Flashcards in EMS Standing Orders Deck (202):
If at least ONE of the following conditions is found, CPR may be withheld:
Blunt or penetrating trauma without signs of life
A valid DNR is discovered
If ALL of the following are present , CPR may be withheld:
1. Known downtime greater than (30) minutes
3. Pupils fixed and dilated
4. No respirations
5. Without hypothermic mechanism for arrest
When there are multiple critical trauma casualties and insufficient resources, choices will have to be made in regard to resource allocation:
Physician in attendance: This order, verbal or in writing, must be given by a Florida licensed ____ or ____ to be legal:
MD or DO
When in doubt, especially when it is not the patient who requested our service, ____ consent should be obtained:
Exceptions to patients under the age of 18 who can refuse care:
1. Emancipated minors
2. Self sufficient minor
3. Married minors
4. Minors in the military
Patients may not refuse care under the following circumstances:
1. AMS (GCS less than 15)
2. Suicide attempt (verbal or actual)
3. Mental retardation or deficiency
4. Not acting as a reasonable person would
5. Patients under the age of 18 (except exceptions)
To be considered valid, the DNR must meet the following criteria:
-The form states it is a DNRO and specifies that the patient is not to be resuscitated.
-Original is signed and dated by the patient's physician. Photocopies are acceptable.
-The form has been signed and dated by the patient or the patient's surrogate or proxy.
-The DNR order is not withdrawn by the patient, the patient's attending physician, or the pt's healthcare surrogate or proxy.
-Identity is verified by the driver's license, other photo ID or form a witness in the presence of the patient.
In mutual aid circumstances, personnel should follow the ____ agency's patient treatment protocols:
BLS Airway: If ventilation is required for more than ___ minutes, an LMA should be inserted:
Ventilation Rates: Adults
10 breaths/min (1 breath every 6 seconds)
Ventilation Rates: Children
20 breaths/min (1 breath every 3 seconds)
Ventilation Rates: Neonates
Patients with advanced airways should be ventilated at a rate of _____ breaths/minute (1 breath every 6-8 sec)
Perform MICCR (CPR for PEDS) with the patient in a ___ degree heads up position and defibrillate as needed:
Begin compressoins for infants and children with a pulse less than ___ with signs and symptoms of poor perfusion (altered mental status):
History of present illness: OPQRST:
Palliative (What makes the s&s better)
Provoke (What makes the s&s worse)
Previous (Previous similar episodes)
Endotracheal intubation shall be confirmed by:
1. Direct visualization
2. Esophageal Intubation Detector (EID)
3. Colormetric paper
4. Continuous EtCO@ monitoring
EZ IO primary site is the:
EZ IO secondary site is the:
Which EZ IO site needs insertion by or approval of EMS 2:
EZ IO will be established after 2 unsuccessful IV attempts.
The goal is having an access site within ___ seconds:
Only EMS 2 has the authority to insert or designate use of EZ IO in priority ___ patients:
EtCO2 should be applied to all patients:
1. In respiratory distress or requiring vent support (ETT, etc)
2. AMS with respiratory difficulty or compromise
3. Sedated patients or patients receiving pain meds
All ALS patients shall have continuous EKG monitoring in 2 leads.
Patients who present with any of the following cardiac or possible cardiac symptoms shall have a 12 lead ECG performed:
1. Chest/arm/neck/jaw/upper back/shoulder/epigastric pain or discomfort.
2 Palpitations, or rate greater than 100 or less than 60
3. Syncope, lightheadedness, general weakness, or fatigue
4. CHF, SOB, or hypotension
5. Unexplained diaphoresis or nausea
12 lead ECG's shall be repeated ever ___ minutes and upon a ROSC:
Patients under the age of 18 who weigh ___ kg or less are considered pediatric patients:
Patients under the age of 18 who weigh more than ___ kg or more shall be treated under the adult section of these protocols:
PEDS: Fluid boluses are ___mL/kg and may repeat 2x for hypotension. Max of ___mL/kg:
The preferred method for ventilating pediatric patients is with a ___ in conjunction with an oral or nasal airway:
If there is a discrepancy between the Broselow tape and these protocols, the protocols shall supersede the Broselow tape:
PED Age Classifications: Neonates:
birth to 1 month
PED Age Classifications: Infants:
1 month to 1 year
PED Age Classification: Children:
1 year to puberty
Once a child reaches puberty use the adult guidelines for CPR.
