HomeMy WebLinkAbout065241 - General - Contract - City of Lake WorthCity Secretary Contract No. 65241
CITY OF FORT WORTH AND CITY OF LAKE WORTH
FIRST RESPONDER AND PROVIDER AGREEMENT
This First Responder and Provider Agreement ("Agreement") is made between the City of
Fort Worth ("Provider") and the City of Lake Worth ("FRO"), both units of local government
organized under the laws of the State of Texas. Provider and FRO may be referred to individually
as a "Party," and collectively as the "Parties" in this Agreement.
WHEREAS, the relationship between the Provider and FRO is established by the EMS
Interlocal Agreement, executed by the Parties;
WHEREAS, FRO, Provider, and each jurisdiction that receives EMS System services
from Provider, adopted a Uniform EMS Ordinance that obligates each jurisdiction to comply
with the terms of their respective EMS Interlocal Agreements and to operate under the
direction of Provider's Medical Director and the department of the Office of the Medical
Director ("OMD");
WHEREAS, FRO, and other jurisdictions that receive EMS System services from
Provider, and as required by its EMS Interlocal Agreement, must establish, operate, and fund a
First Responder Program, as contemplated by Texas Administrative Code (TAC) 157.14, within
their respective jurisdictions;
WHEREAS, Provider, by and through its Medical Director and OMD, publishes
protocols, procedures, and policies in documents entitled the Fort Worth Regional EMS System
Out -of -Hospital & Mobile Integrated Healthcare Protocols ("OMD Protocols");
WHEREAS, Provider and its Medical Director are responsible for, among other things,
credentialing and re-credentialing of personnel, establishing minimum equipment and medication
requirements for first responder vehicles, and monitoring the quality of patient care provided
within Provider's EMS System; and
WHEREAS, Provider and FRO desire to formalize an agreement to comply with Texas
Administrative Code § 157.14, entitled "Requirements for First Responder Organization License."
NOW THEREFORE, known by all these present, Provider and FRO, acting herein by
and through their duly authorized representatives, agree to the following terms:
I. LEVEL OF CERTIFICATION
1.1 Provider recognizes FRO as a ® Basic Life Support / ❑ Advanced Life Support First
Responder Organization. As such, FRO is to meet all requirements listed in the OMD Protocols
associated with the designated level of support.
OFFICIAL RECORD
CITY SECRETARY
First Responder and Provider Agreement FT. WORTH, TX Page 1 of 10
1.2 When deemed necessary by Provider personnel to aid with patient care at a scene or during
patient transport, any of FRO's members or employees who are credentialed by OMD may provide
care within their credentialed scope. In such cases, equipment, supplies, and medications from a
Provider ambulance may be used as needed.
1.3 FRO shall ensure it maintains compliance with Texas Administrative Code § 157.14(e),
including, but not limited to its obligations relating to medical oversight, staffing, recordkeeping,
infection control, data reporting, vehicle condition, and other responsibilities required for licensure
as a First Responder Organization. FRO further agrees to cooperate with Provider and the Medical
Director to the extent necessary to ensure such compliance.
1.4 The above notwithstanding, Provider acknowledges that the Texas Department of State
Health Services (DSHS) recognizes the Emergency Care Attendant (ECA) as a certified level of
EMS provider under Texas law. The ECA level is not a credentialed level under the OMD
protocols and, therefore, ECAs are not subject to medical director credentialing requirements
applicable to credentialed positions. ECAs may, however, provide services consistent with their
DSHS certification level and within the scope of Basic Life Support (BLS) functions as defined
by state law and DSHS. FRO ECAs operating under this Agreement may receive appropriate
training as determined by Provider but such training shall not constitute or imply credentialing
under the Medical Director's protocols. Nothing in this Agreement shall be construed to expand
or restrict the statutory or regulatory scope of practice of ECAs under state law, nor to require the
Medical Director to credential or supervise ECAs beyond that scope.
II. PROTOCOLS AND MEDICAL EQUIPMENT
2.1 FRO is required to adhere to the OMD Protocols, attached hereto as Exhibit "A."
2.2 FRO must equip first response apparatus with the approved supplies, medications and
equipment as referenced in the OMD Protocols consistent with FRO's level of care. A minimum
equipment and medication list is provided in the attached Exhibit `B."
III. FRO OPERATION
3.1 FRO must provide EMS first responder EMS System services twenty-four (24) hours per
day and seven (7) days per week.
3.2 In the event that such EMS System services are interrupted, FRO must notify Provider
and the Medical Director as soon as possible.
IV. PATIENT CARE REPORTING
4.1 Provider and FRO recognize documentation of patient care is essential for effective
communication and continuity of care. FRO must adopt or develop a method by which patient care
provided prior to Provider's arrival can be documented and shared with Provider before the patient
is transported. Such documentation method must be submitted to Provider and the Medical
Director for approval.
First Responder and Provider Agreement Page 2 of 10
4.2 Exhibit "C," attached hereto, contains a copy of the FRO Patient Care Report that has been
approved by the Medical Director. It is agreed that the original copy (Copy 1) will be retained by
FRO and the second copy (Copy 2) will be given to Provider before the patient is transported to
the hospital unless Electronic Patient Care Reports (EPCR) are utilized. If approved by the Medical
Director, EPCRs may be used in place of paper copies. EPCRs shall be compliant with Chapter
157.14 of the TAC.
V. CERTIFICATION OF FRO PERSONNEL WHO RENDER PATIENT CARE
5.1 The Medical Director has established a process requiring personnel to be credentialed to
provide patient care within the Provider's EMS System. FRO personnel must meet and maintain
the OMD requirements of credentialing. The Medical Director and Provider require ongoing
testing of personnel within the EMS System.
VI. ASSESSMENT OF CARE PROVIDED BY FRO
6.1 The OMD will assess care provided by the FRO based on factors including but not limited
to:
a. Contribution to the development and alignment of clinical quality goals and strategies
within the EMS System;
b. Access to relevant clinical data supporting quality assurance, performance measurement,
and improvement initiatives within the EMS System;
c. Ensuring documentation supports the accurate measurement of clinical quality goals based
on nationally endorsed clinical quality measures and benchmarks;
d. Engagement in identified quality improvement initiatives, including the development,
testing, and implementation of changes aimed at improving clinical performance;
e. Compliance and participation with the OMD Quality Assurance Policy, including clinical
case reviews, implementation of clinical restrictions if necessary, and Clinical
Improvement Plans ("CIPs") to address any identified performance gaps or deficiencies;
and
f. Participation in clinical registries and research initiatives as guided by the OMD,
supporting studies aimed at improving patient care and clinical outcomes within the EMS
System.
VII. FRO RESPONSE CODE POLICIES
7.1 FRO agrees to respond to requests for service when deemed necessary by the Provider's
Emergency Medical Dispatch protocols and policies approved by the Medical Director.
7.2 FRO may adopt other response policies that may be necessary to assure the safety and
wellbeing of their personnel and community. When such additional policies affect responses to
high -acuity medical situations, approval from the Medical Director is required.
First Responder and Provider Agreement Page 3 of 10
VIII. ON -SCENE CHAIN OF COMMAND POLICIES
8.1 In addition to FRO's standard operating procedures related to the chain of command, FRO
must recognize the Provider's EMS Supervisor as the highest ranking medically trained EMS
person on scene.
8.2 FRO shall comply with the OMD Protocols, including training of supervisory personnel.
While FRO may be responsible for incident command, the Provider is responsible for patient care
and transport decisions in accordance with the OMD Protocols.
IX. MISCELLANEOUS
9.1 Cancellation of Ambulances. FRO may cancel ambulance responses in accordance with
the OMD Protocols.
9.2 First Responder Personnel Accompanying Patients on Ambulances. When deemed
necessary by Provider and FRO, FRO and Provider agree to allow at least one OMD credentialed
person to assist with patient care on -board an ambulance during transport.
9.3 First Responder Personnel Driving or Operating Provider's Vehicles. When deemed
necessary by Provider and FRO, FRO personnel, that are appropriately trained in the operation
and usage of Provider's vehicles, are authorized to drive and/or operate Provider's vehicles in
situations deemed necessary to care for a patient or to secure the Provider's vehicle(s). (Example:
from time -to -time, it may be necessary for the FRO to drive the Provider's vehicle to a fire station,
or another appropriate facility, to secure it until Provider can reclaim.) Provider shall maintain
adequate insurance coverage for such vehicles whether by separate policy or self -insured status.
Provider agrees that in the event FRO operates and/or drives Provider's vehicle for this limited
purpose, FRO shall be an authorized operator of the vehicle for insurance purposes. FRO, and its
personnel, are not authorized to operate or drive Provider's vehicle for any deviation or detour
from the purpose specified herein.
9.4 Confidentiality. FRO agrees to comply with all relevant confidentiality laws of the State of
Texas and the Health Insurance Portability and Accountability Act of 1996.
9.5 Business Associate Agreement. FRO must execute a separate Business Associate
Agreement (`BAA") in the form, or substantial form, of the BAA attached hereto as Exhibit "D."
9.6 Originalgreement Unaltered. This Agreement is intended to supplement the existing
Emergency Medical Services Interlocal Agreement ("ILA") between the Parties. The terms and
conditions of the ILA shall remain the same, in full force and effect, and are not altered by the
execution of this Agreement.
[Signature Page Follows]
First Responder and Provider Agreement Page 4 of 10
First Responder and Provider Agreement Page 5 of 10
ACCEPTED AND AGREED:
PROVIDER:
41tL at_
Name: William Johnson
Title: Assistant City Manager
Date: 05/20/2026
APPROVAL RECOMMENDED:
�t�2 y�iZeruiO �c�
By: Q
Name: Raymond Hill
Title: Interim Fire Chief
Date: 05/19/2026
ATTEST:
00 anal/ Vee'sjo
By:
Name: Jannette Goodall
Title: City Secretary
Date: 05/26/2026
r nv:
CONTRACT COMPLIANCE
MANAGER:
By signing I acknowledge that I am the
person responsible for the monitoring and
administration of this Agreement, including
ensuring all performance and reporting
requirements.
By:
Name: Ryan Zelazny
Title: Fire Deputy Chief -Operations
Date: 05/19/2026
APPROVED AS TO FORM AND
LEGA�
By:
Name: Taylor Paris
Title: Assistant City Attorney
Date: 05/20/2026
'FlIj� APPROVED AS zuk(
ORM AND
By: �`1.. •"' O%afe b/ri' LEGALITY•
Name: St ey Almon F s
Title: City Manager * i• * By:
(J�
Name:
Date: fu 7—� y Title: City Attorne
aii �� Se Date:
First Responder and Provider Agreement
OFFICIAL RECORD
CITY SECRETARY Page 6 of 10
FT. WORTH, TX
EXHIBIT "A"
OMD PROTOCOLS
First Responder and Provider Agreement Page 7 of 10
EXHIBIT "B"
MINIMUM EQUIPMENT AND MEDICATION LIST
First Responder and Provider Agreement Page 8 of 10
FORT WORTU, Of ice of the
Medical Director
Basic First Responder Minimum
Equipment and Medication List
Oxygen Accessories
Qty I
ledication Delivery Items
Qty
02 - Cylinder with Regulator (>700 psi)
1
Syringe 1 ml
02 - Key
1
Blunt Needle
Airway & Oxygen Delivery
Qty
Hyperdermic Needle 1 1/2" (21g or 25g or 27g)
'
Oral Airway - (50 / 60 / 80 / 90 / 100 / 110)
1 ca
Nasal Atomizer Device
Nasal Airway - (22 / 24 / 26 / 28 / 30)
1 ea
Nebulizer
1
Water-Soluable Lubricant
2
Manual Vital Sign Tools
Qty
Bag Valve Mask - Adult / Pedi / Infant
1 ea
BP Cuff Adult / Pedi /Infant
1 ea
Neonate Size 0 BVM mask
1
BP Cuff Thigh or Adult XL
1
Nasal Cannuta - Adult
1
Stethoscope
1
Non-Rebreather - Adult
1
Glucometer
1
Non-Rebreather - Pedi
1
Glucometer Test Strips
3
BiPap System
1
Disposable Lancers
3
Airway Equipment (Optional)
Qty
Sharps Shuttle
1
AirQ-SP-3g supraglottic airway - Neonate through Adult Sizes
1 ea
Alcohol Preps
10
ETCO2 Nasal*
1
Thermometer
1
ETCO2 In -line*
1
Pedi - Length/Age-based Resuscitation Tape
1
Suction & Accessories
QtY
Electrical Therapy
Qty
Suction - Portable w/Canister & Lid
ED
1
Suction - Rigid Tip
1
Quick Combo Pads Adult/Pedi
1 ea
Suction - Tubing
1
PPE / Cleaning / Biohazard
Qty
Suction - Cath 5 / 14 / 18 Fr
1 ea
Hand Sanitizer
1 bottle
Suction- Gastric Sump Tube 10 & 16 Fr
1 ea
Medical Exam Gloves
1 Box
Hemmorhage Control / Bandaging / Splinting
Qty
Gown
Bandaids
5
Goggles/Face Shield
Burn Sheet
2
Masks
3
Multi Trauma Dressing
1
Safety Vest
2
Roller Gauze
2
EMS Scissors
1
Sterile 5X9 Gauze Pad
enlight
1
Sterile 4X4 Gauze Pad
ingcutter
1
Occlusive Dressing
2
Bio Hazard Bags
2
Triangular Bandages
4
MCI
Qty
Ridged Splints
2
Triage Tape / Tags
_'5
Pelvic Fracture Sling
1
Monitoring Equipment
Qty
1" Tape
1
*Waveform Capnography Device -must be available if carrying
optional airway equipment
2" Tape
1
FRO - Basic Medication List '
Qty
Saline or Sterile Water for Irrigation
1
Acetaminophen 500 mg Tablets (may substitute liquid)
Hot Pack
4
Acetaminophen Liquid 160mg / 5mL
>5ml
Cold Pack
4
Aspirin 81 mg Tablets
Commercial Windless Tourniquet
1
DuoNeb Albuterol 2.5mg/ipratropium 500mcg**
;
Hemostatic Dressing / Packing
2
Epinephrine 1:1000 lmg / lml***
i
Traction Splint (optional)
1
Ibuprofen 200 mg Tablets (may substitue liquid)
3
Pedi Immobilizer (optional)
1
Ibuprofen Liquid 100mg / 5mL
30 mL
Immobilization / Patient Movement
Qty
Isopropyl Alcohol Pads
3
Backboard w/ 3 straps (optional)
1
Naloxone 2 mg / 2 ml
2
Extrication Device w/Straps & Pads
1
Nitroglycerin 0.4 mg SL Spray or Tablet
I btl
C-Collars - Adult & Pedi
1 ea
Odansentron 4 mg ODT
2
Head Immobilizer (optional)
1
Oral glucose 15 g
1
Obstetrics/Labor & Deliver Items
Qty
** If not carrying DuoNeb:
OB - Kit
1
Albuterol 2.5 mg / 3 ml
3
OB - Suction Bulb
1
Ipratropium 500 mcg / 3 ml
3
OB - Foil Blanket
1
***If not carrying Epi 1:1000
Effective: 07/01/2025 Epi Pen Adult and Pediactric 1 ea
�vrd�
Jeffery L. Jarvis, MD, MS, EAPSy,,, Medical Director / Chief Medical Officer
Fort Worth Office of the Medical Director
2900 Alta Mere Dr.
Fort Worth, TX 76116
FORTWORTH. Office of the
Medical Director
ECA First Responder
Minimum Equipment and Medication List
Oxygen Accessories
Qty
Medication Delivery Items
Qtv
02 - Cylinder with Regulator (> 700 psi)
1
Syringe 1 ml
02 - Key
1
Blunt Needle
Airway & Oxygen Delivery
Qty
Hyperdermic Needle 1 1/2" (21g or 25g or 27g)
?
Oral Airway - (50 / 60 / 80 / 90 / 100 / 110)
1 ea
Manual Vital Sign Tools
Qty
Nasal Airway - (22 / 24 / 26 / 28 / 30)
1 ea
BP Cuff Adult / Pedi / Infant
1 ea
Water-Soluable Lubricant
2
BP Cuff Thigh or Adult XL
1
Bag Valve Mask - Adult / Pedi / Infant
1 ea
Stethoscope
1
Neonate Size 0 BVM mask
1
Glucometer
1
Nasal Cannula - Adult
1
Glucometer Test Strips
3
Non-Rebreather - Adult
1
Disposable Lancets
3
Non-Rebreather - Pedi
1
Sharps Shuttle
1
Suction & Accessories
Qty
Alcohol Preps
6
V-vac manual suction
1
Thermometer
1
Hemmorhage Control / Bandaging / Splinting
Qty
Electrical Therapy
Qty
Bandaids
5
AED
1
Burn Sheet
2
Quick Combo Pads Adult/Pedi
1 ea
Multi Trauma Dressing
1
Personal Protective Equipment / Cleaning / Biohazard
Qty
Roller Gauze
2
Hand Sanitizer
1 bottle
Sterile 5X9 Gauze Pad
dical Exam Gloves
1 Box
Sterile 4X4 Gauze Pad
own
3
Occlusive Dressing
?
Goggles/Face Shield
3
Triangular Bandages
i
Masks
3
SAM Splints
?
Safety Vest
2
Pelvic Fracture Sling
1
EMS Scissors
1
1" Tape
I
Penlight
I
2" Tape
1
Ringcutter
1
Saline or Sterile Water for Irrigation
1
Bio Hazard Bags
Cold Pack
+
FRO - ECA Medication List
Qty
Commercial Windless Tourniquet
1
Aspirin 81 mg Tablets
i
Hemostatic Dressing / Packing
?
Epinephrine 1:1000 lmg / 1mL***
1
Obstetrics/Labor & Deliver Items
Qty
Isopropyl Alcohol Pads
3
OB - Kit
1
Oral glucose 15 g
1
OB - Suction Bulb
1
Naloxone 2mg / 2ml or 0.4 mg auto injector or 4 mg nasal spray
1
OB - Foil Blanket
1
***If not carrying Epi 1:1,000
MCI
1 0 Qty
Epi Pen Adult and Pediactric T 1 ea
Triage Tape / Tags 25
effery L. Jarvis, MD , EMT-P System Medical Director / Chief Medical Officer Effective: 07/01/2025
Office of the Medical Director
2900 Alta Mere Dr.
Fort Worth, TX 76116
FORT WORTH.. Office of the
Medical Director
Paramedic First Responder
Minimum Equipment and Medication List
Oxygen Accessories
Qty
Hemmorhage Control / Bandaging / Splinting
Qty
02 - Cylinder with Regulator (>700 psi)
I
Bandaids
5
02 - Key
I
Burn Sheet
1
Air% & Oxygen Defiwry
QtyMulti
Trauma Dressing
1
Oral Airway - (50 / 60 / 80 / 90 / 100 / 110)
1 ea
Roller Gauze
4
Nasal Airway - (22 / 24 / 26 / 28 / 30)
1 ea
Sterile 5X9 Gauze Pad
4
Water-Soluable Lubricant
2
Sterile 4X4 Gauze Pad
4
Bag Valve Mask - Adult / Pedi / Infant
1 ea
10cclusive Dressing
2
Neonate Size 0 BVM mask
l
Triangular Bandages
4
Nasal Cannola - Adult
1
Rigid Splints
2
Non-Rebreather - Adult
l
Pelvic Fracture Sling
1
Non-Rebreather - Pedi
I
l" Tape
1
Bi-PAPSystem
1
2" Tape
1
Airway Equipment
Qry
Saline or Sterile Water for Irrigation
1
ETT - Size 6.0, 6.5, 7.0, 7.5, 8.0
1 ea
Hot Pack
4
UEScope Video Laryngoscope (VL) Camera/Monitor
1
Cold Pack
4
UEScope VL Disposable Blades - size 0, 1, 2, 3, 4
1 ea
Commercial Windless Tourniquet
1
Invasive Airway Securement Device - Adult and Pedi
1 ea
Hemostatic Dressing/packing
2
ETT Introducer - Adult
1
Traction Splint (optional)
1
Magill Forceps - Adult and Pedi
1 ea
Manual Vital Sign Tools
Qty
AirQ-SP-3g supraglottic airway - Neonate through Adult Sizes
1 ea
BP Cuff Adult / Pedi / Infant
I ea
ETCO2 Nasal
P Cuff Thigh or Adult XL
1
ETCO2 In -line
2
Stethoscope
1
Crycothyroidotorny Kit / Transtracheal Needle Kit
1 ea
Glucometer
1
Suction & Accessories
Qty
Glucometer Test Strips
3
Suction - Portable w/Canister & Lid
I
Disposable Lancets
3
Suction - Rigid Tip
I.
