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Guidelines for Use of Restraints

-ALS assessment for restraint pt.
-Pt. direct supervision at all time during tx./transport. ABC's and pulse oximetry
-Circulation to all extremities evaluated/documented q 10minutes
-Cardiac monitor applied and monitor strip documented
-Call online medical direction with medical control as soon as is reasonable
-Pt. in restraints warrants ALS transport


Guidelines for Use of Restraints

-Handcuffs may be used but the officer has to accompany the pt. to the hospital, and handcuff key rides inside ambulance during transport.
-Leather or other agency approved soft restraints may be used.
-Linens may be used as restraint devices if they are secured in a manner that allows rapid pt. access in an emergency.


Guidelines for Use of Restraints

-Do not compromise airway/breathing
-No "hog-tied" or prone position
-No pt. in between backboard and stretcher
-Restraints shall be placed not to preclude evaluation of pt. medical status or to cause injury


Guidelines for Use of Restraints

-Reason why Restraints needed(pt. behavior/statement made by pt. family members, bystanders)
-Type of restraints used
-Pt. position during tx. and transport
-Pt. response to restraints applied
-Data indicating constant vitals assessed
-Status of circulation distal to restraints
-Total time pt. was restrained in FD care
-Any pt. assessment/tx. UTO due to pt. combative/uncooperative state
-Pt. status at time of transfer of care


Guidelines for Prehospital Medical Care Directive(DNR)

-Resuscitative measures listed in DNR are: cardiac compression, endotracheal intubation, and other advanced airway management, artificial ventilation, defibrillation, administration of advanced cardiac life support drugs and related emergency medical procedures.
-DNR do not apply to mass casualties or medical emergencies involving children/disabled adults in public or private schools that are not licensed health care institutions.
-DNR is printed on ORANGE background in letter or wallet size with specific wording refusing resuscitative measures, bracelet can be worn on ankle/wrist and state Do Not Resuscitate; pt. name; pt. physician name and all on orange background
-DNR is effective until revoked or superseded by new document
-Photo is not required


Guidelines for Prehospital Medical Care Directive(DNR)

To Honor DNR Request:
-Pt. pulseless/apniec with no vital signs or signs of life
-Orange DNR available and valid. (up to 2 minutes can be taken to locate document)
-There is no on-scene request for resuscitate


Guidelines for Field Termination

-Pt. must be in cardiopulmonary arrest in a rhythm incompatible with life(asystole, pulseless electrical activity, or sustained Vfib/Vtach)
-On-line Medical direction required for all field terminations
-4 rounds of CCR or ACLS


RSI Indications

-respiratory failure
-severe head trauma
-spinal cord injury
-facial/airway burns
-greater than/equal to 15 years of age
-toxic inhalation
-loss of gag reflex
-GCS < 8
-inability to maintain airway/ventilation


RSI Relative Contraindications

-spontaneous breathing with adequate ventilations
-cric wild be difficult
-ETT intubation would be difficult
-inability to secure airway by other means


RSI Absolute Contraindications

-history of neuromuscular disease
-known hypersensitivity to protocol drugs
-cric or ETT impossible(morbid obesity, recessed chin, fused neck)
-upper airway obstruction
-history of malignant hyperthermia


1. If you have inadequate or no bystander CPR/CCR prior to arrival....

2. Adequate bystander CPR/CCR prior to arrival....


1. 200 chest compressions, establish IV/IO access, apply O2 mask with 100% oxygen, EPINEPHRINE 1mg IV/IO(1:10,000)

2. Rhythm analysis-single shock at 150 if indicated without a pulse


What rate do you perform chest compressions?


-100 per minute


When do you perform ventilation/intubation?

ATP-01, ATP-02

-After the fourth round of 200 compressions and 4th EPINEPHRINE. Then endotracheal intubation and resume standard ACLS procedures



ATP-01, ATP-02


-was bystander CRP/CCR in progress
-if bystander CPR/CCR who was performing, i.e., family, friends, law enforcement, etc
-estimated time of collapse
-AED used prior to arrival
-was patient gasping prior to arrival
-specify that CCR protocol was utilized
-time and dosages of all defibrillation and medication
-all monitored cardiac rhythms


Contraindications for CCR and MICR?

ATP-01, ATP-02

-children less than 8 years old
-known or suspected overdose
-suspected primary respiratory cause of the arrest
-near drowning
-cardiac arrest secondary to traumatic injury


1. Inadequate or no bystander CPR/MICR prior to arrival....

2. Adequate bystander CPR/MICR prior to arrival....


1. 2 minutes of chest compressions(use dynamometer if available), establish IV/IO access, apply O2 mask with 100% oxygen, EPINEPHRINE 1mg IV/IO(1:10,000)

2. rhythm analysis-single shock at 150 if indicated without pulse check


What are reversible causes?