Resp. Rates - Neonates:
Resp. Rates - Infants:
Resp. Rates - Toddlers (1 - 3 y/o)
Resp. Rates - Preschooler (4 - 5 y/o)
Resp. Rates - School Age (6 - 12 y/o)
Resp. Rates - Adolescent ages (13 - 18 y/o)
PED HR - Newborn to 3 months:
85-205, mean 140 bpm
PED HR - 3 months to 2 years:
100-190, mean 130 bpm
PED HR - 2 years to 10 years:
60-140, mean 80 bpm
PED HR - Greater than 10 years:
60-100, mean 75 bpm
PED Hypotension - Neonates:
SBP less than 60
PED Hypotension - Infants:
SBP less than 70
PED Hypotension - Children 1 - 10 years:
SBP less than 70 + (age in years x 2)
PED Hypotension - Greater than 10 years old:
SBP less than 90
All priority 1 patients shall be transported to the closest hospital ER excluding ___.
Pediatric priority one pt's shall be transported to ____ or ___ ER department:
St. Mary's or Palms West
Pregnant trauma patients in cardiac arrest shall be transported to SMMC Trauma Center.
All intubated trauma patients MUST be both ____ and ____ by the sending facility.
paralyzed and sedated
In MCI situations, only patients meeting ______ should be transported to trauma centers:
Trauma Alert Criteria
The guidelines for the Trauma Hawk include but are not limited to the following:
1. Scene to trauma center by ground transport is greater than 20 minutes
2. Trauma Alert with scene extrication time is greater than 15 minutes
3. Ground response time to the scene greater than 15 minutes
The dividing line for WPBFR for transport destinations is:
For the purposes of transport, a pediatric patient is considered less than 18 y/o.
OB patients greater than ___ weeks and less than ___ weeks of gestation OR have anticipated complications with their pregnancy, shall be transported to St. Mary's.
greater than 20
less than 36
OB patients ___ weeks of gestation or greater, may be transported to GSH, if there are no anticipated complications.
Stable psychiatric patients shall be transported to:
Assist patient with Epi Pen administration under the following circumstances:
1. Pt's Ep Pen is prescribed to the pt and not expired
2. Patient presents with respiratory distress and/or hypotension (shock)
Give oral glucose to ADULTS ONLY if available.
Assist ventilations with a BVM and airway adjunct (NPA, OPA) for a respiratory rate less than ___ or greater than ___ with shallow respirtions.
For respirations of ___ or less OR if tidal volume is inadequate, insert NPA/OPA and assist ventilations via BVM (1 breath every 6-8 seconds)
Respirations greater than ___ breaths per minute, maintain oxygen saturations at 95% or greater via NRB mast at 10-15 L/min.
Never apply ice directly to burns
For all burns, apply dry sterile dressing, a burn sheet may be used for large body surface area burns.
Chemical Burns: Remove pt's clothing and ensure that the pt is ____ prior to transport.
Remove contact lenses, with the exception of ____ eye injuries.
Water can be given to responsive patients with an intact gag reflex for heat exposure.
Bites/Stings: Remove the venom sack if still in the skin, by scraping it off.
Do not administer Epi (1 : 1,000) within ___ minutes of Epi-Pen administration.
Anaphylactic Shock is characterized by the signs and symptoms of an allergic reaction, in addition to the loss of a radial pulse AND/OR a SBP of less than ___ mm/Hg:
Establish a second IV/IO in anaphylactic shock.
Pediatric: Max dose for Benadryl ___ mg
Pediatric: Anaphylactic Shock is characterized by s&s of allergic reaction, in addition to the loss of ______.
Anyphylactic Shock: If patient remains hypotensive NORMAL SALINE 500mL may repeat ___.
Pediatric Anaphylactic Shock: If patient remains hypotensive NORMAL SALINE 20mL/kg bolus IV/IO, may repeat ___ prn.
ADULT: Dose: Epi (1:10,000) Anaphylactic Shock:
0.1 mg (1mL), slow IV/IO, may repeat 2x prn in one minute intervals. MAX dose 0.3mg
ADULT: Dose: Epi (1:1,000) Allergic Reaction:
0.3mg (0.3mL) IM, may repeat 1x in 15 minutes prn
PED: Dose: Epi (1:1,000) Allergic Reaction:
0.01mg/kg (0.01mL/kg) IM. Max single doe 0.3mg. Repeat every 15 min as needed.