Sharps Shuttle
1
Suction - Tubing
I
Alcohol Preps
10
Suction - Cath 5 / 14 / 18 Fr
I ea
Thermometer
1
Suction- Gastric Surnp Tube 10 & 16 Fr
1 ea
Pedi - Length/Age-based Resuscitation Tape
1
Vascular Prep,Access & Medication Delivery
PPE / Cleaning / Biohazard
Qty
Syringe lcc
2
Hand Sanitizer
1 bottle
Syringe 3cc
2
Medical Exam Gloves
1 Box
Syringe IOcc
2
Gown
3
Normal Saline Plush IOcc (optional)
2
Goggles/Face Shield
3
Hyperdemic Needle 1 1/2" (21g or 25g or 27g)
2
Masks
3
18g Needle 1 1/2"
2
Safety Vest
3
W Tourniquets
2
EMS Scissors
1
IV Cath. 24G 3/4"
2
Penlight
1
IV Cath. 22G V
2
Ringcutter
1
IV Cath. 20G 1 1/4"
2
Bin Hazard Bags
2
IV Cath. 18G 1 1/4"
1
FRO - ALS Assist Medication List
Qty
IV Cath. 16G 11/4"
2
Acetaminophen 500 mg Tablet (may substitute liquid)
2
IV Cath. 14G 3 1/4"
2
Acetaminophen Liquid 160mg / 5mL
35 mL
Intraosseoua Needle - Pedi, Adult, Bari (If EZIO, then 25 & 45 tutu)
1 -
Adenosine 12 mg / 2 cal (optional)
2
IV Tubing
I
Amiodarone 150mg / 3 mL
3
Veniguard
?
Aspirin 81 mg Tablet
4
Nasal Atomizer Device
2
Atropine ling / IOmL
4
Nebulizer
I
lCalciurn Chloride 10% 1 gm / 10 mL (optional)
1
Obstetrics/Labor & Deliver Items
Qtv
Dextrose 10% (25g / 250mL)
2
OB - Kit
I
Diphenhydramine 50 mg / 2 mL
1
OB - Suction Bulb
I
DuoNeb Abuterol 2.5mg / ipratropium 500mcg*
3
OB - Foil Blanket
I
Epinephrine 1:10,000 ling / IOmL
3
Immobilization / Patient Movement
Qry
Epinephrine 1:1000 ling / mL
6 or, 2 with Racemic Epi
Backboards w/ 3 straps (Optional)
I
Fentanyl 100mcg / 2mL (optional)
3
Extrication Device
I
Ibuprofen 200 mg Tablets (may substitute liquid)
3
C-Collars - Adult & Pedi
1 ea
11buprofen 100mg / 5 mL
30 mL
Head Immobilizer (optional)
1
Isopropyl Alcohol Pads
3
Pedi Immobilizer (optional)
I
Ketamine 200 mg / 20 ml (optional)
1
Monitoring Equipment
Qty
Ketorolac 30 mg. / 2 mL
1
Cardiac Monitor
l
Lidocaine 2% 100 mg / 5 mL
2
Waveform Capnography Device
1
Midazolam 5 mg / 1 ml (optional)
4
Quick Combo Pads Adult / Pedi
I ea
Naloxone 2 mg / 2 mL
2
ECG Electrodes
1 1 set
Nitroglycerin 0.4 mg SL Spray or Tablet
1 btl
ECG Paper
1 roll
rmal Saline 1000 mL
2
MCI
Qty
Normal Saline 250 mL
1
Triage Tape./Tags
25
Ondansetron 4 mg ODT
2
Ondansetron 4mg / ImL 2
Oral glucose 15 g 1
Racemic Epinephrine 2.25% 1125 mg / 0.5 mL (optional) 2
Sodium Bicarb 8.4% 50 ml (1 mEq / mL) 2
*A of 2.5 mg / 3 mL 6 or, 3 with DuoNeb
"Ipmutemaopium 500 mcg / 3 ml If not carrying DuoNeb 3
Jeffery L. J ry s, MD, MS, EMT-P, System Medical Director / Chief Medical Officer Effective: 07101/2025
Fort Worth Office of the Medical Director
2900 Alta Mere Dr.
Fort Worth, TX 76116
EXHIBIT "C"
FRO PATIENT CARE REPORT
First Responder and Provider Agreement Page 9 of 10
Front of First (White) and Second (Yellow) Page
FRO:
FIRST RESPONDER ORGANIZATION
EMS INCIDENT REPORT
Company:
FD Inc #: Date: / / FD Alarm Time:
Inc. Location:
Pt Name:
Address:
SSN: / / —DOB: —/ / Age: (M/F)
SKIN / Capillary Refill
❑Absent ❑Delayed ❑Normal
Parent/
Guardian
TIME
PULSE
BLOOD PRESSURE
RESP
SP02
GLUCOSE
PULSE QUALITY []Regular ❑Irregular []Strong ❑Weak ❑Absent
SKIN CONDITION ❑M ist ❑Dry ❑Warm ❑Cool ❑Pale ❑Blue ❑Red ❑Normal
INITIAL GLASGOW COM SCALE:
INITIAL TRAUMA SCORE:
Chief Complaint:
Past History:
Medications:
Allergies: ❑NKDA
Narrative:
❑AM AS
F.D. Sign Off FWFD EMS Sign Off
Back of First (White) Page
AMA FORM
REFUSAL OF TREATMENT / RECHASO DE TRATAMIENTO
(PARAMEDIC USE ONLY)
This is to certify that I release (FRO) and its employees from liability
for any claim arising from or associated with my injuries or condition; and I refuse further treatment even
though I am informed and I am aware that my injuries may be serious and may require further treatment.
Esto es para certificar que renuncio de cargos al (FRO) y sus
empleados de toda culpabilidad si algun resultado apareciera asodado con mis lastimaduras o condiciones
y rehuso todo tratamiento despues que se me ha informado y me consta que mis lastimaduras pueden ser
mas series y despues requieren mas serios tratamientos.
Legal Representative
Witness
Paramedic
RELEASE AT SCENE FORM
Did patient or LEO activate 911 for EMS? DYes ❑No
Patient disoriented or confused? DYes []No
Any loss of consciousness? DYes ❑No
Any evidence of alcohol and/or drug use? DYes ❑No
Any complaints of pain, illness, or psychological complaint/concem? DYes ❑No
Any significant mechanism of injury? DYes ❑No
Same vehicle DOS? DYes ❑No
Family voicing concerns over patient's refusal? DYes ❑No
If YES is answered to any of the above questions, you MUST complete a
Patient Record Form AMA and a Release At Scene cannot be used.
I refuse any medical assessment, evaluation or treatment and refuse to be transported to a medical facility. I
hereby release MedStar, the AMAA and the EPAB, their officials, officers, agents, and employees from all
liability, claims and causes of action arising from or relating to my decision to refuse medical assessment,
evaluation or treatment.
Signature Phone
Parent/Guardian Signature Relationship
Home Address Date
I performed a scene assessment and observed that there appears to be no significant mechanism of injury
at the scene and it appears has no obvious
injury, illness, medical or physical complaints or symptoms.
EMS Personnel Signature EMS Personnel Printed Name
Date Incident Number Unit Number
Witness Signature Witness Printed Name
REFUSAL TO SIGN
The person named above refused to sign this form.
EMS Personnel Signature EMS Personnel Printed Name
Date Incident Number Unit Number
Witness Signature Witness Printed Name
Incident Address city
Back of Second (Yellow) Page
INITIAL GLASGOW COMA SCALE WORKSHEET
Eye Opening Best Verbal Response Best Motor Response
Spontaneous = 4 Oriented = 5 Obeys Commands = 6
To Voice = 3 Confused = 4 Localizes Pain = 5
To Pain = 2 Inappropriate Words = 3 Withdraws to Pain = 4
None = 1 Incomprehensible Sounds = 2 Flexes to Pain = 3
None = 1 Extends to Pain = 2
None = 1
Eye Opening + Verbal + Motor
Glasgow Coma Scale Total =
INITIAL TRAUMA SCORE WORKSHEET
Systolic Blood Pressure Respiratory Rate Glasgow Coma Scale
89 = 4 10-29 = 4 13-15 = 4
76-89 = 3 > 29 = 3 9-12 = 3
50-75 = 2 6-9 = 2 6-8 = 2
1 —49 = 1 1-5 = 1 4-5 = 1
0 = 0 0 = 0 3 = 0
CGCS + Blood Pressure + Respiratory
Trauma Score =
APGAR WORKSHEET
0 1 2
APGAR at 1 Minute:
APGAR at 5 Minutes:
SKIN COLOR
Cyanosis of Body and
Extremities
Extremities Cyanotic /
Body Pink
No Cyanosis
HEART RATE
Absent
<100
>100
REFLEX
No Response to
Stimulation
Grimace /Feeble Cry to
Stimulation
Sneeze /Cough /Pulls
Away to Stimulation
MUSCLE TONE
None
Some Flexion
Active Movement
BREATHING
Absent
Weak/irregular
Strong
EXHIBIT "D"
BUSINESS ASSOCIATE AGREEMENT
First Responder and Provider Agreement Page 10 of 10
FORTWORTH.
CITY OF FORT WORTH BUSINESS ASSOCIATE AGREEMENT
This Business Associate Agreement (the `BAA") is made and entered into by and between the
City of Fort Worth Texas, a home -rule municipality organized under the laws of the state of Texas
("Covered Entity") and the City of Lake Worth, a home -rule municipality organized under the
laws of the State of Texas ("Business Associate", in accordance with the meaning given to those
terms at 45 CFR § 164.501). In this BAA, Covered Entity and Business Associate are each a
"Party" and, collectively, are the "Parties."
WHEREAS, Covered Entity is a "covered entity" as defined under the Health Insurance
Portability and Accountability Act of 1996, Public Law 104-191, as amended by the HITECH Act
(as defined below) and the related regulations promulgated by HHS (as defined below)
(collectively, "HIPAA") and, as such, is required to comply with HIPAA's provisions regarding
the confidentiality and privacy of Protected Health Information ("PHI");
WHEREAS, the Parties have entered into or will enter into one or more agreements under
which Business Associate provides or will provide certain specified services to Covered Entity
(collectively, the "Agreement");
WHEREAS, in providing services pursuant to the Agreement, Business Associate will
have access to PHI;
WHEREAS, by providing the services pursuant to the Agreement, Business Associate will
become a "business associate" of the Covered Entity as such term is defined under HIPAA;
WHEREAS, both Parties are committed to complying with all federal and state laws
governing the confidentiality and privacy of health information, including, but not limited to, the
Standards for Privacy of Individually Identifiable Health Information found at 45 CFR Part 160
and Part 164, Subparts A and E (collectively, the "Privacy Rule"); and
WHEREAS, both Parties intend to protect the privacy and provide for the security of
Protected Health Information disclosed to Business Associate pursuant to the terms of this
Agreement, HIPAA and other applicable laws.
NOW, THEREFORE, in consideration of the mutual covenants and conditions contained herein
and the continued provision of PHI by Covered Entity to Business Associate under the Agreement
in reliance on this BAA, the Parties agree as follows:
FORTWORTH.
1. Definitions
For purposes of this BAA, the Parties give the following meaning to each of the terms in this
Section 1 below. Any capitalized term used in this BAA, but not otherwise defined, has the
meaning given to that term in the Privacy Rule or pertinent law.
A. "Affiliate" means a subsidiary or affiliate of Covered Entity that is, or has been,
considered a covered entity, as defined by HIPAA.
B. "Breach" means the acquisition, access, use, or disclosure of PHI in a manner not
permitted under the Privacy Rule which compromises the security or privacy of the PHI, as defined
in 45 CFR § 164.402.
C. "Breach Notification Rule" means the portion of HIPAA set forth in Subpart D of 45
CFR Part 164.
D. "Data Aggregation" means, with respect to PHI created or received by Business
Associate in its capacity as the "business associate" under HIPAA of Covered Entity, the
combining of such PHI by Business Associate with the PHI received by Business Associate in its
capacity as a business associate of one or more other "covered entity" under HIPAA, to permit
data analyses that relate to the Health Care Operations (defined below) of the respective covered
entities. The meaning of "data aggregation" in this BAA shall be consistent with the meaning given
to that term in the Privacy Rule.
E. "Designated Record Set" has the meaning given to such term under the Privacy Rule,
including 45 CFR § 164.501.B.
F. "De -Identify" means to alter the PHI such that the resulting information meets the
requirements described in 45 CFR § § 164.514(a) and (b).
G. `Electronic PHI" means any PHI maintained in or transmitted by electronic media as
defined in 45 CFR § 160.103.
H. "Health Care Operations" has the meaning given to that term in 45 CFR § 164.501.
I. "HHS" means the U.S. Department of Health and Human Services.
J. "HITECH Act" means the Health Information Technology for Economic and Clinical
Health Act, enacted as part of the American Recovery and Reinvestment Act of 2009, Public Law
111-005.
FORTWORTH.
K. "Individual" has the same meaning given to that term i in 45 CFR § § 164.501 and
160.130 and includes a person who qualifies as a personal representative in accordance with 45
CFR § 164.502(g).
L. "Privacy Rule" means that portion of HIPAA set forth in 45 CFR Part 160 and Part 164,
Subparts A and E.
M. "Protected Health Information" or "PHI" has the meaning given to the term "protected
health information" in 45 CFR §§164.501 and 160.103, limited to the information created or
received by Business Associate from or on behalf of Covered Entity.
N. "Security Incident" means the attempted or successful unauthorized access, use,
disclosure, modification, or destruction of information or interference with system operations in
an information system.
O. "Security Rule" means the Security Standards for the Protection of Electronic Health
Information provided in 45 CFR Part 160 & Part 164, Subparts A and C.
P. "Unsecured Protected Health Information" or "Unsecured PHI" means any "protected
health information" as defined in 45 CFR § § 164.501 and 160.103 that is not rendered unusable,
unreadable or indecipherable to unauthorized individuals through the use of a technology or
methodology specified by the HHS Secretary in the guidance issued pursuant to the HITECH Act
and codified at 42 USC § 17932(h).
2. Use and Disclosure of PHI
A. Except as otherwise provided in this BAA, Business Associate may use or disclose
PHI as reasonably necessary to provide the services described in the Agreement to Covered Entity,
and to undertake other activities of Business Associate permitted or required of Business Associate
by this BAA or as required by law.
B. Except as otherwise limited by this BAA or federal or state law, Covered Entity
authorizes Business Associate to use the PHI in its possession for the proper management and
administration of Business Associate's business and to carry out its legal responsibilities. Business
Associate may disclose PHI for its proper management and administration, provided that (i) the
disclosures are required by law; or (ii) Business Associate obtains, in writing, prior to making any
disclosure to a third parry (a) reasonable assurances from this third parry that the PHI will be held
confidential as provided under this BAA and used or further disclosed only as required by law or
for the purpose for which it was disclosed to this third party and (b) an agreement from this third
party to notify Business Associate immediately of any breaches of the confidentiality of the PHI,
to the extent it has knowledge of the breach.
FORT WORTH.
C. Business Associate will not use or disclose PHI in a manner other than as provided
in this BAA, as permitted under the Privacy Rule, or as required by law. Business Associate will
use or disclose PHI, to the extent practicable, as a limited data set or limited to the minimum
necessary amount of PHI to carry out the intended purpose of the use or disclosure, in accordance
with Section 13405(b) of the HITECH Act (codified at 42 USC §17935(b)) and any of the act's
implementing regulations adopted by HHS, for each use or disclosure of PHI.
D. Upon request, Business Associate will make available to Covered Entity any of
Covered Entity's PHI that Business Associate or any of its agents or subcontractors have in their
possession.
E. Business Associate may use PHI to report violations of law to appropriate Federal
and State authorities, consistent with 45 CFR §164.5020)(1).
3. Safeguards Against Misuse of PHI
Business Associate will use appropriate safeguards to prevent the use or disclosure of PHI
other than as provided by the Agreement or this BAA and Business Associate agrees to implement
administrative, physical, and technical safeguards that reasonably and appropriately protect the
confidentiality, integrity and availability of the Electronic PHI that it creates, receives, maintains
or transmits on behalf of Covered Entity. Business Associate agrees to take reasonable steps,
including providing adequate training to its employees to ensure compliance with this BAA and
to ensure that the actions or omissions of its employees or agents do not cause Business Associate
to breach the terms of this BAA.
4. Reporting Disclosure of PHI and Security Incidents
Business Associate will report to Covered Entity in writing any use or disclosure of PHI
not provided for by this BAA of which it becomes aware and Business Associate agrees to report
to Covered Entity any Security Incident affecting Electronic PHI of Covered Entity of which it
becomes aware. Business Associate agrees to report any such event within five business days of
becoming aware of the event.
5. Reporting Breaches of Unsecured PHI
Business Associate will notify Covered Entity in writing promptly upon the discovery of
any Breach of Unsecured PHI in accordance with the requirements set forth in 45 CFR § 164.410,
but in no case later than 30 calendar days after discovery of a Breach. Business Associate will
reimburse Covered Entity for any costs incurred by it in complying with the requirements of
Subpart D of 45 CFR § 164 that are imposed on Covered Entity as a result of a Breach committed
by Business Associate.
FORTWORTH.
6. Mitigation of Disclosures of PHI
Business Associate will take reasonable measures to mitigate, to the extent practicable, any
harmful effect that is known to Business Associate of any use or disclosure of PHI by Business
Associate or its agents or subcontractors in violation of the requirements of this BAA.
7. Agreements with Agents or Subcontractors
Business Associate will ensure that any of its agents or subcontractors that have access to,
or to which Business Associate provides, PHI agree in writing to the restrictions and conditions
concerning uses and disclosures of PHI contained in this BAA and agree to implement reasonable
and appropriate safeguards to protect any Electronic PHI that it creates, receives, maintains or
transmits on behalf of Business Associate or, through the Business Associate, Covered Entity.
Business Associate shall notify Covered Entity, or upstream Business Associate, of all
subcontracts and agreements relating to the Agreement, where the subcontractor or agent receives
PHI as described in section 1.M. of this BAA. Such notification shall occur within 30 (thirty)
calendar days of the execution of the subcontract by placement of such notice on the Business
Associate's primary website. Business Associate shall ensure that all subcontracts and agreements
provide the same level of privacy and security as this BAA.
8. Audit
Upon request, Business Associate will provide Covered Entity, or upstream Business
Associate, with a copy of its most recent independent HIPAA compliance report (AT-C 315),
HITRUST certification or other mutually agreed upon independent standards based third parry
audit report. Covered entity agrees not to re -disclose Business Associate's audit report.
9. Access to PHI by Individuals
A. Upon request, Business Associate agrees to furnish Covered Entity with copies of
the PHI maintained by Business Associate in a Designated Record Set in the time and manner
designated by Covered Entity to enable Covered Entity to respond to an Individual's request for
access to PHI under 45 CFR § 164.524.
B. In the event any Individual or personal representative requests access to the
Individual's PHI directly from Business Associate, Business Associate within ten business days,
will forward that request to Covered Entity. Any disclosure of, or decision not to disclose, the PHI
requested by an Individual or a personal representative and compliance with the requirements
applicable to an Individual's right to obtain access to PHI shall be the sole responsibility of
Covered Entity.
10. Amendment of PHI
FORTWORTH.
A. Upon request and instruction from Covered Entity, Business Associate will amend
PHI or a record about an Individual in a Designated Record Set that is maintained by, or otherwise
within the possession of, Business Associate as directed by Covered Entity in accordance with
procedures established by 45 CFR § 164.526. Any request by Covered Entity to amend such
information will be completed by Business Associate within 15 business days of Covered Entity's
request.