-hydrogen ions(acidosis)
-tension pneumothorax
-tamponade, cardiac
-thrombosis, pulmonary
-thrombosis, coronary



-maintained oxygen saturation of greater or equal to 94%, consider advanced airway and waveform capnography, do not hyperventilate, obtain 12 lead ECG, treat hypotension(fluid bolus/vasopressor), consider treatable causes


CPR Quality for cardiac arrest: ACLS Protocol

-push hard greater than or equal to 2inches(5cm) and fast(>100/min) and allow chest recoil
-minimize interruptions in compressions
-avoid excessive ventilation
-rotate compressors every 2 minutes
-if no advanced airway, 30:2 compression-ventilation ratio
-quantitative waveform capnography: if
ETCO2 <10mmHg, attempt to improve CPR quality
-support use of dynamic feedback devices(hockey puck) during resuscitation if available


ROSC for cardiac arrest: ACLS Protocol

-get pulse and blood pressure
-abrupt sustained increase in ETCO2(typically >40mmHg)


Shock Energy for cardiac arrest: ACLS Protocol

-biphasic: 120-200J, if unknown use maximum available. Second and subsequent doses should be equivalent and higher doses may be considered
-monophasic: 360J


Drug Therapy for cardiac arrest: ACLS Protocol

-EPINEPHRINE IV/IO dose: 1mg.(1:10,000) every 3-5minutes
AMIODARONE IV/IO dose: first dose-300mg. bolus; second dose--50mg(may use lidocaine if amiodarone is not available)


Advanced Airway for cardiac arrest: ACLS Protocol

-supraglottic advanced airway or endotracheal intubation
-waveform capnography to confirm and monitor ET tube placement
-consider OG tube placement for gastric decompression when advanced airway adjuncts are placed
-8-10 breaths per minute with continuos chest compressions


Bradycardia: With a Pulse

1. Identify and treat underlying causes.....

2. Persistent bradyarrhythmia causing....


-HR typically <50/min

1. -maintain patent airway; assist breathing as necessary
-oxygen(if hypoxemic)
-cardiac monitor to identify rhythm; monitor blood pressure and oximetry
-IV/IO access
-12 lead ECG if available; don't delay therapy

2. -hypotension
-acutely altered mental status
-signs of shock
-ischemic chest discomfort
-acute heart failure


Obvious Death

-Decapitation or decomposition(contact PD)


Apparent Death

-Apneic and pulseless with dependent lividity or rigor mortis(may be pronounced dead without contacting Medical Control, document time and findings)
-asystole in two or more leads


Other signs of irreversible death.....

-evidence of massive external blood loss
-massive blunt head/thoracic/abdominal trauma


Who can refuse:

-18 years or older, if under 18 then needs to be released to parent, guardian, law enforcement personnel. Patient under 18 claiming to be emancipated legal documents must be produced and verified with valid ID.
-is patient A/Ox4
-exhibits no signs of ALOC, alcohol or drug ingestion that impairs judgment
-understands the nature of his/her medical condition and risk/consequences of refusing care


Who CANNOT refuse without an On-Line physician order(high risk refusal)

-patients stunned/stopped by means of electro-muscular disruption weapon(i.e., taser) 4lead and 12lead must be attached to the chart for a patient involved in with a taser
-patient is impaired by drinking alcohol or using drugs
-injury to head or face or possible head injury
-person thought to be danger to themselves or others
-PEDS patient with REPORTED(does not have to be observed) apparent life threatening event(apnea, color change(cyanosis, pallor, erythema)marked change in muscle tone, choking or gagging.
-person that has been given medications including oxygen which resulted in relief of symptoms and no wish to refuse
-patient would be given ALS treatment if they would not refuse
-patient that is post-ictal
-patient cannot understand consequences of their refusal
-patient does not speak/understand English unless interpreter is present
-patient has/appear have mental illness/retard
-minors that wish to be released to anyone other than a parent or legal guardian. Adult accepting minor must sign refusal(approved by on-line medical direction)
-Patient with any of the mechanisms or conditions listed: -falls adult >20ft, children>10ft or 2-3times the height of child, intrusion into occupant compartment >12inches or >18 inches any site, ejection(partial/complete), death in same passenger compartment, auto-pedestrian/auto-bicyclists thrown/run over with significant (>20mph) impact, motorcycle crash >20mph
-Patient with any of the following characteristics or complaints: -abdominal pain, altered mental status(altered for pt), any acute cardiac dysthymia, chest pain, electrocution, foreign body ingestion, inability to ambulate(not normal for pt), overdose or poisoning, pt volunteers high risk condition, pregnancy related complaint, seizures, syncope/near-syncope, taser incident, water related submersion incidents, penetrating injuries.


What are the high-risk indications that must be absent to release patient BLS.....

-abdominal pain
-alerted mental status(altered for pt.)
-any acute cardiac dysthymia
-chest pain
-foreign body ingestion
-inability to ambulate(not normal for pt.)
-overdose or poisoning
-patient volunteers high-risk condition
-pregnancy-related complaint
-water related submersion incidents
-penetrating injuries

*absence of significant findings on physical exam=BLS