PED: Dose: Epi (1:10,000) Anaphylactic Shock:
0.01mg/kg (0.1mL/kg) Repeat pen for profound respiratory distress and/or hypotension. Max dose 0.3mg
A - Alcohol
E - Epilepsy (Seizures)
I - Insulin (Hyper/Hypoglycemia)
O - Overdose (and Oxygenation)
U - Uremia (or Underdose)
T - Trauma
I - Infection (Sepsis)
P - Psychiatric (and Poisoning)
S - Stroke (and Shock)
Diabetic emergencies, retest glucose in ___ minutes:
ADULT: Glucagon Dose:
1 mg IN or IM
Oral Glucose Dose:
15g/tube May repeat 1x prn
If blood glucose level is greater than ____ mg/dl with s&s of DKA:
PEDS: If blood glucose levels are less than 60 mg/dl (newborns ___ mg/dl)
Oral Glucose not recommended for patients less than ___ years old.
PEDS: D10 5mL/kg IV/IO for birth to ___ years of age.
PEDS: D50 1mL/kg for > ___ but
PEDS: Zofran for patients greater than ___ y/o. Dose:
0.1mg/kg Max dose of 4mg
PEDS: Glucagon 0.5 mg IM/IN for patients less than ___ kb.
PEDS: Glucagon 1 mg IM/IN for patients greater than ___ kg.
Dextrose 10%: Mixture is:
1 amp of D50 into a 250 ml of D5W will yield D10.
Adults normotensive with s&s of dehydration or non-traumatic bleeding Normal Saline: Max of ____.
Pediatric normotensive with s&s of dehydration Normal Saline 20mL/kg WIDE OPEN.
Consider Sepsis for all dehydrated patients.
Typically, Anitpsychotic, Antiemetic, or Antidepressant meds are responsible for Dystonic Reactions.
Minimum of ___cc flush before administering Calcium and Sodium Bicarb in the same line.
If patient is in cardiac arrest secondary to hyperkalemia ,administer ____ & ____ first, then follow standard Pulseless Algorhythm.
Calcium Chloride & Sodium Bicarb
____ occurs during assisted ventilations when air goes inbefore patient is allowed to fully exhale.
Increasing intrthoracic pressure DECREASES venous return to the heart which can result in hypotension.
COPD or Ashtma patients who develop poor bag compliance or hypotension during PPV should have PPV discontinused for ____ seconds for Adults and ____ for pediatrics.
CPAP (10-12 cm H2O)
1. Discontinue CPAP for asthma patients whom's condition worsens after applying CPAP.
2. SBP less than 90mm/Hg
3. For patients with spontaneous respiratoins
4. For unconscious patients
Administer in-line nebulized albuterol of ALL intubated asthma patients.
1. Usually less than3 y/o
2. "Sick" for a couple of days
3. LOW grade fever
4. Not "toxic" appearing
1. Usually 3-6 y/o
2. Sudden Onset
3. HIGH grade fever
4. Bad general impressoin
6. Tripod position
PEDS: For febrile seizures lasting longer than ___ minutes, or if the seizure stops and the patient has another seizure, administer Versed.
PEDS: Versed DOSE:
0.1 mg/kg. Max single dose 2.5 mg. Max dose of 5mg
PEDS: Ativan DOSE:
.05mg/kg. Max single dose of 1mg. Max dose of 2mg!!
It is imperative that once sepsis is identified, that the patient is kept from becoming ____.
Sepsis: Initiate Treatment for patients with the following:
1. 18 years and older and NOT pregnant
2. Suspected or documented infection
3. At least TWO SIRS criteria:
-Pulse greater than 90
-Respirations greater than 20
-Temp >100.4 or less than 96.8 F
4. Hypoperfusion as manifested by any ONE of the following:
-SBP less than 90mmHG
-Mean Arterial Pressure (MAP) of less than 65
-Lactate level >4 mmol/L (if lactate monitor avail)
Sepsis: Normal Saline ___ liters, regardless of blood pressure.
Fentanyl or MS can be administered to all patients complainin of pain with the exception of pregnant patients near term (__ weeks or greater).
PEDS: Fentanyl (greater than __ years old). DOSE:
1mcg/kg. Max single dose of 50mcg/kg.
Max total dose of 150mcg.
STROKE ALERT CRITERIA CHECK LIST
Cincinnati Pre-Hospital Stroke Scale
•Arm Drift (palm up)
•Speech (Slur or inappropriate use of words)
•Time (Last seen normal)
-Lower Extremity Weakness
-Finger to Nose
-Sudden onset of a severe headache with neurological symptoms
Call a STROKE ALERT for failure of any of the above…. AND
Deficit not due to low blood sugar
Deficit not likely due to head trauma
Stroke: Normal Saline 500cc Bolus (REGARDLESS of BP)
• Onset of stroke symptoms greater than 2 hours
• Seizure prior to stroke symptoms
• Prior stroke or serious head injury within the previous 3 months
• Major Surgery within 14 days
• Known history of intracranial hemorrhage
• Gastrointestinal or urinary tract bleeding within 21 days.