B. In the event that any Individual requests that Business Associate amend such
Individual's PHI or record in a Designated Record Set, Business Associate within ten business
days will forward this request to Covered Entity. Any amendment of, or decision not to amend,
the PHI or record as requested by an Individual and compliance with the requirements applicable
to an Individual's right to request an amendment of PHI will be the sole responsibility of Covered
Entity.
11. Accounting of Disclosures
A. Business Associate will document any disclosures of PHI made by it to account for
such disclosures as required by 45 CFR § 164.528(a). Business Associate also will make available
information related to such disclosures as would be required for Covered Entity to respond to a
request for an accounting of disclosures in accordance with 45 CFR § 164.528. At a minimum,
Business Associate will furnish Covered Entity the following with respect to any covered
disclosures by Business Associate: (i) the date of disclosure of PHI; (ii) the name of the entity or
person who received PHI, and, if known, the address of such entity or person; (iii) a brief
description of the PHI disclosed; and (iv) a brief statement of the purpose of the disclosure which
includes the basis for such disclosure.
B. Business Associate will furnish to Covered Entity information collected in
accordance with this Section 10, within ten business days after written request by Covered Entity,
to permit Covered Entity to make an accounting of disclosures as required by 45 CFR § 164.528,
or in the event that Covered Entity elects to provide an Individual with a list of its business
associates, Business Associate will provide an accounting of its disclosures of PHI upon request
of the Individual, if and to the extent that such accounting is required under the HITECH Act or
under HHS regulations adopted in connection with the HITECH Act.
C. In the event an Individual delivers the initial request for an accounting directly to
Business Associate, Business Associate will within ten business days forward such request to
Covered Entity.
12. Availability of Books and Records
FORTWORTH.
Business Associate will make available its internal practices, books, agreements, records,
and policies and procedures relating to the use and disclosure of PHI, upon request, to the Secretary
of HHS for purposes of determining Covered Entity's and Business Associate's compliance with
HIPAA, and this BAA.
13. Responsibilities of Covered Entity
With regard to the use and/or disclosure of PHI by Business Associate, Covered Entity agrees to:
A. Notify Business Associate of any limitation(s) in its notice of privacy practices in
accordance with 45 CFR § 164.520, to the extent that such limitation may affect Business
Associate's use or disclosure of PHI.
B. Notify Business Associate of any changes in, or revocation of, permission by an
Individual to use or disclose Protected Health Information, to the extent that such changes may
affect Business Associate's use or disclosure of PHI.
C. Notify Business Associate of any restriction to the use or disclosure of PHI that
Covered Entity has agreed to in accordance with 45 CFR § 164.522, to the extent that such
restriction may affect Business Associate's use or disclosure of PHI.
D. Except for data aggregation or management and administrative activities of
Business Associate, Covered Entity shall not request Business Associate to use or disclose PHI in
any manner that would not be permissible under HIPAA if done by Covered Entity.
14. Data Ownership
Business Associate's data stewardship does not confer data ownership rights on Business
Associate with respect to any data shared with it under the Agreement, including any and all forms
thereof.
15. Term and Termination
A. This BAA will become effective upon execution by the Covered Entity's City
Manager, Deputy City Manager, or Assistant City Manager, and will continue in effect until all
obligations of the Parties have been met under the Agreement and under this BAA, unless earlier
terminated in accordance with the terms of this BAA.
B. Covered Entity may terminate immediately this BAA, the Agreement, and any
other related agreements if Covered Entity determines that Business Associate has breached a
material term of this BAA and Business Associate has failed to cure that material breach, to
Covered Entity's reasonable satisfaction, within 30 days after written notice from Covered Entity.
FORTWORTH.
Covered Entity may report the problem to the Secretary of HHS if termination is not feasible.
Notwithstanding the foregoing, Covered Entity may also terminate the Agreement any other
related agreements as provided by the terms of such agreements. Additionally, Covered Entity may
terminate this BAA for convenience upon 30 days' prior written notice to Business Associate.
C. If Business Associate determines that Covered Entity has breached a material term
of this BAA, then Business Associate will provide Covered Entity with written notice of the
existence of the breach and shall provide Covered Entity with 30 days to cure the breach. Covered
Entity's failure to cure the breach within the 30-day period will be grounds for immediate
termination of the Agreement and this BAA by Business Associate. Business Associate may report
the breach to HHS.
D. Upon termination of the Agreement or this BAA for any reason, all PHI maintained
by Business Associate will be returned to Covered Entity or destroyed by Business Associate.
Business Associate will not retain any copies of such information. This provision will apply to
PHI in the possession of Business Associate's agents and subcontractors. If return or destruction
of the PHI is not feasible, in Business Associate's reasonable judgment, Business Associate will
furnish Covered Entity with notification, in writing, of the conditions that make return or
destruction infeasible. Upon mutual agreement of the Parties that return or destruction of the PHI
is infeasible, Business Associate will extend the protections of this BAA to such information for
as long as Business Associate retains such information and will limit further uses and disclosures
to those purposes that make the return or destruction of the information not feasible. The Parties
understand that this Section 14.1). will survive any termination of this BAA.
16. Effect of BAA
A. This BAA is a part of and subject to the terms of the Agreement, except that to the
extent any terms of this BAA conflict with any term of the Agreement, the terms of this BAA will
govern.
B. Except as expressly stated in this BAA or as provided by law, this BAA will not
create any rights in favor of any third party.
17. Regulatory References
Regulatory References. A reference in this BAA to a section in HIPAA means the section
as in effect or as amended at the time.
FORTWORTH.
18. Notices
Notices required pursuant to the provisions of this BAA will be conclusively determined
to have been delivered when (1) hand -delivered to the other party, its agents, employees, servants
or representatives, (2) delivered by facsimile with electronic confirmation of the transmission, or
(3) received by the other party by United States Mail, registered, return receipt requested,
addressed as follows:
To Covered Entity:
City of Fort Worth
Attn: Assistant City Manager
100 Fort Worth Trail
Fort Worth, TX 76102-6314
Facsimile: (817) 392-8654
With copy to Fort Worth City Attorney's
Office at same address
19. Amendments and Waiver
To Business Associate:
City of Lake Worth
Attn: City Manager
3805 Adam Grubb St.
Lake Worth, TX 76135
Facsimile: (817)237-9684
This BAA may not be modified, nor will any provision be waived or amended, except in
writing duly signed by authorized representatives of the Parties. A waiver with respect to one event
shall not be construed as continuing, or as a bar to or waiver of any right or remedy as to subsequent
events.
20. HITECH Act Compliance
The Parties acknowledge that the HITECH Act includes significant changes to the Privacy
Rule and the Security Rule. The privacy subtitle of the HITECH Act sets forth provisions that
significantly change the requirements for business associates and the agreements between business
associates and covered entities under HIPAA and these changes may be further clarified in
forthcoming regulations and guidance. Each Party agrees to comply with the applicable provisions
of the HITECH Act and any HHS regulations issued with respect to the HITECH Act. The Parties
also agree to negotiate in good faith to modify this BAA as reasonably necessary to comply with
the HITECH Act and its regulations as they become effective but, in the event that the Parties are
unable to reach agreement on such a modification, either Party will have the right to terminate this
BAA upon 30- days' prior written notice to the other Party.
FORTWORTH,
[Executed effective as of the date signed by the Assistant City Manager below.] / [ACCEPTED
AND AGREED:]
Covered Entity:
Name: William Johnson
Title: Assistant City Manager
05/20/2026
Date:
Business Associate
►►►►►tt�ilrrrr
`o. of -a ke
Or
By: F f
Name: Stady Almond
Title: Ci . Manager N
e
Date: 2-i .ZD2 lD— ''' �'ta oOfTel
CITY OF FORT WORTH INTERNAL ROUTING PROCESS:
Approval Recommended:
By:
Name:
Title:
RaT Hill
Interim Fire Chief
Approved as to Form and Legality:
By:
Name:
Title:
Taylor C. Paris
Assistant City Attorney
Contract Compliance Manager:
By signing I acknowledge that I am the
person responsible for the monitoring and
administration of this contract, including
ensuring all performance and reporting
requirements.
By:
Name: Ryan Zelazny
Title: Fire Deputy Chief - Operations
City Secretary:
By:
Name:
Title:
Jannette S. Goodall
City Secretary
� v �
FORTWbRTH
Fort Worth Regional EMS System
Out -of -Hospital & Mobile Integrated
Healthcare Protocols
These protocol's jurisdictional authority pertains to the following members of the Fort Worth Regional EMS
System:
Bell Helicopter Fire Department
Blue Mound Fire Department
Edgecliff Village Fire Department
Forest Hill Fire Department
Fort Worth Fire Department
Fort Worth Police Department
Haltom City Fire Department
Haslet Fire Department
Lake Worth Fire Department
Richland Hills Fire Department
River Oaks Fire Department
Saginaw Fire Department
Sansom Park Fire Department
Westover Hills Police Department
Westworth Village Police Department
White Settlement Fire Department
These protocols apply to clinicians who are credentialed by the Fort Worth Office of the Medical Director
(FWOMD). Clinicians are authorized to practice within these protocols while considered to be "On -Duty" by
their respective agencies. When outside the service area jurisdiction and not responding with another agency,
credentialed clinicians may operate under these protocols within the borders of the State of Texas. Any
advanced procedures may be performed, if allowed within the system, only at the request of the on -scene EMS
agency.
Clinicians will remain authorized under these protocols for all deployments out-of-state with state programs
(EMTF or TIFMAS) under EMAC requests. All deployments must be reviewed by and approved by the
medical director.
Questions regarding the applicability of this document within any specific jurisdiction or for a particular event
should be directed to the FWOMD by calling 817-923-1500 or in writing to the following address:
Fort Worth Office of the Medical Director
2900 Alta Mere Drive
Fort Worth, Texas 76116
EFFECTIVE:
July 1, 2025
Jeffrey L. Ja i S, MT-P, FACEP, FAEMS
Chief Me i al Officer / System Medical Director
Medical Direction and Oversight of the system includes the following components:
Medical Control Advisory Board
By resolution, the City of Fort Worth established the Medical Control Advisory Board (MCAB) to
advise the City about the clinical performance of the EMS System, review medical protocols,
clinical policies and procedures for the EMS System, and make recommendations to the Medical
Director. MCAB should also represent the interests of the medical community, first responders,
medical transportation clinicians, and ambulance standby clinicians by making recommendations
for improvements to the EMS System as needed, and recommending and reviewing research
conducted within the associated service area of the EMS System. The MCAB is composed of the
System area hospital Emergency Department Medical Directors and additional specialty
physicians.
Medical Director
The Medical Director is responsible for all aspects of clinical care for the System, including
establishing clinical care requirements, credentialing standards, training & education, quality
improvement processes, and research. The Medical Director must approve all medical protocols.
The Medical Director's power and duties are defined in the Texas Medical Board Rules in the
Texas Administrative Code, Title 22, Part 9, Chapter 169, Subchapter C, and in the employment
agreement and job description. The Medical Director is also the Chief Medical Officer of the EMS
System and has all powers and duties afforded and required of EMS medical directors under state
law. The Medical Director provides all independent medical direction and is the exclusive source of
medical direction and oversight for the EMS System.
Office of the Medical Director
The Medical Director may appoint members of staff to aid in the provision of medical direction
and oversight, which may include physician (Associate/Assistant Medical Directors), and non -
physician staff. The Medical Director may delegate certain tasks and responsibilities to this staff.
The selection, hiring, separation, and day-to-day direction of members of this staff solely resides
with the Medical Director.
Medical Directives
Medical Directives are issued by the Medical Director and describe specific clinical changes that
modify these protocols. Each System Agency is responsible for disseminating Medical Directives to
their stakeholders and credentialed EMS clinicians.
Medical Advisories
Medical Advisories are issued by the Medical Director and describe general medical topics that do
not modify these protocols. Each System Agency is responsible for disseminating Medical
Advisories to their stakeholders and credentialed EMS clinicians.
On-line Medical Control (OLMQ
OLMC is provided through direct communication with FWOMD EMS Physicians and is to be
used for the purpose of further guidance and advisement of patient treatment, transport, and
medical direction outside of, or as required within, these protocols. Contact FWOMD EMS
Physicians by calling 682-302-4911.
Organization of the Protocol Document
This document was designed for efficient navigation. Protocol, Procedures, and Pharmacopeia references are underlined and
in red. OMD clinical policies reference are underlined, italicized, and in purple.
The major sections are color coded to allow for rapid identification and are organized as follows:
The master sections are identified by the top -most heading within each protocol, e.g. cardiac, medical, trauma, environmen-
tal, and distinguished by their color -coding. The definition of an adult and pediatric patients is outlined in the Patient As-
sessment protocol.
General
Spans multiple protocols due to their relevance to all facets of patient care, including Drug Assisted Airway, Circulatory Sup-
port, Respiratory Support, Acute Pain Management, Release at Scene, Against Medical Advice
Cardiac
Cardiac Arrest, Ischemic Chest Pain, and treatment of dysrhythmias
Medical
General medical emergencies, including Abdominal Pain, Respiratory Distress, Stroke/CVA/TIA
Environmental
Bites/Envenomation, Hypothermia, Hyperthermia, Near Drowning
Trauma T
Treatment protocols for the injured patient
OB/GYN
Emergency Childbirth and Newly Born
Protocol Conventions
All 911 protocols are listed in their entirety on a single page.
—> Interventions, including the use of skills or medications, are preceded by individual bullets or lists of bullets.
Henwrthape Comm[
. Cover the srump with saline -soaked sterile dressing and wrap with dry dressing
• Wrap severed part in saline -moistened sterile dressing
Simple If statements provide specific indications for the interventions that follow.
!fmyiG&Ytd itizuve,1,r Pretchimpsia i Eiplampsia
While bullets are generally listed in the order of importance, numbers are avoided for the purpose of deemphasizing a
rote, cookbook, approach to patient management
The following pages provide a visual guide to the key elements of each protocol page, including:
Master and Subsection identification
Provider Tabs for individual credentialing levels, i.e. Basic, Paramedic, Critical Care Paramedic (CCP)
Pearls & Pitfalls
Procedures
Detailed Procedures are provided in either the Procedure section or, in some cases, are located directly within the individual
protocols (Respiratory Support) to standardize the approach to high -risk low -frequency procedures (endotracheal intubation,
cricothyrotomy, needle thoracostomy, and vasopressor administration for shock).
Pharmacopeia
Summarization of medications use within protocol with dosing and mixing references along with indication and contraindica-
tion of the medication.
Master & Subsection Identification
Bulleted
Actions
If /•
statement
Master Section
(Medical)
I
_ -Disease Process
Ti�x�c�lf�gv► —
ff sJ<s,(te WWI egVIArre to &txie aged!.
• RemOvc patient from environment if safdrrained?cquipped (PPE) to do so
+ Ensure appropriate decontamination
lfksamov or sots)trcYrd spriale ruttrxicatiaa, see 012iatc I1sc DLSorder
if rarb*a m¢mttridr fC01 exfanlrm
+ Consider with CO lin c s above 5 % in non-smoker or 10% in a smoker if available
+ High flow 0, by NR1B+ 14FNC (as available) 15 LPM each
!f t'aNWbr lkt(¢A!!tM
• Do not induce vomiting or allow the patient to ear or drink
r.
).
if tae'liy ar iia ani+xiattd wilt symp athwnimetir int++.xieatlau (t.g_, ctaraiw, amp&iamise. AMMA).
• Adult and Fed
Adult-2m
Adult - 2.5-5.0 mg slow 1V fi0 or 5 mIh g 111N, repeat PRN q 5 dun (max total dose 10 m
Pcdi - 0.05 mg)kg (max duce 2.5 mg) IV, repeat PRN q 5 thin x 1
lfdyst•nie rmeti•n. Treatmeni
P
+ Dinhenlrt•draminc
Adult - 50 mg IVrlIWIO
Pcdi - 1 mglkg (max dose 50 mg)
L l L ]
Io yed cyanide paiwshiig (Iia a inba�'(azzon, drrwai or 1Rgmizom eApomim) e'iND' if dFd� lAmial itaw. /�t'✓Anvs F'Aa nw inma! dal, 9r
�iJlIdl{
[artslac'mmY,
+ lfavaihJ6le, I fydroxacolralamin Over 15-minutes through a dedicared IV110;. contact OLAIC fallowing initial dnsc
Adult - 5 g IV AO, repeat PRN x 1
Pedi - 0-2 years: 0_625 g IV'/10 (1/8 lwttle)
3-5 years: 1.25 g IVt1I0 (114 bottle) Hyd€nstocob'damin
6-13 years: 2.5 g IV110 (112 bottle) 1 bottle = 5 g
CoxjilBr the fd1xving tkSrdiTIR,Yel11'redJtJ'eJtlS'
TrivAhe Antidepn-ssant (TCh.)
-
+ Sodium Bicarbonate
-
Adult - 1 mEq&g IV/10, repeat MN 1 mL•q&g x 1
Pedi - Same as Adult, repeat PRN 0.5 m>gjkg x 1
Srta-hln[
+ C'Iucagon
Adult - t mg IV110 slow push over l-minute, repeat PRN q 5 min x 1
Pedi - 0.1 mgAg IV?+10, slim push over 1-minute (max single dose l mg), repeat PRkN) 0.2 mg/kg IVAO xl
Calcium Channel B14icker
+ Calcum Chl,,ndc
Adult - 1 g IV slow push
Pcdi - 20 mg/kg (0.2 mL g) I V AO, slow push (max dose t g)
OrganuY Aumphatc
+ Atropine
Adult - 2 mg 1VJIO, repeat PRN q 3 min until secretions dry up
Pedi - 0.02 mglkg IVAO/IM, rcpear until secretions dry up
SpO s mad' he a paxxr indicator of scventy m {A} poisoning,; therehare, regardless of Sp0_, always treat the {+anent
Toxicimrnes secondary to toxic substanccs or to toxic doses of common medications may remlt from exlxisurc in the form of inges-
tion, inhalation, injection, skin absorption
Dysronias may result from, a number of p ychiatric and GI medications, including droperidol, haloperidol, fluphcnaaiae, fluvactinc,
duloxetine, sercraline, metodopramidc
atric
1
Provider Tabs
Interventions for each provider credentialing level are listed within their individual tabs on the right of the
page:
• Basic
• Paramedic
• Critical Care Paramedic (CCP)
Each successive credentialing level includes interventions for that specific tab, as well as those interventions
in the tabs preceding it. Paramedic level providers perform all interventions in both the Basic and Para-
medic tabs, while Critical Care level providers are responsible for all interventions in the Basic, Paramedic,
and CCP tabs.
l
1
i
r
Pre-Eclampsia , Eclam} sia
I
�. Pre-Ei-hi ttipsia is present in patients laetw•een 20 weeks gestation and +6 weeks postpartum with.=
• SBP � 140 and DBP �:_90 with severe katures, or
Severe Features: new onset headache, visual changes, or RtiQ pain I '!
