20mL/kg NS boluses
Treat underlying causes