Bradycardia in the presence of an MI go directly to transcutaneous pacing.
ADULT: Transcutaneous pacing start rate at ___ BPM and increase prn to maintain BP.
If unable to establish IV/IO access, begin ___ until an acceptable BP is obtained.
PED Bradycardia: Ensure proper ____ and ____ first, as hypoxia is most likely to be the cause of the bradycardia.
oxygenation and ventilation
After oxygenation and ventilation for 1 minute for infants/children and ___ seconds for neonates, begin chest compressions if the HR remains below 60 BPM with s&s of poor perfusion (AMS).
PED Bradycardia: If no response to Epinephrine start pacing at ___ BPM and increase the rate as needed.
Pediatric sedation Etomidate (greater than 1 y/o) DOSE:
Chest Pain: The right ___ and anywhere on the left is acceptable site for IVs.
Withold ASA if:
Patient administerd 162mg of aspirin within 24 hours
If patient self-administered less than 162 mg of ASA within 24 hours, administer ____
full 162 mg dose
An IV must be established prior to NTG administration.
Contraindications for NTG:
1. SBP less than 90 mmHg
2. EDD (Viagra & Levitra within 24 hrs and Cialis within 48 hours)
3. Right Ventricular Infraction
4. HR less than 50 or greater 100 BPM
ST-Segmaent Elevation of __mm or greater in two or more contigous leads ( __mm in V2 and V3)
The most used drug per year by WPBFR is ____ @ 379.
All 12 lead ECG's shall have the patients:
last name and first initial
PEDS: Sickle Cell: Morphine Sulfate DOSE:
0.1mg/kg slow IV/IO/IM. Max single dose of 4mg, may repeat every 5 min prn. Max total dose 8mg.
Rapid A-Fib and A-flutter are defined as VENTRICULAR rates greater than ____ BPM.
-Wide Complex QRS
-Hx of WPW or Sick Sinus Syndrome
-Use with caution for pt's taking beta blockers
If hypotension develops after Cardizem administration, administer ____ mL of Normal Saline and ____ mg of Calcium Chloride
500 , 500
Unstable A-Fib and A-Flutter, if patient still remains hypotensive after fluid bolus call ______ for further orders.
PED Bradycardia: If no response to oxygenation and ventilation (no AV heart block), next step is:
Atropine 0.02mg/kg (0.2mL/kg) Minimum single dose of 0.1mg. Max single dose of 0.5mg. May Repeat 1x prn
PED Bradycardia: Epi (1:10,000) Dose:
0.01 mg/kg (0.1mL/kg) IV/IO. Repeat every 3-5 minutes prn
Cardiogenic Shock: Left Ventricular Failure: Pulmary Edema and Hypotension your initial treatment is:
Dopamine 5-20 mcg/kg/min. Titrate to SBP 90 mmHg.
Cardiogenic Shock: RVF: Positive V4R, Clear Lung Sounds, and Hypotension, if patient remains hypotensive after fluids administration:
Dopamine 5-20 mcg/kg/min. Titrate to SBP 90 mmHg.
For STEMI Alerts or suspected STEMI Alerts, the ___ hand and wrist should be avoided if at all possible for IV Access.
The ___ AC and anywhere on the left is acceptable of IV access in regards to STEMI Alerts.
Contraindications for Aspirin:
-Active GI bleeding
Withhold ASA is patient administered 162mg of ASA withing 24 hours.
Mild to moderate chest pain, treatment:
-Aspirin: two 81mg baby aspirin (162mg total)
-NTG: 0.4 SL Max 3 doses
In rare occasions, Fentanyl may cause _____.
Fentanyl: Dose for Moderate to Severe Chest Pain:
50 mcg slow IV/IM/IN. Max total dose 150mcg.
Morphine Sulfate: Dose for Chest Pain:
5mg slow IV/IO/IM. Max total dose 10mg
All STEMI Alerts are considerers priority ___ patients.
STEMI ALERT Criteria: ST-Segment Elevation of ___mm or greater in two or more contiguous leads ( __mm in V2 and V3)
1 , 2
The following are STEMI mimics:
-QRS complexes greater than 0.12 (LBBB, Pacemaker, etc.)
-Left Ventricular Hypertrophy
Patient presentations indicative of myocardial ischemia that DO NOT meet STEMI Alert Criteria should still be transported priority 2 to ____, ____, _____, _____, or ____.