• SBP L 160 or DBP _> 11 U r rgardlless of gmptoms
Eclampsia should the considered present fur all tonic -conk seizures in pregnancy of post-partum patients
I
VSHP 2t 140 and D13P --L' 90 uilh Setae F iivi i confirmed.b- evrre-t4? fined f mff &n a rvrading! 5 tnirtartes *J!rt
Magnesium Sub stc (10 ; 250neL NIS) bolus 6 g IVIIO over 15 min; Followed by ? &r infusian
+ Bolus: race = 648 tnlJhr; total volume = 150
• Infusion. rate = 50 mL/hr
if SBP > 160 or L>HP � 1f 10 a enfirmted i -dy fitted cmff on ? readings 5 tminuits aparl
• l+ i edipin '10 mg sL
• Magnesium Suffate (14)i. J 251)mL l`+15 bolus b b IVAO over 15• inin, followed by 2 g1hr infusion
• Bolus. rate = 648 tr&hr; total volume = 150
• Infusion. rate = 50 mLJhr
V.ru.,Maed eclamph, seizure
MiLLIZOlaum as per w izure protocol (only Fete ongoing; seizure)
+ Magnesium Sulfate l 1i)_a; ' 0tnL MO bolus fi g IVAO over 15 miry; followed by 2 gAir infisian
+ Bolus. rate = B mlJhr; total volume = 150
I I
a Infusion. rage = 50 niL/hr
(ad minwere l etwn rf srtzrr t strrpf)
I
1f awernal .F R is > 60 duct SBP � 160 or DBP -110 ervtrfrrmed by cot? ll}, fitted cuff on 2 Makrrgr 5 minutes t*an Ir�l
6rtm syvj&om s z4-f cribwle v t v pare pywerrt
Labetalul 20mg IV over 2 mnirnures, repeat 40 mg IV PRN q 10 minutes �
W. — — — — )
Pearls & Pitfalls
Additional guidance may be listed below the tabs in a white, un-tabbed "Pearls & Pitfalls" box. This may include additional
diagnostic and treatment considerations, recommendations, and links to other relevant protocols.
I
I
I
I
I
I
I
l
Seizure/Status E .ite .ticus
• Position patient to avoid injury and aspiration, consider recuvery Position �■
1f m¢ rrrarrmwd ra "eline, etalarurr bloodglmurram and mmider Dulieuc Emergencies
If rarrivdj Jriain ur iR at�,rtrar ejailejxicxeJ _?-rti�rei trprd z ijbomi intty-utning iu,id jieairxiJ,
t AlcditiOlan� midazolam is the Firs¢ line route of administration if an Iv not .already established
Ad—r- 10 mg JMJIN; or 5 m slow W110, repeat PRNN €l 5 min x 2
Peck - 0.l5 mg)kg slate lam,+ICp (max dose 7-5 mg' repeat q 5-min PRN x 1 �
1f,0sr-ictal and MW eactit4 mizilT Or not in Fi arras epilepri vs, pbfarnLAYAWie riwrapl , with mrct'iculsrm it mat ift ralyd
M�rc vji, rr?Vile nukviw;rm arirlci.enimr ,
rarn ne
A- uu�mgA 11ujo
P'edi - Same as Adult
l(jx.ijrerted er-1ampriallwripartarrm miaaery, jre Preedmul2sia / Ccplarnpsia
Consider toxicologic causes of seizure
Organophosphate/nerve gas (see chemical warfare policy)
Sympathomimetic toxidrome (stuffersl'packers, methamphetamine)
Anticipate that dispatch or initial clinical picture of seizure may be initial presentation cardiac arrest
Most confused patients following a seizure do not need treatment. Monitor for up to 15-minutes before considering
intervention or determining a disposition.
Always consider eclampsia in 311 trimester pregnancy or up to 6 weeks post-partum.
Scope of Practice
It is the responsibility of each individual clinician to operate within their credentialed scope of practice. Credential level and
scope of practice can only be changed by successful completion of the FWOMD credentialing process. Except when
specifically detailed, such as in an FWOMD-approved training program, no provider may authorize or delegate clinical care
to another provider, which is outside of either's scope of practice. Consideration may be given is cases of declared disasters,
and resource limitation in mass casualty incidents.
Credontialing
L7
Education
EMS
`e of Pra�
Licensure
C
Minimum State Certification
EC"
EMT EMT-P
Credential Level
ECA
'
Airway
Airway Adjuncts (OPA & NPA)
X
Airway Maneuvers (Head tilt -chin lift, Jaw -thrust)
X
Airway Obstruction (dislodgement via Magills forceps)
Airway Obstruction (manual dislodgement techniques)
X
Bag -valve -mask
X
BiPAP via transport ventilator
CPAP/BiPAP
Delayed Sequence Intubation (DSI)
Emergency Tracheostomy Exchange
Endotracheal Intubation
Gastric tube insertion via SGA port
High flow nasal cannula via transport ventilator
Nasogastric tube placement
Orogastric tube placement
Oxygen therapy (Nasal Cannula or Non-Rebreather Mask)
X
Pulse Oximetry
Rapid Sequence Airway (RSA)
Suctioning - Tracheobronchial via Endotracheal Tube
Suctioning - Tracheobronchial via Tracheostomy
Suctioning - Upper Airway
X
Supraglottic Insertion
Surgical Airway
Thoracostomy - Needle
Thoracostomy - Simple
Transtracheal Ventilation
Waveform Capnography
Cardiovascular
Automated External Defibrillator (AED) Placement & Use X
Blood or Blood Products
Initiation of Transfusion
Continuation of Transfusion
Blood pressure automated
Blood pressure manual
X
Cardiac monitoring - 12 lead ECG acquisition & transmission
Cardiac monitoring - 12 lead ECG interpretation
Cardiopulmonary resuscitation (CPR)
X
Electrical Cardioversion
Manual Defibrillation
Mechanical Compression Device Placement
Pericardiocentesis
Transcutaneous pacing
Ventricular Assist Device (VAD) NON-VAD therapy complaint
Skills - Trauma/Restraint
Extremity stabilization & splinting
X
Hemorrhage Control (direct pressure, tourniquet, wound packing)
X
Manual Cervical Stabilization & Cervical Collar
X
Manual Patient Restraint
X
Pelvic Binder
Spinal Motion Restriction (LSB, Scoop Stretcher, KED)
Traction Splinting
Skills - Access/Maintenance
Central Catheter Access (Broviac, Central Line) for Emergency
Central Line Catheter Monitoring Only
Intraosseous initiation (adult, pediatric, tibial, humeral)
Peripheral intravenous access (extremity, truncal, external jugular)
Peripherally Inserted Central Catheter Access (PICC)
Skill - Miscellaneous
Blood glucose monitoring
X
Emergency Childbirth
X
Eye irrigation
Telehealth Consultation Facilitation
Venous blood sampling
Skill - Critical Care
All Chest Tubes (suction or gravity)
Extracorporeal Membrane Oxygenation (ECMO)
Impella
Intra-Aortic Balloon Pump (IABP)
Invasive Line Monitoring (Arterial Line, Swan -Ganz)
Mechanical Ventilation
Point of Care Ultrasound
Ventricular Assist Device (VAD) with complaint related to VAD therapy
Medications
Aspirin X
Acetaminophen
Oral
IV administration
Adenosine
Albuterol
Amiodarone
Atropine
Symptomatic bradycardia
All other Indications
Buprenorphine
Calcium Chloride
Entrapment/Crush/Traumatic Rhabdomyolysis
All other Indications
Dexamethasone
Dextrose 10%
Diltiazem
Droperidol
Diphenhydramine
Epinephrine
Auto -injector Epinephrine (patient or EMS supplied)
X
Intramuscular (anaphylaxis)
Cardiac Arrest
Intravenous Push -Dose Pressor
Intramuscular (asthma)
Infusion
Esmolol
Fentanyl
Glucagon
Glucose - Oral
X
Hydroxocobalamin
Ibuprofen
Ipratropium
Isopropyl Alcohol
X
Ketamine
Analgesia
For facilitation of pacing/cardioversion
Behavioral Emergencies/Agitation
Delayed Sequence Intubation (DSI)
Rapid Sequence Airway (RSA)"
Ketorolac
Labetalol
Lidocaine
Magnesium
Midazolam
Pacing if Ketamine insufficient
Sedation after invasive airway placement
All Other Indications
Naloxone
Auto -injector
X
Intranasal
X
Intravenous
Nicardipine
Nitroglycerin
Assist with self -administration of already prescribed NTG & on scene
X
EMS Supplied Nitroglycerin
IV administration
Norepinephrine
Normal Saline (0.9%)
Ondansetron
ODT
Intravenous
Oxytocin
Phenylephrine
Racemic Epinephrine
Rocuronium
Sodium Bicarbonate
Suboxone
Tranexamic Acid (TXA)
Vasopressin
Immunizations
Mobile Integrated Healthcare Paramedic
Credential Level
MHP
Approved medications prescribed for MIH programs
X
Consultation for Medical Director Refusal
X
Foley Insertion/Removal
X
Furosemide
X
In -Home Diuresis
X
Peak Flow
X
Point of Care Laboratory Analysis
X
Potassium Chloride ER Tablets
X
Suture/Staple Removal
X
Glossary (Abbreviations and Terms)
Delayed Sequence Intubation - a goal -directed and stepwise procedure to facilitate intuba-
tion using procedural sedation with ketamine to maximize physiologic preparation prior to
administration of a paralytic
External Laryngeal Manipulation, also known as "Bimanual laryngoscopy", similar to BURP
Ear -to -sternal notch (airway position, previously known as "sniffing position"), performed by
elevating the patient's head, and confirmed from the patient's side by visualizing that the
auditory canal is level with sternum and parallel to the ground.
Mobile Integrated Healthcare services that are designed to enhance, coordinate, effectively
manage, and integrate out -of -hospital care
Patient Centered Medical Home refers to the function and/or group of providers through
comprehensive, patient -centered, and coordinated care
"as needed"
Rapid Sequence Airway - the placement of a supraglottic airway facilitated by the use of se-
dation +/- use of a paralytic
Systolic Blood Pressure/Diastolic Blood pressure - all units of measurement are in mmHg,
e.g. SBP >_ 90 means Systolic Blood Pressure >_ 90 mmHg
Drying of mucus membranes and airway secretions resulting from appropriate dosing of at-
ropine in organophosphate poisoning
Abnormal or unstable low blood pressure. Signs and symptoms include diminished organ
function (e.g. AMS, pallor/diaphoresis) due to a low perfusion (blood flow) state; may be
manifested as absolute hypotension (e.g. SBP <_ 90 in adults) or relative hypotension in pa-
tients with signs of poor perfusion.
The anatomic location used to guide needle thoracostomy insertion site selection, especially
in patient's with difficult to visualize anatomic landmarks. Defined as the line where the
breast meets the torso.
Organized approach to advanced airway management for the purpose of minimizing error
and, therefore, adverse patient outcomes (e.g. oxygen desaturation, bradycardia, hypoten-
sion, aspiration, cardiac arrest). All equipment necessary for appropriate airway manage-
ment is placed out of the packing, in 2 sizes, within the airway manager's field of view.
BVM with 2 NPA (Nasopharyngeal Airway) + OPA (Oropharyngeal Airway)+ HFNC (High
flow Nasal Cannula)+ HFBVM02 ( High flow bag valve mask oxygen)
Insertion of a large -bore catheter into the chest for the purpose of relieving a tension pneu-
mothorax
A person who requests EMS or, A person whom EMS has been requested and who has any
medical or psychological complaint, obvious injury/distress, or has a significant
mechanism of injury
A hemodynamic parameter used to assess shock severity. SI is calculated by dividing heart rate (HR) by sys-
tolic blood pressure (SBP). An SI >0.9-1.0 is associated with hemodynamic instability and an increased risk
of adverse outcomes in traumatic/non-traumatic hemorrhagic shock, sepsis, and peri-intubation patients.
Means to mitigate potential or further trauma in patients with suspected spinal injury
Repeat ECGs, at minimum 2-tracings prior to arrival at the destination
The process of stopping resuscitation once begun by professionals
A combination of delirium (confusion) with agitation and violence. It is often associated
with stimulant use and may be linked to sudden cardiac arrest.
The visual representation of the measured exhaled carbon dioxide in graphic form as op-
posed to a numeric value. Visualized as a 4-phase generally square shaped waveform with
each breath. Monitoring is required for all patient's receiving advanced airway intervention,
including endotracheal intubation or blind insertion supraglottic airway
The process of not beginning professional resuscitation or not continuing bystander CPR,
as differentiated from `Termination of Resuscitation'
J.J. �1
Tl • lL ,f
tic:ute rain lvianaUernenL
• Place in position of comfort, splint extremity injuries, and ice packs, as appropriate
• Document body weight
• Assess and document initial and final pain scale (see below)
• Monitor and document vital signs and pain scales pre and post every intervention
• Acetaminophen
Adult - 1 g PO
Pedi - 15 mg/kg PO (max dose 1 g)
• Ibuprofen
Adult - 600 mg PO
Pedi > 6 months - 10 mg/kg PO (max dose 600 mg)
• EtCO2 monitoring required for fentanyl or ketamine
• Acetaminophen
Adult - 15 mg/kg IV (max dose 1 g)
Pedi > 2 years of age, same as Adult
• Ketorolac
Adult - 15 mg IV or 30 mg IM once
Pedi - 0.5 mg/kg IM or IV once (max dose 15 mg)
• Fentanyl - titrate to pain relief and respiratory/hemodynamic status
Adult - 1 mcg/kg IV/IN/IM (max single dose 100 mcg), repeat q 5-min PRN
Pedi - same as Adult
• Ketamine - Do not re -dose if RASS < 0
Adult - IV/IO - 0.3 mg/kg in 100 mL NS over 10 min (max single dose 30 mg), repeat PRN x 1;
IM - 0.6 mg/kg (max single dose 50 mg), repeat q 10-min PRN x 1
Pedi - > 3 years old, same as Adult
Ketorolac is contraindicated in trauma, bleeding, or kidney injury (acute and chronic)
Benzodiazepines should not be co -administered with opiates
In general, ketamine should not be the initial option, however, there may be circumstances where it is an appropriate
initial agent. Clinical judgement based on the specifics of the situation should drive management.
Use 1 mL syringe for accuracy in drawing up Ketamine as concentration carried is 50 mg/mL and thus all dosing will be
less than 1 mL.
0(i)
C_!�),0
1�a`�
(:_)
0 2 4 6 8 10
NO HURT HURTS HURTS HURTS HURTS HURTS
LITTLE BIT LITTLE MORE EVEN MORE WHOLE LOT WORST
Wong -Baker pain scoring for non -communicative patients
Subdissociative Ketamine (SDK) Dosing Chart
500 mg/ 10 mL vials (50 mg/ml concentration)
POUNDS (Ibs)
mL (mg) of Ketamine
KILOS (kg)
37- 69 Ibs
0.1 mL (5 mg)
17-33 kg
70-109 Ibs
0.2 mL (10 mg) 34-49 kg
0.3 mL (15 mg) 50-66 kg
110-149 Ibs
150-179 Ibs
0.4 mL (20 mg) 67-82 kg
180- 219 Ibs
0.5 mL (25 mg) 83-99 kg
220 Ibs or more
0.6 mL (30 mg) 100 kg or more
Blood Administration (911)
Contraindications:
• Known religious objection to receiving blood or blood products
Criteria:
• Hemorrhagic Shock in medical or trauma patients
SBP < 70 mm Hg or,
—> SBP < 90 mm Hg and HR > 120 bpm or,
—� Age > 65 and SBP < 100 and HR > 110 or,
—> EMS witnessed traumatic arrest secondary to suspected hemorrhagic only if blood can be flowing in under 5 mins
• Age < 15 contact OLMC
Ifpatient in hemorrhagic shock,
• Obtain baseline patient temperature
• Transfuse 1 unit Low Titer O+ Whole Blood (LTO+WB)
OR
If Whole Blood is unavailable, transfuse,
• 1 unit Packed Red Blood Cells (PRBC) and/or
• 2 units Liquid Plasma
• Calcium Chloride 2 g IV/IO
• Tranexamic Acid, do not give if injury occurred >_ 3 hours before
Adult - 2 g IV/IO, slow push over 1-minute
Pedi - N/A
• Repeat transfusion above PRN if additional blood and/or blood product is immediately available
If suspected febrile non -hemolytic transfusion reaction (FNHTR), including temperature rise >_ I' F above baseline and/or rigors, during blood
product administration:
• Immediately stop infusion and disconnect IV tubing
• Acetaminophen
Adult - 1 g PO
Pedi - 15 mg/kg (max dose 1 g) PO
• Diphenhydramine
Adult - 50 mg IV/IM/IO
Pedi - 1 mg/kg IV/IM/IO (max dose 50 mg)
—. Beta Blockers and Calcium Channel Blockers may not allow HR to increase appropriately
BLS Transuort Criteria
Clinical judgment should be used when deciding whether to wait on scene for ALS or rapidly transport to the ED. In
general, ALS should transport the following types of patients:
• Altered mental status (from baseline)
• Respiratory distress or failure
• Unstable vital signs
• Any interventions performed beyond scope of transporting clinician
Exceptions:
• IV locks not used for medications
• Ketorolac, dextrose, glucagon, naloxone, or ondansetron
• Note: BLS can transport profoundly unstable hospice patients IF ALS interventions are not desired.
Any credentialed ALS clinician may transport a patient meeting above criteria with a BLS ambulance.
If ALS resources are not available in a reasonable time period,
• BLS may transport patients meeting the above criteria.
• In general, this is appropriate for time critical conditions and short transport times.
• ALS intercept enroute to hospital is an option.
—> If a patient meets BLS transport criteria and an ALS/Advanced credentialed clinician has interpreted an ECG (no ischemia or
dysrhythmia), they should sign the appropriate field in the ePCR before transferring care back to the BLS unit.
Circulatory Support
• Position patient in supine position with legs elevated, as appropriate and tolerated (no Trendelenburg)
If suspected traumatic etiology
go.
• Hemorrhage Control as appropriate
If gravid uterus
• Manually displace fundus to the patient's left (may be accomplished by left lateral decubitus positioning, if tolerated)
If suspected tension pneumothorax with hypotension, see Thoracostomy Procedure
• Cardiac monitoring; obtain 12-lead ECG and treat dysrhythmias as appropriate
• IV/10 access
Fluid Resuscitation
• Fluid Bolus
• Adult: 500 mL, repeat PRN to meet target BP goals
• Pedi: 20 mL / kg, repeat PRN to meet target BP goals
• Titrate to target BP goals:
• TBI/Stroke: > 110 mm Hg
• Blunt Trauma: = 100 mm Hg (max 500 mL)
• Hemorrhagic Shock or Penetrating Trauma: SBP = 90 mm Hg (max 500 mL)
• Other patients:
Adult - MAP > 65 (or SBP > 90 mm Hg if manual measurement)
Pedi - SBP > 70 mm Hg + (age in years x 2) or > 90 mm Hg for age 10 or greater
If persistent hypotension despite adequate fluid administration, to temporarily stabilize blood pressure until vasopressor infusion can be initiated
• Epinephrine push dose (0.1 mg in 10ml NS)
Adult - 10 mcg (1 ml) IV/10, repeat q 5-minutes PRN, max total dose 50 mcg (5 ml)
•
Pedi - 1 mcg/kg (max single dose 10 mcg), repeat q 5-minutes PRN, max total dose 50 mcg (5 ml)
If significant traumatic or OB related hemorrhage and SBP <_ 90 or HR? 110 with poor perfusion, see Hemorrhage Control
If suspected anaphylaxis/anaphylactic shock or symptomatic bradycardia
• Epinephrine infusion (1 mg 1:10,000 / 250 mL NS or 1 mg 1:1,000 / 250 mL NS; 4 mcg / mL)
Adult - start at 5 mcg/min, titrate to goals above
Pedi - start at 0.1 mcg/kg/min, titrate to goals above
If any other suspected etiology of shock unresponsive to initial fluid resuscitation
• Norepinephrine infusion (4 mg / 250 mL NS; 16 mcg / mL)
Adult - 5 mcg/min, titrate to goals above
Pedi - 0.1 mcg/kg/min, titrate to goals above
If septic shock with vasopressor infusion or documented history of Addison diseaseladrenal insufficiency
• Dexamethasone
Adult - 10 mg IV/IO/IM
Pedi - 0.6 mg/kg PO/IM/IV (max 10 mg)
If response refractory to norepinephrine infusion, contact OLMC for
• Vasopressin (20 units / 100 mL NS; 0.2 units / mL)
Adult - 0.04 units /min infusion (12 mL / hr)
Pedi - N/A
• Phenylephrine push dose (10 mg / 100 mL NS; 100 mcg/mL)
Adult - 50 mcg (0.5 mL) q 3 min, titrate to target BP goals
Pedi - N/A
The goal of vasopressor use in trauma is to meet, but not exceed the target goal
Notify receiving facility of vasopressor use in patient report
Consent for Treatment and Transport
Before treating an individual, you must first obtain consent either from the individual or from a legal surrogate.