CPAP (10-12 cm H20) Contraindications:
-SBP less than 90mmHg
CHF (Pulmonary Edema): First dose of NTG may be administered prior to 12 lead is SBP is greater than ____
CHF: SL NTG may be given concurrently with NTG paste for SBP greater than ____.
Regular, narrow complex tachycardia of 150 BPM or greater without discernible P-waves and/or flutter waves:
SVT Adult: Adenosine dose:
6mg rapid IVP, with 20mL flush. If no change in one minute, 12mg IVP with 20mL flush.
Unstable SVT Adult: If patient is Alert:
Adenosine 6mg IVP. If no change, 12mg IVP with 20mL flush each
Unstable SVT Adult: if patient has altered mental status consider sedation prior to cardioversion Etomidate ____ mg IV/IO. May repeat 1x prn.
Unstable SVT Adult: if cardioversion fails:
Call For Orders
PED SVT: Adenosine dose:
0.1mg/kg rapid IV/IO with 10mL flush. Max dose 6mg.
PED SVT: If no change in one minute after initial dose of Adenosine:
Adenosine 0.2mg/kg IV/IO with 10mL flush. Max dose 12mg
PED SVT: Synchronized cardioversion dose:
0.5j/kg, if not effective increase to 2j/kg
SVT in infants is considered greater than ___ BPM.
SVT in children is considered greater than ___ BPM.
PEDS SVT: QRS greater than ____ sec is considered a Wide Complex.
Stable VT: Adult: Administer ALL 150mg, REGARDLESS, if the VT terminates.
Unstable VT Adult: If cardioversion terminates the VT and the patient returns to VT, begin cardioversion at the last successful energy setting and increase as needed.
PED: Stable VT: Amidodarone is infused over ___ minutes. 25 gtt/min using a Macro drip set. Max dose ___ mg.
20 , 150
PED: Unstable VT: If cardioversion is successful DO NOT administer antiarrhythmics.
Emphasis is placed on minimizing interruptions in compressions to no more than ___ seconds.
Infants and children with a heart rate less than ___/min with signs of poor perfusion shall have 2 person CPR initiated at 15:2
Medications should be delivered as soon as possible after the _____ (during compressions) and circulated for 2 minutes.
Follow all IVP medication administrations with a ___mL Flush NaCL (Adult Only).
Consider terminating efforts when an EMS Captain is on scene and:
1. Asystole/PEA has been documented for 15 minutes
2. All ALS interventions have been completed and reversible causes have been addressed.
Prolapsed Cord: Place mother in the knee to chest position and manually displace the uterus to the _____.
Prolapsed Cord: Wrap the exposed cord in what type of sterile dressing?
Nuchal Cord: If you are UNABLE to free the cord, clamp the cord in TWO places and cut between the clamps
Meconium Staining: If meconium staining is present AND the infant has depressed respirations, limp and/or a heart rate of less than 100, DIRECT suctioning of the _____ must take place AFTER delivery, before the infant takes too many breaths.
Meconium Staining: Insert a laryngoscope and suction posterior pharynx with a ___F or ___F suction catheter so that you can visualize the glottis.
Meconium Staining: Apply suction as the tube is slowly withdrawn for ____ seconds.
If meconium is present with the FIRST SUCTION:
1. Repeat suction until there is little additional meconium recovered OR
2. Neonates HR drops below 100, requiring PPV
Breech Birth: If the head does not deliver within ___ minutes of the body, elevate mother's hips and insert gloved hand into the vagina and push the vaginal wall away from the babies nose and mouth.
1. Dry, Suction, tactile stimulation, position
2. Bag & mask ventilation
3. Chest Compressions
Check a ____ on all infants requiring resuscitation.
Cut the umbilical cord by placing two clamps. The first ___in away from the infants abdomen and the second ___ in away from the infants abdomen.
-Sudden onset of severe abdominal pain and tenderness
-Painful uterine contractions
-Vaginal Bleeding with DARK RED BLOOD
-Patient may present in shock
Characterized by PAINLESS vaginal bleeding (BRIGHT red blood):
Sudden, intense abdominal pain and vaginal bleeding:
All patients with third trimester bleeding shall be transported to _____
All THIRD TRIMESTER patients in cardiac arrest should be treated if they are in ____ arrest and transported to SMH.
_____ usually occur in the FIRST trimester and may present with sudden onset of severe lower abdominal pain and or vaginal bleeding.
Patients with amenorrhea, vaginal bleeding and abdominal pain are highly suspicious for an _____ pregnancy
Ecchymosis of the flanks:
Grey Turner's sign