Consent to treatment may be implied when an individual is:
unable to effectively communicate because of an injury, accident, or illness; or
unconscious and suffering from a life -threatening injury or illness; or
a minor who is suffering from an immediate life -threatening injury or illness and whose parents, healthcare surro-
gate, or legal guardian is not present.
Otherwise, you cannot treat a person without their consent.
The right to refuse treatment includes the right to refuse assessment and the right to refuse all or specific treatments
or assessments.
A person in law enforcement custody has the right to refuse treatment but not to refuse transport.
If a patient refuses all contact or assessment
• Record disposition of call as "refused all contact"
If a patient effectively communicates a refusal of assessment, treatment, or transport
• Follow Against Medical Advice (AMA) protocol
If a patient communicates a refusal of assessment, treatment, or transport but appears to lack decision making capacity
• Follow Refusal Without Demonstration of Capacity protocol
Crashing Patient: Medical
If acutely ill with oxygenation l ventilation or hemodynamic instability:
Address Clinical Instability Prior to Movement*
• Consider requesting additional resources
• Obtain full set of vital signs (BP, HR, SpO,, ECG, Temp, BGL)
• Initiate waveform capnography
• Obtain 360' access
Assess & Address Oxygenation & Ventilation
• See Respiratory Support, Delayed Sequence Intubation, Rapid Sequence AirwaX
GOAL: SPOZ >_ 906; or persistent hypoxia despite appropriate interventions
Assess & Address Hemodynamic Stability
• See Circulatory Support
GOAL: Resolution of hypotension or initiation of treatment
*Only initiate movement before goals are met/addressed for safety or to obtain 360 access
--* Do not delay transport to meet SBP goals once initial therapy is initiated or attempted
Crashing Patient: Trauma
If acutely injured with oxygenation l ventilation or hemodynamic instability
Assess & Address Catastrophic Hemorrhage
• See Hemorrhage Control
GOAL: Bleeding controlled or minimized
Address Clinical Instability Prior to Movement*
• Consider requesting additional resources
• Obtain vital signs (BP, HR, SpO,)
• Initiate waveform capnography
• Obtain 360' access
Assess & Address Oxygenation & Ventilation
• See Respiratory Support, Delayed Sequence Intubation, Rapid Sequence Airway
GOAL: SPOZ >_ 94%; or persistent hypoxia despite appropriate interventions
Initiate Transport
Assess & Address Hemodynamic Stability Enroute
• See Circulatory Support
*Only initiate movement before goals are met/addressed for safety or to obtain 360 access
—> Most interventions for critical trauma patients, other than bleeding control and airway management, should be performed enroute
if possible
T\ 1 fi T i / T f� T\ 1 1 1
"Clayeu JCqUCIIce lI1tuDaL1011 k"3jl) - twult
Begin Invasive Airway Preparation
Ensure appropriate monitoring including: BP q 2 min cycle, ECG, EtCO2, Sp02 opposite arm from BP cuff
Begin preoxygenation via Max BVM, NRB + HFNC, or NIPPV, as appropriate
Preparation
• Evaluate airway and identify/palpate surgical cricothyrotomy anatomic landmarks
• Confirm Push Dose Epinephrine (PDE) is readily available
If hypotensive, see Circulatory Support
Sedation & Preoxygenation
• Ketamine - 2 mg/kg IV/IO (max 200 mg); repeat PRN x 1
• Verify all appropriate monitoring/positioning (ETSN, HOB @ 30' elevation)
• Increase NC to flush rate
• Preoxygenate/Denitrogenate
If adequate respirations
• Set BVM @ flush rate, form tight mask seal, and allow spontaneous respirations to continue. Ensure
PEEP >_ 5 mmHg.
If inadequate respirations
• Perform Max BVM with assisted ventilations
• Titrate PEEP to reach maximal Sp02
• Upon reaching Sp02 >_ 94%, begin 3-minute timed countdown
• If Sp02 drops below 94% - reset 3-min timed countdown once Sp02 ? 94% obtained
• Complete Intubation Checklist in entirety (MANDATORY)
Abort DSI if Sp02 remains < 94% and/or SBP < 100 mmHg, maintain BVM or RSA
Paralysis ' '
• Rocuronium - 1.5 mg/kg IV/IO once (max 150 mg)
• Begin 90-second timed countdown after administration to allow complete paralysis
• Initiate or continue assisted ventilations PRN
• Must have affirmative confirmation of SBP >_ 100 & at least 3 minutes continuous Sp02 >_ 94% at time of intu-
bation attempt
Intubation (ONLY after all above steps have been successfully achieved)
• Perform Intubation Procedure
• Immediately abort attempt if Sp02 < 94176 and begin BVM ventilations
• Ensure Sp02 >_ 94% for at least 3 min before final intubation attempt
• Max 2 intubation attempts per patient (NOT per clinician)
• Place Supraglottic Airway at any time PRN
• If Can't Oxygenate, Can't Ventilate (COCV) by jjnX other means - Surgical Airway Procedure (Cricothyrotomy)
Confirm ETT placement with:
• EtCO2 (4-phase waveform >_ 5 mmHg with every breath within 5-breaths)
• Visualization on VL of ETT through cords by two clinicians
Post -Invasive Airway Management
DSI is intended to be a deliberately controlled process with meticulous attention to preoxygenation/denitrogenation and hemodynamic
optimization to ensure safe intubating conditions and optimize the chance for first pass success without hypoxia and/or hypotension.
DSI uses ketamine for procedural sedation, where the procedure is preoxygenation/preparation.
Decision SBP > 100
to DSI Sp02 >_ 94% Paralysis Intubate
I I I
Setup/Kit Dump
Hemodynamic Optimization
Ketamine & Preoxygenation
3-min countdown
(Reset if SPO, drops < 94%) 90-sec countdo« n
Fever
If teffaperature >_ 100.4 ° F
• Acetaminophen
Adult - 1 g PO
Pedi - 15 mg/kg (max dose 1 g) PO
• Ibuprofen
Adult - 600 mg PO
Pedi > 6 months - 10 mg/kg (max dose 600 mg) PO
• Acetaminophen
Adult - 15 mg/kg IV (max dose 1 g)
Pedi > 2 years of age - same as Adult
-� Fever in newborns under 90 days is sepsis until proven otherwise and should be transported or OLMC contacted prior
to release
Consider other protocols as appropriate
Circulatory Support
—� Seizure
Hemorrhage Control
If ongoing bleeding:
• Apply firm, persistent direct pressure
If ongoing bleeding after persistent direct pressure:
• Apply Tourniquet
If ongoing bleeding despite direct pressure and tourniquet to junctionallextremity bleeding:
• Pack wound with hemostatic gauze
If bleeding dialysis fistulas or varicose veins:
• Elevate extremity straight up for gravity assist
• Firm, direct pressure with hemostatic gauze. (consider plastic bottle cap to enhance direct pressure)
• Tourniquet above and below for ongoing massive bleeding despite these measures for 10 minutes.
(Very rarely needed for varicose veins)
If hemorrhagic shock with suspected pelvic fracture:
• Pelvic binder
If significant traumatic, OB, or tracheostomy related hemorrhage and SBP <_ 90 or HR >_ 110 with poorperfusion :
• Tranexamic Acid - (do not give if injury occurred >_ 3 hours before administration OR if isolated TBI)
Adult: 2 g IV/IO slow push over 1 minute
Pedi: N/A
If ongoing epistaxis despite direct pressure:
• Blow nose, then immediately:
• Oxymetazoline
Adult: 2 squirts to affected nare
Pedi: Same as Adult
• Tranexamic Acid - Topical to affected nare(s)
Adult: 2 g saturated on cotton ball or gauze
Pedi: Same as Adult
• Mechanical nose clamp persistently until ED arrival
If significant OB related hemorrhage following complete placental delivery:
• Oxytocin
Adult: 10 units IM followed by 20 units / 1 L NS IV run wide open
Pedi: N/A
• Prehospital Blood Administration
Don't loosen pressure dressing or tourniquet to check for ongoing bleeding.
Don't wait for hemodynamic instability to apply tourniquet.
Use commercial windlass -type tourniquet.
—> Document time of tourniquet application and be sure to notify ED staff of location.
IFT Blood & Blood Products
1. Verify consent for administration of blood product. A copy should be included in the patient's chart.
2. Patients receiving blood or blood products are to have a recipient band in place.
3. If product is infusing at time of initial patient contact, verify facility transfusion checklist.
a. Patient's name and hospital number matched with transfusion record form (attached to product bag).
b. Type and number on transfusion record form matched with product bag.
c. Pre -transfusion vital signs are documented on transfusion record form.
d. Nurse administering product has signed, dated and timed the transfusion record form.
e. All original copies of the transfusion slip should remain with the patient.
4. If the transfusion of blood or blood products is initiated during transport, verify the order and facility transfusion
checklist with patient's primary RN prior to transport.
5. Obtain necessary equipment, i.e. tubing, filters, etc. from sending facility to administer transfusion.
6. Prior to administering blood or blood products enroute, complete the facility's pre -transfusion checklist and doc-
ument accordingly on the product slip and in the run report.
7. Blood or blood products may NOT be piggybacked into an existing IV line.
8. Vital signs including temperature should be obtained and recorded 15 min, 45 min and then 1 hour, at a mini-
mum, after initiating the transfusion until completed. If patient spikes a temperature 2 ° F greater than baseline,
discontinue the blood infusion.
9. If the transfusion is completed enroute, document on the transfusion slip the date and time completed, amount
given, whether or not the blood is warmed, if a reaction occurred and post -transfusion vital signs. All completed
bags and tubing should be turned over to the receiving facility with the patient.
10. It is the receiving facility's responsibility to return the transfusion slip to the sending facility's blood bank.
Whole Blood, Packed RBCs, Frozen RBCs, FFP, Platelets & Cryoprecipitate
1. Verify transfusion checklist.
2. Prime Y-type blood tubing with Normal Saline and begin infusion slowly.
3. Attach blood bag to Y-type blood tubing. Clamp tubing to saline. Open clamp to blood and adjust flow to run
slowly for the first 15 minutes. If no adverse reaction, increase flow based on patient condition and transfusion
times.
a. Whole Blood: 1-1/2 — 3 hours
b. Packed RBC's: 1-1/2 — 3 hours
c. Washed Packed Cells: 2 hours maximum
d. Fresh Frozen Plasma: 30 min (all units must be infused within 4 hours from thaw time)
e. Platelets: 30 min max
f. Cryoprecipitate: rapid infusion
4. Monitor vital signs as previously outlined.
5. Monitor for signs/symptoms of adverse reaction. If adverse reaction noted, stop infusion and see Allergic Reac-
tion protocol.
6. Blood tubing should be changed after each unit. EXCEPTION: If emergent situation and several units of blood
are being administered rapidly, tubing should be changed every 4 hours or every other unit.
7. If suspected febrile non -hemolytic transfusion reaction (FNHTR), including temperature rise >_ 1° F above base-
line and/or rigors, either during or within 3-hours following blood product administration:
• Acetaminophen - per Fever protocol, and
• Diphenhydramine - 50 mg IV
Lift Assist
If request of "lift assist"
• Make scene and evaluate patient
Assess for signs of trauma, infection or altered mental status (AMS)
• Assess vital signs
• Evaluate cause of patient fall or need for assistance
If a patient meets any below criteria
Medical cause of fall
—> Signs of new trauma (e.g. pain or injury)
Altered mental status
Any loss of consciousness
Currently on blood thinners (not including ASA)
HR > 100
SBP < 100 or > 200
DBP > 140
RR > 20
Sp02 < 90%
Blood Glucose < 70 or > 300 (check if diabetic or otherwise indicated)
New inability to ambulate
• Recommend further evaluation and transport to hospital
For a patient refusing transport
• Follow AMA Protocol
If an individual meets none of the above criteria
• Assist individual with request
• Disposition call per agency policy regarding lift assistance
Agencies may have alternative dispositions for "lift assist", e.g. assist citizen, assist invalid, etc.
Mechanical Ventilation (Hamilton-T 1)
Indications for ventilator:
• Cardiac Arrest
• Presence of invasive airway (intubation or SGA)
• Pre -oxygenation prior to DSI
• Need for both non-invasive ventilation (CPAP/BiPAP) and CCP care during transport
• Otherwise stable patients who are not hypoxic and are comfortable on CPAP may be transported without
ventila-tor or CCP.
• See Mechanical Ventilator (Hamilton-T1) procedure
• CCP must accompany any patient on our ventilator
Nausea and Vomiting
• Position patient to avoid aspiration
Consider recovery position
• Suction, as appropriate
• Isopropyl Alcohol - Instruct patient to hold pads 1-2 cm from nose and inhale deeply as frequently as required to
achieve nausea relief.
• Ondansetron
Adult - 4 mg ODT, may repeat q 10-min PRN x 1
Pedi - 8-15 kg: 2 mg ODT, repeat q 10-min PRN x 1
16-30 kg: Same as Adult
• Ondansetron
Adult - 4 - 8 mg IM/IV, may repeat q 10-min PRN xl
Pedi - 0.15 mg/kg (max dose 4 mg) IM/IV
if vomiting despite ondansetron, or for patients with suspected gastroparesis, cyclic vomiting, or cannabinoid hyperemesis syndrome
• Droperidol
Adult - 1.25 mg IM/IV, may repeat at 0.625 mg q 10-min PRN xl
Pedi - N/A
IV opioids do not require co -administration of antiemetics
Consider other conditions/protocols which may present with nausea/vomiting (e.g. myocardial ischemia)
Patient Assessment
A patient is defined as a person:
who requests EMS, or for whom EMS has been requested, AND
who has any medical or psychological complaint, obvious injury/distress, or has a significant mechanism of injury.
A pediatric patient is defined as:
—> Patients 14-years of age or younger, AND
Lack secondary sex characteristics, AND
Fit on a length -based -resuscitation tape (e.g. Broselow) OR estimated or known weight <36 kg (-80 lbs)
• Assure scene safety
• Perform initial assessment, including evaluation for life threats to airway, breathing, and circulation.
• Assess mental status (e.g., AVPU) and disability (e.g., GCS).
If provider impression of extremis, including new -onset altered mental status, airway issues, severe respiratory distress/failure,
signs and symptoms of shocklpoor perfusion, or imminent cardiac or respiratory arrest.
• See Crashing Patient Medical or Crashing Patient Trauma
• Form a differential diagnosis based on patient complaint
• Perform a focused history and physical exam to narrow differential diagnosis and guide treatment
• Utilize reference guide (Broselow/pre-calculated dosing reference) for medication dosing and equipment sizing
• Document findings and interventions in the chart
If valid DNR, regardless if pulse present or absent see, DNR Policy
Initial Assessment
Appeara
%AJ of
-athing
Pediatric GCS
Eye Opening (4)
Spontaneous
To Speech
To Pressure 2
None 1
Circulation to Skin
Verbal Response (5)
General Vital Signs and Guidelines
coos, Babbles (infant)/Talks normally 5
Irritable cry (infant)/Words 4
Age
Heart Rate BloodPressureRespindurry
Rate
Cries to pressure (infant)/Sounds 3
(beatsi1 in) (mn1�nH1
(bpea f mia) _
Moans to pressure 2
Premature
110-170 SBP 55.75 DBP 35-45
40-70
None 1
0-3 months
110.160 SOP 65.05 DBP 45.55
35-55
Best Motor Response (6)
3-6 months
110.160 SOP 70.90 DBP SQ-65
30-45
Spontaneous Movement 6
6,12 months
90-160 SBP 80-100 DBP 55-65
22-38
Withdraws to touch 5
1-3 years
80.150 S8P90-105 DBP 55-7+0
22-30
Withdraws from pressure 4
3-6 years
74.120 SBP 95.110 D13P b0-75
20.24
Abnormal flexion 3
6-12years
60.110 SBP 100.120DBP 60.75
16-22
Abnormal extension 2
> 12years
60-100 SOP 110.135 DRP 65.85
12- 0
None 1
CCP may use point of care ultrasound to aid in assessment as needed, provided it does not otherwise interfere with
treatment or unreasonably delay transport.
Post -Invasive Airwav Management
• Maintain SP02 >_ 94% and EtCO2 35-45 mmHg
• Avoid providing excessive tidal volume with BVM ventilations
• Re -confirm EtCO2 with all transfers/movements of the patient
• Maintain HOB at >_ 30°, if no suspected spinal injury
• Consider wrist restraints for airway device protection
• Monitor and document serial RASS scores
Monitor closely for post -airway hypotension and treat per Circulatory Support
Ketamine
Adult — 2 mg/kg IV/IO immediately after invasive airway secured then q 15 min or more frequently PRN
Pedi - same as Adult (max dose 70 mg)
• Maintain RASS goal of -5
If sudden or unexpected clinical deterioration (e.g., profound hypotension, falling Sp02, difficulty ventilating)
DOPES
Dislodgement
• Confirm EtCO2 waveform and evaluate for airway dislodgement/migration
• Remove airway if EtCO2 unable to be confirmed
Obstruction
• Suction airway, as indicated; Ensure airway not kinked
Pneumothorax (tension)/Patient
• Thoracostomy Procedure, as indicated
• Check pulses/cardiac rhythm
Equipment
• Verify 02 source and tubing appropriate
• Check airway cuffs for leaks
• Verify EtCO2 button pressed on monitor and trace detector line from monitor to airway
Stacking
• Consider breath stacking in bronchospasm; Evaluate BVM compliance and EtCO2 waveform
If suspected
• Briefly disconnect BVM, allow full exhalation (apply chest wall pressure to assist PRN), and reconnect
BVM
. Monitor and ensure EtCO2 waveform returns to baseline, repeat above PRN
If RASS not at goal or signs of awakening, movement, or discomfort
• Ketamine bolus as per above
OR
• Ketamine infusion
Adult — 200 mg in 100 mL NS, start at 1 mg/min, titrate by 1 mg/min to goal RASS
Pedi - 50 mg in 100 mL NS, start at 10 mcg/kg/min, titrate by 5 mcg/kg/min to maintain goal RASS
Any patient receiving paralytics during DSI/RSA must receive adequate sedation to prevent awareness during paralysis.
Patients with invasive airways commonly experience pain and anxiety, paralytics may obscure this and make recognition difficult
for EMS clinicians.
Signs of inadequate pain control/sedation may include eye opening, coughing or gagging, sweating, tearing, tachypnea, or new/
worsening hypertension and/or tachycardia. 60
Breath stacking capnography tracing:
40 ---- - -
30
20
W 1 0
0
Time
Rapid Sequence Airway (RSA)
• Begin Invasive Airway Preparation ••
• Ensure appropriate monitoring including: BP q 2 min cycle, ECG, EtCO2, Sp02 on opposite arm from BP cuff
• Begin preoxygenation via Max BVM, NRB + HFNC, or NIPPV, as appropriate
Preparation
• Confirm appropriate equipment prepared
• Evaluate airway and identify/palpate surgical cricothyrotomy anatomic landmarks
If hypotensive, see Circulatory Support (optimize hemodynamics as possible)
Preoxygenation & Induction/Paralysis
• Verify all appropriate monitoring/positioning (ETSN, HOB @ 30' elevation)
• Preoxygenate/Denitrogenate
If adequate respirations
• Set BVM @ flush rate, form tight mask seal, and allow spontaneous respirations to continue. Ensure PEEP >_ 5 mmHg.
If inadequate respirations
• Perform Max BVM with assisted ventilations
• Titrate PEEP to reach maximal Sp02
• Ketamine
Adult - 2 mg/kg IV/10 (max 200 mg); repeat PRN x 1
Pedi - same as Adult
• Increase NC to flush rate
Placement
• Place Supraglottic Airway (only after all above steps completed)
Ifplacement unsuccessful - maintain Assisted Ventilation, or consider 2n1 SGA attempt with a change of size or inser-
tion technique
• Confirm airway with EtCO2 (4-phase waveform >_ 5 mmHg with every breath within 5-breaths)
If Can't Oxygenate, Can't Ventilate (COCV) by anv other means
• Surgical Airway Procedure (Cricothyrotomy)
If paralysis required, and only after ketamine given
• Rocuronium
Adult - 1.5 mg/kg IV/IO once (max 150 mg)
Pedi - same as Adult
• Allow sufficient time after administration for complete paralysis
• Initiate or continue assisted ventilations PRN
• Post -Invasive Airway Management
RSA is used ONLY to facilitate SGA placement and SHALL NOT be used for intubation.
Best attempts at preoxygenation/hemodynamic optimization should be made prior to performing RSA in routine situations
RSA may be used in conditions where adequate pre-oxygenation/hemodynamic optimization isn't possible BUT, best efforts
should still be used to increase Sp02 and BP even with RSA.
—> RSA may be a better option than DSI in patients for whom the need for rapid transport outweighs the need for intubation
Anticipated airway compromise (e.g., burns, angioedema, expanding neck hematoma) MAY benefit from endotracheal
intubation if appropriate for DSI.
Preemie
Newborn to 2 mo
3 - 5 mo
2 yr
3 - 4 yr
7 - 8 yr
0
<2KG2KG
3KG 4KG 5KG
6-7KG
12-14KG
15-18KG
24-29KG
1
Ketamine
mg
N/A
5
10
10
15717
20
25
33
740
55
65
(2 mg/kg, 50 mg/ml.)
mL
N/A
0.1 mL
0.2 mL
0.2 mL
0.3 mL3
mL 0.4 mL
0.5 mL
0.7 mL
mL
1.1 mL
1.3 mL
Rocuronium
mg
N/A
5
6
8
1013
16
20
25
2
40
50
(1.5 mg/kg, 10 mg/mL)
mL
N/A
10.5 mL
0.6 mL
0.8 mL
1 mL
1.3 mL 1.6 mL
2 mL
2.5 mL
3.2 mL
I 4 mL
5 mL
Air-Q Size & Connector Color
Size 0 Size 0.5 (pink)
Size 1(Blue)
Size 1.5 (Green)
Size 1.5 or 2
Size 2 (Orange)
Size 3 (Yellow)
Refusal Against Medical Advice (AMA)
All AMAs must be initiated by patient or guardian. DO NOT SUGGEST THIS
Anytime a patient or their parent/guardian communicates a refusal of treatment, or transport to the extent allowed:
• Perform a thorough history & physical
• Develop a differential diagnosis specific to the patient presentation
• Offer appropriate treatment and transport to the patient, parent, and guardian
• Explain the risks and consequences of refusing treatment and/or transport at the patient or parent/guardian's
level of understanding, based on the differential diagnosis
• Explain they should call 911 again for new/worsening symptoms or if they change their mind
If a patient or their parent/guardian that refuses an assessment or continues to refuse treatment or transport after the risks of refusal
have been explained
• Attempt to speak with whomever called 911, as well as any family, friends, bystanders, patient surrogates, or
guardians and/or medical personnel on scene.
• Assess the patient or parent/guardian's understanding of the risks and consequences of refusing treatment and/or
transport, and document this in their own words
• Perform capacity assessment (evaluation of patient's understanding of risk of refusal)
• Document all of the above in the PCR
For the patient suffering from a life -threatening injury or illness
• Enlist the help of an EMS Supervisor
For the patient that appears to lack decisional capacity, and refuses treatment or transport
• Refer to Refusal Without Demonstration of Capacity
A patient's decisional capacity may be impaired as a result of, but not limited to, the following:
=> Use and/or abuse of alcohol, illegal or prescription drugs, or toxic substances
=> Head trauma, dementia, encephalopathy, and/or mental retardation
=> Acute or chronic psychiatric illness
=> Medical illness including, but not limited to, the following: hypoxia, hypotension, hyperglycemia, hypoglycemia, dehy-
dration, and sepsis
Decisional capacity and mental status are distinct:
=> Mental status is their level of alertness and orientation
=> Decisional capacity is the patient's ability to understand the risks / benefits of treatment / transport, potential conse-
quences of their decisions, and voice their desires. They should be able to voice a rationale for their choice. We do not
have to agree with it or thing its accurate, but it should be consistent for them.
Refusal Without Demonstration of Capacity
If a patient without apparent decision making capacity, effectively communicates their desire to refuse assessment, treatment, or
transport
• Ensure provider safety first and foremost
• If concern of acute mental illness or behavioral emergencies, including self -harm or harm to others, request Po-
lice
• Contact EMS Supervisor
• Reassess patient's medical decision making capacity in person
If patient lacks decisional capacity and is
- Acute (< 1 day), and
- Felt to be caused by acute medical emergency and lack of treatment and transport is felt to be life threatening
• Transport using minimum level of coercion, sedation, and restraint needed to safely facilitate transport
If patient lacks decisional capacity and does not meet above criteria and is refusing care
• No transport without LEO detention app
• Document:
—> Capacity assessment as it was performed
All personnel on scene — including any law enforcement name and badge number
If any family members present/spoken to, including content of discussions
• Record disposition of call as "refusal without demonstration of capacity" JL
• Contact OLMC PRN
Making a decision against medical advice does not alone demonstrate a lack of capacity.
—> Lack of capacity does not imply consent if the patient is able to communicate.
The components of medical decision -making capacity include the following four key abilities:
• Understanding: The ability to comprehend the information relevant to the medical decision, including the na-
ture of the condition, the proposed treatment, and the potential risks and benefits.
• Appreciation: The ability to recognize how the information applies to one's own situation, including acknowl-
edging the potential consequences of the decision.
• Reasoning: The ability to compare options logically and to weigh the risks and benefits to make an informed
choice.
• Expressing a Choice: The ability to communicate a clear and consistent decision regarding the treatment.
Release at Scene (RAS)
A Release at Scene (RAS) may only be performed if "no" is answered to all of the following questions:
Did the individual activate 911 for EMS?
Did law enforcement activate EMS for evaluation?
Is the individual disoriented, confused, or otherwise impaired (e.g. alcohol or drugs, language barrier, MHMR)?
Was there any loss of consciousness?
Is there any complaint of illness, pain, or injury?
Is there a psychological complaint/concern?
Was there a significant mechanism of injury (e.g. MCC, ejection, auto vs. pedestrian)?
Were any patients on -scene dead?
Does anyone object to the individual being released (e.g. family member, first -responder)?
r% n ♦ t 1
ne5uiratury 3uuuurt - Ac.tuit
• Titrate 02 to SP02 >_ 94176 or improved work of breathing
• Respiratory monitoring required (EtCO2 and SP02), if equipped
• Suction airway as appropriate
If signs of upper airway obstruction or severe respiratory insufficiency l impending respiratory failure
• Assisted Vent/BVM (Max BVM), confirm EtCO2 waveform with each breath if equipped
• Consider Supraglottic Airway if equipped with EtCO2 waveform monitoring
• Remove foreign body airway obstruction (FBAO), as appropriate (Heimlich maneuver, chest compressions)
If moderate to severe respiratory distress
• NIPPV as indicated (EtCO2 required if equipped), caution/consider discontinuation if SBP < 90
If contraindication for NIPPV
• NRB -� HFNC or nasal cannula
If suspected bronchospasm regardless of eitiology
• Albuterol 2.5 mg/Ipratropium 0.5 mg in 3 ml NS nebulized, repeat PRN x 2
If persistent wheezing/respiratory distress after 3 albuterol/ipratropium doses
• Albuterol - 7.5 mg in 9 ml NS (continuously nebulized)
Ifpulmonary edema, see Sympathetic Crashing Acute Pulmonary Edema (SCAPE)
• Cardiac monitoring, acquire and transmit 12-lead ECG
If progression to severe respiratory insufficiencylrespiratory failure, or unable to manage the airway
• Intubation Procedure (as part of DSI with CCP)
• Consider Supraglottic Airway if ETT unsuccessful or if unable to meet goals for intubation
If COCV - Can't Oxygenate AND Can't Ventilate (unable to obtain EtCO2 waveform and persistent hypoxia) via any other means, see
Surgical Airway Procedure (Cricothyrotomy)
If suspected tension pneumothorax with hypotension, see Needle Thoracostomy Procedure
If AsthmalCOPD/Wheezing
Consider, especially if subacute presentation (>_ 1-2 days) "
• Dexamethasone - 10 mg IV/IM x 1
If severe (e.g. accessory muscle use)
• Magnesium Sulfate - 2 g in 250 ml NS over 15 min
For asthma only, and if impending respiratory failure or unable to tolerate nebulizer
• Epinephrine 1:1,000 - 0.5 mg IM, repeat PRN q 5 minx 1
If invasive airway placement is needed
• Delayed Sequence Intubation
• Rapid Sequence Airway
For further management and analgesialsedation after invasive airway obtained, see Post -Airway Management ,
If SGA in place and ventilations are adequate, do not replace with endotracheal tube
Patients with COPD may have chronic low baseline SP02 (88-92%), so do not indiscriminately place on high flow 02
Start 2-3 1pm 02 via NC, or double baseline flow rate; titrate to patient's baseline SP02 and work of breathing
Respiratory Support - Pediatric
Titrate OZ to SP02 >_ 94% or improved work of breathing
Respiratory monitoring required (EtCO2 and SP02), if equipped
Suction airway as appropriate
If signs of upper airway obstruction
• Attempt to open the airway by:
Jaw thrust/head-tilt-chin-lift
Nasopharyngeal and/or oropharyngeal airway placement (NPA/OPA)
Position in ETSN; Place padding under infant's shoulders, up to 5 y/o lay flat, and head elevation for >_ 5 y/o
Remove foreign body airway obstruction (FBAO), as appropriate (Heimlich maneuver, chest compressions)
If severe respiratory insuffrciencylimpending respiratory failure
• Assist ventilation with bag -valve -mask (BVM); confirm EtCO, waveform with each breath if equipped (goal 35-45 mmHg)
• Consider Supraglottic Airway (if EtCO2 equipped)
If moderate to severe respiratory distress
• Seat patient (semi-) upright if not hypotensive
• Nasal cannula or NRB ± HFNC
If asthmalreactive airway disease
• Albutero12.5 mg/Ipratropium 0.5 mg in 3 ml NS nebulized, repeat PRN x 2
Ifpersistent wheezinglrespiratory distress after 3 albuterol/ipratropium doses
• Albuterol - 7.5 mg in 9 ml NS (continuously nebulized)
• NIPPV as indicated, if mask size equipped (EtCO, required if equipped); caution/consider discontinuation if hypotensive
If suspected broncbiolitis (< 2 years of age with rbonchi, or undifferentiated illness with rhinorrhea, tacbypnea, and/or fever)
• Suction the nose and/or mouth (via bulb or suction catheter), particularly if excessive secretions are present
If suspected croup (stridor & barking cough) or epiglottitis (toxic appearance, drooling, difficulty swallowing, distress)
• Keep patient calm and avoid stimulating
• Cardiac monitoring
If suspected croup AND stridor at rest or exertion
• Racemic Epinephrine
<_ 10 kg - 0.25 m 1 (1 /2 -ampule) mixed with 3 ml NS nebulized, repeat PRN x 1
> 10 kg - 0.5 ml (I-ampule)mixed with 3 ml NS nebulized, repeat PRN x 1
If COCV - Can't Oxygenate AND Can't Ventilate (unable to obtain EtCO, waveform and persistent hypoxia) via any other means, see
Transtracheal Ventilation Procedure
If suspected tension pneumothorax with hypotension, see Needle Thoracostomy Procedure
If suspected croup OR asthmalwheezing (especially if subacute presentation (>_ 1-2 days)
• Dexamethasone - 0.6 mg/kg PO/IM/IV once (max 10 mg)
If asthma/reactive airway disease
If severe (e.g. accessory muscle use)
• Magnesium Sulfate - 40 mg/kg IV/IO over 15 min (max dose 2 g)
If impending respiratory failure or unable to tolerate nebulizer
• Epinephrine 1:1,000 - 0.01 mg/kg IM. repeat PRN q 5 min x 1 (max dose 0.5 mg)
If invasive airway placement is needed, see Rapid Sequence Airway
For further management and analgesialsedation after invasive airway obtained, see Post -Invasive Airway Mana eg ment
Intubation and DSI are prohibited for pediatric patients (per Pediatric Patient Assessment definition)
Ensure notification to ED staff of any dexamethasone administration
Bronchiolitis does not traditionally respond to albuterol/ipratropium or steroids, and asthma is unlikely in the < 2 yo age group
Telemedicine Navigation
If suspected low -acuity medical or trauma complaint and meets inclusion criteria and has no exclusion criteria as listed below,
• Contact Telemedicine Provider
Inclusion:
, Alert, oriented, and have decisional capacity
Children should have parent or guardian present and available
Adults without decisional capacity because of baseline conditions (ex: dementia), must have POA available
Adults > 65 refusing transport or don't appear to need transport and have decisional capacity
Stable vital signs:
Systolic blood pressure > 110 mmHg (or age appropriate)
Heart rate 50-120 beats per minute
Respiratory rate 8-28 breaths per minute
Pulse oximetry > 92176 on room air
Exclusion:
—> Patients with isolated depression or suicidal ideation without immediate plan (these patients are eligible for iCare).
> Patients in a healthcare facility under the direct care of a physician
—> Age <_ 3 months with a fever
—> Combative or agitated patients
—> Pregnancy related complaint (pregnancy, by itself, is not an exclusion)
> Clinician suspicion of moderate or high acuity illness/injury
a
STEMI, Stroke, Trauma alert criteria
—> No demonstrated decisional capacity (refusals without capacity)
• Complete patient assessment, including:
Vital signs, including BP, HR, RR, and SpO2
Any diagnostics as indicated (blood glucose, 4 lead ECG, or 12 lead ECG)
• Contact telehealth provider
• Provide a brief patient report to the telehealth physician
• The disposition determined by the telehealth provider in consultation with the patient is final
• Follow telehealth physician orders including use of EMS intervention/medication for indications not included within proto-
col. Contact OLMC for conflicts with telehealth physician orders.
• Complete the documentation on the ePCR
• All patient contacts, excluding IFTs, will have a validated question: "Was the patient offered a telehealth consult?" with
the following options:
"Yes, and patient accepted", use one of the following dispositions as appropriate:
If treated by telehealth, "Treated, transferred care to telehealth provider"
If transported after consult, "Transported — by this unit"
If patient refuses telehealth recommendations and transport, "AMA — Assessed and/or Treated and Released"
"Yes, but patient refused telehealth consult", use appropriate disposition as though there was no consult.
"Yes, but unable to contact telehealth provider", use appropriate disposition as though there was no consult.
Stable vital signs are ranges used as guidelines. Clinical judgement can and should apply when determining eligibility.
Termination of Resuscitation
If CPR in progress by non-
professional rescuerlbystander
• Consider Withholding Resuscitative Efforts
Termination of Resuscitation requires OLMC
Keep family informed of prognosis and begin setting realistic expectations early.
If after in person CCP assessment and prior to ALS interventions, withholding criteria is present and patient is in asystole
• Resuscitation efforts can stop under Withholding Resuscitative Efforts
Prior to calling OLMC for termination:
• POCUS - Obtain video clip assessing for cardiac wall motion or other significant findings
If traumatic etiology,
• Consider potential for underlying medical causes and manage appropriately
• Contact OLMC for TOR once the following have been assured/performed:
• Oxygenation & ventilation confirmed by waveform EtCOZ
• Hemorrhage control
• All appropriate procedures
There is no minimum resuscitation time
If medical etiology:
• Contact OLMC for TOR once the following have been assured/performed:
• Monitored* professional rescuer CPR
• Oxygenation & ventilation confirmed by waveform EtCO2
• IV/IO access
• Appropriate medications given
• Defibrillation as needed
• EtCO2 values as follows:
• EtCO2 < 10 @ 10 minutes
• EtCO2 > 10 but < 20 @ 20 minutes
• EtCO2 > 20 @ 30 minutes
When calling OLMC for termination, present information in the following format:
Medic name
—> Location type
Age, Sex
—> Pertinent medical history (cancer, dementia, etc.)
—> Estimated down time, witnessed or not
Presence of bystander CPR
Initial presenting rhythm
Duration of professional rescuer resuscitation efforts
Method of ventilation
Initial EtCO2 following advanced airway placement
Current EtCO2
—> Type of vascular access
Medications given
Any periods of ROSC or CPR -induced consciousness
Arrest in a public place, by itself, is not a contraindication for termination. Consider full dynamics of scene.
With the exception of ECPR, transport without ROSC has less than 1 % survival.
Family/friends should be supported and kept informed of the progression and prognosis of the resuscitation effort.
Document time of death and physician's name.
Notification of law enforcement is required. Remain with the deceased until relieved by law enforcement unless unsafe to do so.
* Monitored professional CPR is the duration of resuscitation on the cardiac monitor.
Withholding Resuscitative Efforts
If patient has Out -of -Hospital Do Not Resuscitate order or there is expression of their desires regarding resuscitation
— See DNR policy
Consider withholding resuscitative efforts if any of the following clinical signs of irreversible death/futility and criteria are present:
Rigor mortis/dependent lividity
Fetal death after preterm delivery (<_ 20 weeks gestation by best determination)
Decapitation, decomposition, or incineration
Exposed brain matter
—> Head -under submersion (excluding vehicular submersions) for greater than:
90-minutes if water temperature <_ 6 ° C (43 ° F)
30-minutes if water temperature > 61 C (43 ° F)
AND if all of the following
--* Pulseless
> Apneic
Without pupillary response
• If patient does not meet above criteria, begin appropriate resuscitation efforts
For blunt and/or penetrating trauma, consider withholding if NO clinical signs of irreversible death AND if all of the following:
-+ Pulseless
Apneic
No pupillary response
—> Asystole or PEA < 40 bpm on cardiac monitor
• If patient does not meet above criteria, begin appropriate resuscitation efforts
For the purpose withholding of resuscitation, electrical/lightning strikes are not considered trauma
—> Remain with the deceased until relieved by law enforcement (Unless unsafe to do so)
—> Document objective findings including (each responding agency):
• Position/location found
• Any movement of the patient/surroundings
• Access limitations
• Assessment findings as appropriate
• Suspicious/inconsistent scene or physical findings
C�irdia�
6- �arAiaE A
Acute Coronary Svndrome/STEMI
• Aspirin - 324 mg PO chewed
• Nitroglycerin - 0.4 mg SL q 5-minutes PRN for pain
Titrate to SBP >_ 100 mmHg and signs/symptoms (recheck BP before each dose)
Do not administer if patient has recently taken medication for erectile dysfunction
• Acquire 12-lead ECG within 10 minutes of patient contact
• Transmit 12-lead as soon as possible
• Assure time of initial ECG is documented in the PCR
• Cardiac monitoring
Treat dysrhythmias as identified
If ST-Elevation MI (STEMI)
• Place defibrillation pads
• Do not delay transport or other treatment to obtain VA lead if inferior STEMI
• Be cautious with nitroglycerin in RV infarcts; however, it is not contraindicated
• Notify facility of STEMI alert within 10 minutes of first diagnostic 12-lead for STEMI
—> See Hospital Capabilities List for most appropriate transport destination
Consider Occlusive Myocardial Infarction (OMI) if appropriate clinical presentation and one of the following ECG patterns:
Posterior STEMI
De Winter Pattern/T-waves
• Horizontal ST-segment depression " : " ' "' • Tall prominent symmetrical T waves arising
in leads V 1-V3, a dominant R wave from upsloping ST-segment depression > 1 mm
(R/S ratio > 1) in lead V2 at the J-point in the precordial (V1-V6) leads
• Upright T waves in anterior leads- - - • Slight (0.5-1 mm) ST-segment elevation may be
• A prominent and broad R-wave I ::: __: _:::.:: seen in lead aVR
(> 30 ms) V7
�
Confirmed by posterior ECG with
ST-segment elevation in leads V7-V9
Y$
Note: Voltage on posterior ECG may be very small t
and difficult to see. The posterior ECG has poor
sensitivity V9
t
Left Bundle Branch Block or Ventricular Paced Rhythm
with Smith -modified Sgarbossa Criteria
Positive if Any criteria A)
below are present: 1A.
Concordant ST elevation
>_ 1 mm in leads with apositive
YVIAN3
QRS complex
B. Concordant ST depres-
sion>_1 into in V1-V3
C. ST Elevation at the a
J-point, relative to Hvg ;„ ,
QRS onset, is at least $7t
1 mm AND has an
H"M.f
amplitude at least
2 5 %' of the preceding
S-wave
Cardiac Arrest - Adult
High quality BLS interventions are the key to successful resuscitation. Nothing should interfere with them.
• Begin 2-minute cycles of Pit Crew CPR with 30:2 compression/ventilation @ 100-120 compressions per minute, limit com-
pression pauses to < 10 seconds
• Rapidly place SGA with waveform EtCO2 (no PEEP). If delayed or no EtCO2 begin Max BVM
• Ventilate during 30:2 pause, 1 second breath "squeeze - release - release". No breaths with compression.
• Goal EtCO2 > 20 mm Hg, if < 20 mm Hg, evaluate quality of rate, depth, and recoil of compressions
• Apply compression feedback device as soon as possible
• Place AED (or monitor in AED mode) with multi -function pads in anterior -lateral (A-L) configuration
If arrest witnessed by EMS/FRO -apply AED and analyze immediately
If arrest unwitnessed by EMS/FRO - apply during initial CPR cycle and analyze at end of cycle
• Mechanical compression device may be considered only when:
• At least 15 minutes of monitored professional rescuer CPR has occurred or,
• Transport is necessary or,
• ROSC has been achieved and the device is being pre -positioned for transport or,
• Critical shortage of man power prevents adequate Pit Crew CPR
If patient has gravid uterus
• Manually displace fundus to the patients left
• Patient to remain on initial cardiac monitor throughout entirety of resuscitation
Initial Shockable Rhythm
Initial Non -Shockable Rhythm
• Defibrillate at highest energy setting q 2-minutes
• Epi 1:10,000 - 1 mg IV/IO x 1, then
• Epi 1:10,000 - 1 mg IV/10 x 1
• Epi Cardiac Arrest Infusion - 2 mg (20 mL) of 1:10,000 in
• Amiodarone - 300 mg IV/IO x 1 after 2" defib;
250 mL NS, infuse @ 67 mcg/min or 540 ml/hr
• 2"d dose PRN after 3`d defib, 150 mg IV/IO x 1
If arrest not witnessed by bystander or EMS,
If persistent or recurrent VF/VT
• Sodium Bicarbonate - 1 mEq/kg IV/IO (max
• DSED (as soon as 2nd monitor available), do not delay
dose 100 mEq)
single shocks while setting up for DSED
• Flush line before and after administration
• If 2nd monitor unavailable, continue with single shock
If PEA,
with pad placement change to Anterior -Posterior (A-P)
• Fluid bolus 20 ml / kg IV/IO
• If conversion to non -shockable - start Epi Cardiac Arrest Infusion
• Consider reversible causes
If signs/symptoms of CPR -Induced Consciousness,
• Ketamine - 1 mg/kg IV/IO (max single dose 200 mg)
For any of the following give early in the course of cardiac arrest management.
Metabolic acidosis etiology (e.g. DKA) • Sodium Bicarbonate - 1 mEq/kg IV/IO (max dose 100 mEq)
• Calcium Chloride - 1 g IV/10, slow push
Hyperkalemia:
• Sodium Bicarbonate - 1 mEq/kg IV/IO (max dose 100 mEq)
Torsades de Pointes: • Magnesium Sulfate - 2 g IV/10, slow push
Tension Pneumothorax: • Needle Thoracostomy Procedure
Tricyclic Antidepressant Overdose: • Sodium Bicarbonate - 1 mEq/kg IV/IO (max dose 100 mEq)
Calcium Channel Blockers: • Calcium Chloride - 1 g IV/10, slow push
Beta Blocker Overdose: • Glucagon - 1 mg IV/10 slow push over 1-minute, Repeat PRN x 1
• Contact OLMC for ECPR after 2" d dose of Amiodarone or when appropriate for TOR considerations
If after second dose of Amiodarone, as long as the patient remains in a shockable rhythm,
• Esmolol - 0.5 mg/kg (max 50 mg) bolus x 1 then infusion at 0.05 mg/kg/min (max 5 mg/min)
• Resuscitate in the location found unless scene is unmanageable `
• Consider tension pneumo in patients with severe asthma/COPD who
have poor ventilation compliance not resolved with "burp" technique
• If ROSC, see Post-ROSC f Lj
-
• If hang infusion 10
no pump available, epi to gravity using a gtt/mL-'
CPY of Q nttC
Anterior -Posterior pad placement Double -Sequential Defibrillation pad placement
Cardiac Arrest - Pediatric
• Begin 2-minute cycles of Pit Crew CPR; 15:2 compressions -ventilation, 100-120 bpm, no pauses > 10 seconds
• Rapidly place SGA with waveform EtCO2 (no PEEP). If delayed or no EtCO2 begin Max BVM
• Ventilate during 15:2 pause, 1 second breath "squeeze - release - release". No breaths with compression.
• Goal EtCO2 > 20 mm Hg, if < 20 mm Hg, evaluate quality of rate, depth, and recoil of compressions
• Apply AED
If arrest witnessed by EMS/FIRE - apply AED immediately
If arrest unwitnessed - perform 2-minutes of CPR before applying AED
• Utilize Broselow tape
• Apply cardiac monitor only after completion of last 2-minute cycle of CPR
• IV/IO access
VF/VT
• Defibrillate at 2 J/kg, Repeat PRN q 2 min, increase by
2 J/kg (max 10 J/kg or max energy setting)
• Epinephrine 1:10,000 - 0.01 mg/kg (max single
dose 1 mg) IV/IO q 5-min. 3-dose-max
• Amiodarone - 5 mg/kg IV/IO (max 300 mg) after sec-
ond defibrillation, Repeat PRN x 2 every other cycle or
4 min, if persistent or recurrent VF/VT
Asystole/PEA
Epinephrine 1:10 000 - 0.01 mg/kg (max single
dose 1 mg) IV/IO immediately, then q 5 min, 3-
dose-max
For any of the following give early in the course of cardiac arrest management.
Metabolic acidosis etiology (e.g. DKA) • Sodium Bicarbonate - 1 mEq/kg IV/IO(max dose 100 mEq)
Hyperkalemia: • Calcium Chloride - 20 mg/kg (0.2 ml/kg) IV/IO, slow push (max dose 1 g)
• Sodium Bicarbonate - 1 mEq/kg IV/ICI (max dose 100 mEq)
Torsades de Pointes: • Magnesium Sulfate - 25-50 mg/kg (max 2 g) IV/I0, slow push
Tension Pneumothorax: • Needle Thoracostomy
If any of the below causes are suspected, contact OLMC following initial dosing
Tricyclic Antidepressant Overdose: • Sodium Bicarbonate - 1 mEq/kg IV/IO (max dose 100 mEq)
Calcium Channel Blockers: • Calcium Chloride - 20 mg/kg (0.2 ml/kg) IV/IO, slow push (max dose 1 g)
Beta Blocker Overdose: • Glucagon - 0.1 mg/kg Iv/10 slow pushover 1-minute (max single dose
1 mg), Repeat PRN 0.2 mg/kg iv/IO X 1 (max single dose 1 mg)
If signs of obvious death, see Withholding Resuscitative Efforts
Resuscitate in the location found unless scene is unmanageable
Limit chest compression pauses and individual pause length to < 10-seconds
Do not interrupt CPR for airway management
Open airway; If choking suspected, remove FBAO as early as possible
Waveform EtCO2 required for all advanced airways
Confirm waveform EtCO2 >_ 5 mmHg for every breath
Remove airway if EtCO2 < 5 mmHg
Switch AED to monitor/defibrillator only after completion of the current CPR cycle
Do not interrupt CPR or defibrillation for ACLS drug administration
If ROSC, optimize patient hemodynamics, oxygenation, and ventilation prior to initiating transport
Sodium bicarbonate is not indicated for prolonged down time
Post ROSC
If ROSC occurs in place,
• Remain in -place for a minimum of 10 minutes, accomplishing the following:
• Assess ventilation effectiveness and vital signs
• BP q 2 minutes �•
• Obtain 12-lead ECG ASAP following ROSC
• Assess blood glucose
• Notify receiving PCI center, activate STEMI alert as appropriate
• Place MCD in ready mode for transport
• Secure patient
• Reassess rhythm
• Assure >_ 2 routes of IV/IO access
If ROSC or rearrest occurs in transport,
• Continue transport and update PCI center of change in patient condition, while accomplishing the above
• MCD should already be in place for transport
If sedation required,
• Ketamine
Adult - 1 mg/kg N/IO (max single dose 200 mg)
Pedi - Same as Adult
• Maintain MAP >_ 65 or age appropriate goals
If hypotensive,
• Discontinue Esmolol if infusing
• Utilize Epi infusion if in place, or
• Norepinephrine
Adult - 5 mcg/min, titrate to MAP >_ 65
Pedi - 0.1 mcg/kg/min, titrate to age appropriate goals
Pediatric SBP goals: > 70 mm Hg + (age in years x 2) or > 90 mm Hg for age 10 or greater
Re -arrest is common immediately after ROSC. Carefully monitor to detect re -arrest.
12-lead ECG early after ROSC can be difficult to interpret. If unclear, obtain serial ECGs as able.
Post--ROSC
Position FD
Optimize Airway
Pit Crew
• Co2 35- 45
Place MCD
Intervention Paramedic EM
• Determines pt care plan
• Cain 2111 N/IO access
Reassess rhythm
Interpret 12 lead
• I3otif , recei«ng facility
• Prepare/initiate vasopressors
Sedate, if needed
0
�t
Communicate plan to family
and others as needed
Famiaming Providers:
Assist in movement of pt
• Assist Mth other activities
as needed
itiorl }; l)
Ui�giin 1_' Irbil �
Place MCD
Monitor watcher—
does not carry
equipment to unit
Code Commander I _ u
Assign activities to positions
Ensure goals are met before pt
movement
BPg2
• Optimized hemodynamics
• Optimized airway
Coordinate and initiate pt
movement to unit
SCAPE
If respiratory insufficiency / failure, with prior medical history of CHF, and SBP > 180
• Request EMS Supervisor
• NIPPV with ETCO2 monitoring
• Nitroglycerin - 0.4 mg SL q 5 min until SBP < 180
• 1 ? T.Parl FCC,
If SBP > 200 and, (RR > 30 or Sp02 < 90%)
• BPg2mins
• Nitroglycerin IV - 1 mg Slow IV push
If after IV push, SBP and RR meet above criteria
• Nitroglycerin Infusion - 100 mcg/min infusion, titrate rapidly down as SBP drops, goal SBP < 180
Consider as appropriate:
• DSI
• RSA
Sympathetic Crashing Acute Pulmonary Edema (SCAPE) is acute onset severe respiratory distress / failure as a result of a weakened
heart's ability to overcome severely elevated after load. Treatment is aimed primarily at rapidly lowering SBP while supporting ven-
tilation.
Nitroglycerin push and infusion can rapidly lower blood pressure. While this is the desired effect, be prepared to rapidly titrate in-
fusion down as blood pressure drops to avoid hypotension. It isn't uncommon to be able to turn infusion off all together.
6- �.UAI*A'E A
S
• Cardiac monitoring and 12-lead ECG
If Infant < 1, see Newly Born
omatic Bradcardia
If Pediatric with heart rate < 60 with signs of hypoperfusion or end -organ dysfunction,
• CPR; 15:2 compressions -ventilation, 100-120 bpm, no pauses > 10 seconds
If chest pain or anginal equivalent symptoms, see Acute Coronary Syndromes/STEMI
ADULT
External Cardiac Pacing procedure
• Do not delay pacing for IV placement or medications in the pres-
ence of hemodynamic instability
• Ensure adequate oxygenation/ventilation
• Begin at 30 mA, increasing energy in 10 mA increments
until capture achieved
• Begin at 70 ppm, increasing rate in 10 ppm increments
until hemodynamic response/improved perfusion
• Atropine - 1 mg IV/I0, repeat PRN to max dose of 3 mg
If hypotensive, consider Circulatory Support protocol
PEDI
• Epinephrine 1:10,000 - 0.01 mg/kg IV/IO (max dose 0.1 mg)
• Atropine - 0.02 mg/kg IV/IO (minimum single dose 0.1 mg
with max dose 1 mg), repeat PRN x 1
• External Cardiac Pacing procedure if bradycardia resistant to
medications
• Ensure adequate oxygenation/ventilation
• Begin at 30 mA, increasing energy in 10 mA increments
until capture achieved
• Begin pacing rate at:
• Age 0-36 months - 120 ppm
• Age 36 months to 12 years - 100 ppm
• Age > 12 years - see Adult
• Increase rate in 10 ppm increments until hemodynamic
response/improved perfusion
If time permits, consider sedation prior to/during pacing
• Ketamine - 0.3 mg/kg IV/IO Slow Push or 0.6 mg/kg IM (max dose 30 mg)
• See Circulatory Support
Wide complex rhythm, 12-lead ECG findings, or dialysis hx
• Calcium Chloride
Adult - 1 g IV slow push
Pedi - 20 mg/kg (0.2 ml/kg) IV/I0, slow push (max dose 1 g)
• Sodium Bicarbonate
Adult - 1 mEq/kg IV/IO (if suspected acidosis)
Pedi - Same as Adult
• Glucagon
Adult - 1 mg IV/10 slow push over 1-minute
Repeat PRN q 5 min x 1
Pedi - 0.1 mg/kg IV/I0, slow push over 1-minute (max single dose 1 mg)
Repeat 0.2 mg/kg IV/IO xl PRN (max single dose 1 mg)
• Epinephrine Infusion
Adult - Start at 5 mcg/min titrate to MAP > 65
Pedi - Start at 0.1 mcg/kg/min, titrate by 0.1 mcg/kg/min q 2 min
• Calcium Chloride
Adult - 1 g IV slow push
Pedi - 20 mg/kg (0.2 ml/kg) IV/10, slow push (max dose 1 g)
Pacing is only indicated for hypotension caused by bradycardia
Symptomatic Bradycardia (symptoms/signs do not generally occur unless rate < 50 bpm)
Monitor pads for burns, pediatrics have more sensitive skin
Tachwardias
• Cardiac monitoring and 12-lead ECG •
If patient < 65 yo, stable with regular pulse rate >_ 150 bpm and prior history of SVT and no suspicion for sepsis, trauma, or volume depletion
• Modified Valsalva: forcefully blow into a 10 cc syringe up to 3 times
• Assess rhythm for rate, width and regularity
Do not delay cardioversion for IV placement or medications in the presence of severe hemodynamic instability
• IV access; consider 500 mL NS IV/IO rapid bolus for hypotension
If suspected sinus tachycardia or MAT
• Treat the underlying condition
Stable (HR ? 150 with SBP >_ 120)
Unstable
Narrow (QRs < 0.12) M Wide UQRs > 0.12)
• Synchronized Cardioversion • Vagal maneuver • Treat underlying causes
Adult - At highest energy setting Diltiazem
(no adenosine or diltiazem)
Pedi - 0.5-1.0 J/kg, then 2 J/kg Adult - 0.25 mg/kg slow IV/10 push . Amiodarone (150 mg / 100 mL NS)
If time permits, consider sedation prior to/ Repeat PRN x 1 Adult - 150 mg IV/10 over 10 mins
during Cardioversion � (max single dose 20 mg) (600 mL / hr)
• Ketamine Pedi - N/A Pedi - 5 mg/kg IV/10 (max dose 150
Adult - 0.3 mg/kg IV/IO slow push • Adenosine mg)
(max dose 30 mg) P� Adult - 12 mg IV/I0,
or 0.6 mg/kg IM (max dose 50 mg) Repeat PRN 18 mg x 1
Pedi - same as Adult Pedi - 0.1 mg/kg IV/I0, Torsades de Pointes
Repeat PRN 0.2 mg/kg • Magnesium Sulfate (slow push)
(max dose 12 mg) Adult - 2 g IV
If sympathomimetic associated, see Pedi - 2 5 - 5 0 mg/kg IV/1O (max dose 2
Toxicolov g)
U • Diltiazem
Adult - 0.25 mg/kg slow IV/IO push
a�
Repeat PRN x 1
(max single dose 20 mg)
Pedi - N/A
Unstable Tachycardia (symptoms/signs do not generally occur unless rate >_ 150)
• Hypotension (or relative hypotension with signs of poor perfusion or end -organ dysfunction)
Diltiazem is better tolerated by patients than adenosine and should be first line therapy.
If Afib with RVR associated with trauma, fever, hyper/hypothermia, possible sepsis or CHF, do not treat with rate control
medications.
Do not give diltiazem with nitroglycerin
Do not give adenosine if wide QRS complex
Common etiology of narrow complex regular tachycardiac
• SVT, PAT, A -flutter, or sinus tachycardia
Common etiology of narrow complex irregular tachycardiac
• A -fib or A -flutter
Assume a wide complex regular tachycardia is V-tach until proven otherwise
• Other causes could be SVT with aberrant conduction
Assume wide complex irregular tachycardias are A -fib with aberrant conduction pathway
—� Upper limit of sinus tachycardia is approximately 220 - patient age
Carotid sinus massages are dangerous and not authorized
* Consult OLMC for non -sinus tachycardias that do not meet these parameters, but are felt to need treatment.
Abdominal Pain
• NPO
• Position patient for comfort
• Assess for hemodynamic instability and monitor for impending shock
If complaint of upper abdominal pain consider, Acute Coronary Syndrome, STEMI
If nausea/vomiting, see Nausea and Vomiting
If acute pain, see Acute Pain Management
• Treat other potential causes (e.g., ACS, Overdose/Poisoning, Diabetic Emergencies, Emergency Childbirth, gastroparesis,
cyclic vomiting, or Cannabinoid Hyperemesis, )
I
Kidneys
Right Upper Quadrant (RUO): , / Left upper Quadrant (LUO):
Right lobe of liver, gallbladder, ( I Left lobe of liver, stomach, 1
right kidney, portions of small pancreas, left kidney. Ureter
�►
and large Intestines — spleen, portions of small
and large intestines ` ZJN
Right Lower Ouadrant (RLO): ( Left Lower Quadrant (LLO): t J.
j
Cecum, appendix, portions of Most of small intestine,
small and large Intestines, portions of large Intestine,
reproductive organs left ureter, reproductive /
P a \ / eP
(right ovary in female and organs (left ovary in female
right spermatic cord in mate), and left spermatic cord 1 + •
right ureter (a) in male) ►
Allergic Reaction/Anaphylaxis
If suspected respiratory failure, see Respiratory Support
• Remove inciting agent (e.g. stinger), if possible
If local reaction / rash / hives
• Observe for respiratory distress and hypotension
• Diphenhydramine
Adult - 25 to 50 mg PO
Pedi - N/A
If wheezing / bronchospasm
• Albuterol
Adult - 2.5 mg/ipratropium - 0.5 mg in 3 ml NS nebulized, repeat PRN x 2
Pedi - Same as Adult
If anaphylactic reaction or severe signs
Stridor
—> Oropharyngeal swelling/difficulty swallowing/throat tightening
Severe dyspnea
Wheezing with accessory muscle use
Poor air -movement to auscultation
—> Difficulty spearing in full sentences
—> Hypotension ± signs of shock
• Epinephrine 1:1,000
Adult - 0.5 mg IM, repeat PRN q 5 min
Pedi - 0.01 mg/kg (max dose 0.5mg) IM, repeat PRN q 5 minutes x 2
• Diphenhydramine
Adult - 50 mg IV/IM/IO
Pedi - 1 mg/kg IV/IM/IO (max dose 50 mg)
If hypotension, see Circulatory Support
In presence of signs of anaphylaxis/anaphylactic shock (stridor and or hypotension/end-organ dysfunction)
• Epinephrine push dose (0.1 mg in 1Oml NS)
Adult - 10 mcg (1 ml) IV/IO, repeat PRN q 5-minutes, max total dose 50 mcg (5 ml)
Pedi - 1 mcg/kg (max single dose 10 mcg), repeat PRN q 5-minutes, max total dose 50 mcg (5 ml)
• Epinephrine infusion
Adult - start at 5 mcg/min titrate to MAP > 65
Pedi - start at 0.1 mcg/kg/min, titrate by 0.1 mcg/kg/min q 2-minutes
Consider
• Dexamethasone
Adult - 10 mg IV/IM
Pedi - 0.6 mg/kg PO/IM/IV (max 10 mg)
Anaphylactic reaction is defined by:
1. Exposure to suspected allergen WITH hypotension
2. Exposure to suspected allergen with symptoms from two or more of the below body systems.
A. Respiratory
B. Cardiovascular
C. Gastrointestinal
D. Integumentary
If history of ACE inhibitor use, or if personal/family history of non -allergic angioedema, above interventions may provide no
benefit
Use extreme caution if patient wishes to refuse transport following treatment (several hours of monitoring may be necessary)
Altered Mental Status
• Assess blood glucose concentration
• If <_ 60 mgldl, see Diabetic Emergencies
If known or suspected opiate intoxication, see Opiate Use Disorder
Consider other causes of AMS and treat as per indicated protocol
Look for signs of toxicologic or environmental exposure
Atraumatic Headache - Adult
• Obtain focused history and neurologic exam to evaluate for red flags
• Decrease noxious stimuli as able (e.g., move to quiet, dark environment)
• Acetaminophen - 1 g PO
• Cool compress to forehead
If clinical suspicion of cluster headache
• High -flow oxygen via NRB (regardless of SpO2)
• Acetaminophen - 15 mg/kg IV (max dose 1 g)
• Ketorolac - 15 mg IV, 30 mg IM
• Droperidol - 1.25 mg IM/IV, may repeat at 0.625 mg IM/IV, q 10-min PRN xl
If nausea/vomiting, see Nausea and Vomiting
IV opioids are contraindicated for atraumatic headache. They increase rate of rebound headaches.
Do not administer ketorolac if suspicion of SAH/intracerebral hemorrhage
Benign headaches have no historical red flags and no neuro deficits
Consider cluster headache particularly in males with severe headaches that occur in clusters over weeks, is unilateral in
the orbital, supraorbital or temporal region, and is associated nasal congestion, conjunctival injection, and tearing
Historical and physical exam red flags:
Subarachnoid hemorrhagelICH - sudden onset, instantly peaks in intensity ("thunder -clap"), onset during exertion,
associated with syncope/LOC, neck stiffness/pain, anticoagulation
Meningitis - AMS, fever, neck stiffness, +/- rash
Giant CelllTemporal Arteritis - Age >_ 50, temporal artery tenderness, jaw claudication, monocular vision changes
Acute Angle -Closure Glaucoma - abrupt onset of severe monocular pain, fixed/non-reactive mid -dilated pupil, con-
junctival injection, nausea/vomiting, blurred vision or halos around lights
Pre-eclampsia - pregnancy >_ 20 weeks through 6 weeks post-partum, edema, hypertension
--> Carbon monoxide - AMS, dizziness, N/V, dyspnea, multiple individuals with similar complaints, situational factors
Presence of red flags does not preclude symptomatic treatment, however response to treatment does not exclude emer-
gent conditions.
Behavioral Emergencies/Agitation
• Use Physical Restraint Procedure, only after verbal de-escalation has failed
• Passive/active cooling, see Hyperthermia Protocol as appropriate
• Blood glucose assessment and treatment, see Diabetic Emergencies Protocol
• Determine and document initial and ongoing reassessments of RASS score
• Target goal for all interventions is RASS 0
• Frequent BP and continuous Sp02, ECG and EtCO2 monitoring required for any restrained or sedated patient
(RASS + 1)
Anxiety and/or
Mild Agitation
These patients are anxious/
apprehensive with no aggres-
sion. They typically do NOT
require medications and should
not require restraint.
If non pharmacological
interventions are unsuccessful
• Midazolam
Adult - 2.5 mg N/IO/EVI N,
repeat PRN q 10-
min xl
Pedi - 0.05 mg/kg (max
dose 2.5 mg) IV/IO/
IM/IN, repeat PRN
q 10-min x 1
(RASS +2 to +3)
Moderate Agitation
—� These patients are not aggres-
sive but are impeding essential
patient care, monitoring, or
diagnostics.
(RASS +3 to +4)
Severe Agitation
> These patients display similar
characteristics as those with a
BASS 2+ to +3, however are
aggressive and a potential
danger to self or clinicians.
If non pharmacological interventions are unsuccessful
• Midazolam
Adult - 5 mg IV/IO/IM, repeat PRN q 10-min
Pedi - 0.1 mg/kg IV/IO/IM, repeat PRN q 10-min
• Droperidol
Adult - 5 mg IV/IO/IM,
repeat PRN 2.5 mg
q 10-min xl
Pedi - Contact OLMC first
0.05 mg/kg IV/IO
IM, repeat PRN q
10-min x 1
• Droperidol
Adult - 10 mg IM, repeat
PRN 5 mg q 10-
min x 1
Pedi - Contact OLMC first
0.1 mg/kg IV/IO/IM,
repeat PRN 0.05
mg/kg (max 5 mg)
q 10-min x 1
(RASS +4)
Violent Agitation
with Delirium
These patients are altered, overtly
combative or violent, and are ac-
tively a danger to self or others.
They continue to struggle despite
physical restraint.
• Request EMS Supervisor
• Droperidol
Adult - 10 mg IM, repeat
PRN 5 mg q 10-min
xl
Pedi - Contact OLMC first
0.1 mg/kg IM, repeat
PRN 0.05 mg/kg
(max 5 mg) q 10-min
xl
• Ketamine
Adult - 4 mg/kg IM x 1 (max
single dose 400 mg),
repeat PRN 2 mg/kg
IM q 10-min x 1
Pedi - Same as Adult
z
For patients >_ 65 years of age, decrease Droperidol to half the original dose.
—� Sedation and/or EMS restraints shall NOT be used to assist law enforcement in the detainment of a person without an
underlying medical etiology. The decision about sedation that must be made only by the EMS clinician.
Request EMS Supervisor to the scene for any agitated patient needing physical restraint or in PD custody.
Evaluate for underlying metabolic/endocrinologic, neurological, infectious, traumatic and toxicological causes.
For RASS +4: Physical restraint alone is often inadequate to mitigate the potential for continued self -harm and danger to clinicians.
Frail/elderly patients or young children rarely have violent agitated delirium posing a threat to themselves or others. Thus, they will
rarely require ketamine.
All patients receiving pharmacological intervention shall be transported or OLMC contacted prior to release.
Diabetic Emergencies
• Assess blood glucose concentration
If <_ 60 mgldl and if conscious/able to tolerate
• High carbohydrate meal
• Glucose (Oral)
Adult - 15 g buccal
Pedi - 7.5 g buccal
Hypoglycemia: If blood glucose <_ 60 mg/dl
• Dextrose 1096 (25 g/250 mL)
Adult - 100 mL IV/IO bolus, repeat PRN to 50 g (500 mL)
Pedi - 5 mL/kg repeat PRN up to 25 g (250 mL)
Hyperglycemia: If blood glucose >_300 mgldl
• Normal Saline
Adult - 250-500 ml IV bolus, repeat PRN to 2 L
Pedi - 20 ml/kg IV/IO up to 2 L total
If blood glucose concentration <_ 60 mgldl and If IV access cannot be obtained
• Gluca og_n
Adult - 1 mg IM
Pedi - 0.1 mg/kg IM (max dose 1 mg)
Consider differential diagnosis for hyperglycemia
Diabetic Ketoacidosis (DKA)
Hyperosmolar hyperglycemic state (non-ketotic hyperosmolar coma)
Infection/sepsis
ACS/MI
Opiate Use Disorder
If approached for Narcan and no clinical complaints
• Provide intranasal leave behind Narcan Rescue kit(s)
• Review instructions for use with patient and/or family
• Document required demographics of those furnished leave behind Narcan
If known or suspected opiate intoxication with respiratory and CNS depression.
• Naloxone
Adult - 2 mg IN (1 mg in each nostril), repeat PRN q 5-min x 1
Pedi - 0.5 mg IN, repeat PRN q 5-min (max total dose 4 mg)
If clinical assessment reveals no life threats and suspected opiate withdrawal
• Perform Clinical Opiate Withdrawal Score (COWS)
If COWS score is < 8 or no patient interest in Buprenorphine treatment
• Send referral MIH group
• Provide Narcan Rescue kit with education
If COWS score is >_ 8 and patient is interested in Buprenorphine treatment, request EMS Supervisor
• If patient chooses AMA, provide Narcan Rescue kit
If known or suspected opiate intoxication with respiratory and CNS depression.
• Naloxone
Adult - 0.5 mg IV/IO, repeat PRN in 0.5 mg increments q 5-min to 4 mg max total dose
Pedi - Same as Adult (max dose 2 mg)
If COWS score is >_ 8 and patient is interested in Buprenorphine
• Contact OLMC for consultation for administration
• Premeditate as indicated for nausea/vomiting and pain
• N/V - Ondansetron 8 mg ODT
• Pain - Acetaminophen 1 g PO
• Buprenorphine / Suboxone*
Adult - 8-24 mg buccal (SL strips or tabs) per physician order
Repeat 8-16 mg (max 32mg) PRN COWS score >8 or symptoms not resolved q 15 minutes x 1
Second and subsequent day doses covering weekend and holiday periods will be based on previous effective-
ness
I f precipitated withdrawal
• Contact OLMC immediately
• Normal Saline 500 mL IV fluids bolus
• Ondansetron 8 mg IV or ODT PRN nausea (max total dose 16 mg)
• Diphenhydramine 25-50 mg IV PRN anxiety/abdominal cramps (Max total dose 75 mg)
• As directed by OLMC - Buprenorphine 8-16 mg (Max total dose 32 mg) 14a
No limit to the number of boxes of Narcan that can be left behind
Advise patients/family during reviewing of use that 911 must still be called as the opiate effects can return when Narcan wears off
—> If patient meets Criteria for enrollment into the MAT Program, the medication will be provided at No Cost for the first 60 days
—> Exclusion for Suboxone administration does not mean patient cannot be referred to Rehab or Treatment
* Suboxone is buprenophine + naloxone and the naloxone is chemically inactive when taken SL/oral. Either is acceptable and supply
may vary based on availability. Dosing is the same between the two agents."
Seizure/Status Epilepticus
• Position patient to avoid injury and aspiration, consider recovery position
If not returned to baseline, evaluate blood glucose and consider Diabetic Emergencies
If actively seizing, or in status epilepticus ( >_ 2-seizures and without intervening lucid period),
• Midazolam IM midazolam is the first line route of administration if an IV not already established
Adult - 10 mg IM/IN; or 5 mg slow IV/IO, repeat PRN q 5 min x 2
Pedi - 0.15 mg/kg slow IV/IO/IM (max dose 2.5 mg), repeat q 5-min PRN x 1
If post-ictal and not actively seizing or not in status epilepticus, pharmacologic therapy with midazolam is not indicated
If refractory despite maximum midazolam,
Op.
Ketamine
Ad�mg/kg IV/IO
Pedi - Same as Adult
If suspected eclampsia/peripartum seizure, see Pre-Eclampsia / Eclampsia
Consider toxicologic causes of seizure
Organophosphate/nerve gas (see chemical warfare policy)
Sympathomimetic toxidrome (stuffers/packers, methamphetamine)
, Anticipate that dispatch or initial clinical picture of seizure may be initial presentation cardiac arrest
, Most confused patients following a seizure do not need treatment. Monitor for up to 15 -minutes before considering
intervention or determining a disposition.
, Always consider eclampsia in 3rd trimester pregnancy or up to 6 weeks post-partum.
Stroke/CVA/TIA
• Assess blood glucose
• If <_ 60 mg/dl, see Diabetic Emergencies
• Complete Initial Stroke Screen (Modified Cincinnati Prehospital Stroke Scale)
Facial Droop
Arm-Pronator Drift
Speech/language (dysarthria or aphasia)
Time patient was last seen prior to onset of symptoms required
If initial stroke screen is positive (any of 3-criteria):
• Complete LAMS evaluation
If symptom onset within 24-hours, and
LAMS 4+
• Transport to closest Comprehensive Stroke Center (CSC)
LAMS 0-3
• Transport to closest Stroke Center (Primary or CSC)
If symptom onset greater than 24-hours
• Transport to closest Stroke Center (Primary or CSC)
• Bedside Stroke Alert to receiving facility, as appropriate
Consider posterior stroke in patients with acute imbalance with inability to walk straight without other cause. This is
not a Stroke Alert; however, these findings need to be included in your bedside report at the ER.
Syncope
Syncope is a brief loss of consciousness and postural tone that resolves spontaneously with return to baseline neurological function
q ickly.
• 12-lead ECG
• Assess orthostatic pulse and blood pressure, as tolerated
• Cardiac monitoring; treat dysrhythmias
If hypotensive / hypovolemia, see Circulatory Support
Consider causes of presyncope/syncope:
1. Subarachnoid hemorrhage / ICH
2. Aortic stenosis: loud murmur with exertional syncope
3. Ectopic pregnancy
4. Vasovagal
5. Orthostasis
6. Tachydysrhythmias
7. Bradydysrhythmias and Heart Blocks
8. Wolff -Parkinson -White (WPW): short PR, prolonged QRS, and a delta wave
9. Brugada Syndrome: RSR' similar to a right bundle block and ST elevation in the anterior leads
10. Hypertrophic Cardiomyopathy (HCM): high voltage and narrow ("needle -like", <20 millisecondslone small box) q waves in the
lateral (VS-aVL) and possibly inferior leads; may also have left atrial enlargement, ischemic-appearing ECG, tall R wave in VI
11. Long or Short QT interval: QTc <300 (autosomal dominant inheritance) or >500
12. Arrhythmogenic Right Ventricular Dysplasia (ARVD): epsilon waves ± T-wave inversions in leads VI-V3
13. Miscellaneous: (PE, right -sided heart strain; electrolytes, ICH, etc.)
VI
1.L Coved ST
segment
V2 elevation
_r
VI
saddleback
V2 i shaped
V3
I—
V2e
V1
Saddleback
V2 +shaped
Vnn3
II
AVRD Epsilon Wave
V -,
I
Hypertrophic Cardiomyopathy k` _ y
Toxicology
If suspected exposure to toxic agent.
• Remove patient from environment if safe/trained/equipped (PPE) to do so
• Ensure appropriate decontamination
If known or suspected opiate intoxication, see Opiate Use Disorder
If carbon monoxide (CO) exposure.
• Consider with CO levels above 59o' in non-smoker or 10176 in a smoker if available
• High flow OZ by NRB+ HFNC (as available) 15 LPM each
If caustic ingestion
• Do not induce vomiting or allow the patient to eat or drink
If tachycardia associated with sympathomimetic intoxication (e.g., cocaine, amphetamine, MDMA),
• Midazolam
Adult - 2.5-5.0 mg slow IV/IO or 5 mg IM/IN, repeat PRN q 5 min (max total dose 10 mg)
Pedi - 0.05 mg/kg (max dose 2.5 mg) IV, repeat PRN q 5 min x 1
If dystonic reaction.
• Diphenhydramine
Adult - 50 mg IV/IM/IO
Pedi - 1 mg/kg (max dose 50 mg)
In suspected cyanide poisoning (smoke inhalation, dermal or ingestion exposure) AND if altered mental status, hemodynamic instability, or
cardiac arrest,
• Ifavailable, Hydroxocobalamin (5 g / 200 mL NS) over 15-minutes through a dedicated IV/IO; contact OLMC following
initial dose
Adult - 5 g IV/IO, repeat PRN x 1
Pedi - 70 mg/kg IV/IO, repeat PRN x 1
Consider the following toxidromes/treatments:
Tricyclic Antidepressant (TCA)
• Sodium Bicarbonate
Adult - 1 mEq/kg IV/IO, (max dose 100 mEq)
Pedi - Same as Adult
B eta-blocker
• Gluca og_n
Adult - 1 mg IV/10 slow push over 1-minute, repeat PRN q 5 min x 1
Pedi - 0.1 mg/kg IV/IO, slow push over 1-minute (max single dose 1 mg), repeat PRN 0.2 mg/kg IV/IO xl
Calcium Channel Blocker
• Calcium Chloride
Adult - 1 g IV slow push
Pedi - 20 mg/kg (0.2 ml/kg) IV/IO, slow push (max dose 1 g)
Organophosphate
• Atropine *
Adult - 2 mg IV/IO, repeat PRN q 3 min until secretions dry up
Pedi - 0.02 mg/kg IV/IO/IM, repeat until secretions dry up
SPOZ may be a poor indicator of severity in CO poisoning; therefore, regardless of SpOZ, always treat the patient
Toxidromes secondary to toxic substances or to toxic doses of common medications may result from exposure in the form of inges-
tion, inhalation, injection, skin absorption
Dystonias may result from a number of psychiatric and GI medications, including droperidol, haloperidol, fluphenazine, fluoxetine,
duloxetine, sertraline, metoclopramide
-> * A true organophosphate poisoning is almost certainly going to require more atropine than can reasonably be stocked on any giv-
en response unit. These cases will also have many additional units responding. Use all atropine needed from additional units.
Tracheostomv Emergencies
• Look, listen, and feel at the mouth and tracheostomy for air movement
• Place non-rebreather mask to tracheostomy, and to mouth (unless history of laryngectomy)
• Titrate 02 to Sp02 >_ 949 or work of breathing
• Reposition airway in slight extension (unconscious), or upright (conscious)
• Respiratory monitoring required (in -line EtCO2 and Sp02) if equipped
• Obtain tracheostomy history (e.g., age of tracheostomy, laryngectomy)
• If unable to determine if laryngectomy, assume upper airway patent
Tracheostomy Respiratory Distress/Failure
• Assume all acute distress or respiratory failure to be dislodgement or obstruction until proven otherwise
• Remove all accessory items (valves/caps) and stoma padding (if present)
• Perform 3 C's, reassess patient condition and SpO,/EtCO2 after each step
Cannula
• Remove inner cannula and inspect for obstruction (do not discard)
If obstructed with secretions
• Consider rinsing with saline or tap water, may use 3 ml syringe/suction catheter to "pressure wash"
Catheter
• Attempt to pass suction catheter down tracheostomy
If suction passes and tracheostomy patent
• Perform suctioning and consider partial obstruction
Cuff
If unable to pass suction
• Deflate tracheostomy cuff (if present)
If no improvement after 3 Cs
• Remove tracheostomy tube and reassess
If respiratory distress, see Respiratoa Sgpport
If Acute Respiratory InsufficiencylFailure or chronic mechanical ventilation, and patent airway
• Assist ventilation with bag -valve -mask (BVM) to face; cover stoma with gloved hand or gauze
If laryngectomy or unable to ventilate via face
• Assist ventilation with pediatric BVM mask to stoma; if no laryngectomy, may need to close mouth/nose
Tracheostomy Hemorrhage
• Obtain history to determine likely source of bleeding (skin, pulmonary, GI, potential trachea)
• Strongly advocate for transport for even small volume tracheostomy bleeding
If rapid and massive hemorrhage from tracheostomy (suspected tracheo-innominate artery fistula)
• Apply oxygen or BVM to face
• Apply external digital compression with index finger at sternal notch (do not delay cuff inflation below)
• Immediately inflate trach cuff to 50 ml
Tracheostomy Respiratory Distress/Failure
If no distresslfailure and tracheostomy exchange or replacement required, see Tracheostomy Replacement/Exchange Procedure
If no improvement
If tracheostomy less than 7-days since initial placement
• Do not attempt tracheostomy replacement or stoma intubation, manage with BVM
If tracheostomy > 7-days since initial placement, see Tracheostomy Replacement/Exchange Procedure
• If unable or replacement/backup unavailable, consider intubation of stoma with 6.0 ETT
If unable ventilate or exchange track or place stoma
• Consider orotracheal intubation (unless laryngectomy)
Tracheostomy Hemorrhage
If uncuffed tracheostomy
• Consider exchange for 6.0 ETT using Bougie
If continued severe bleeding
• Consider orotracheal intubation OR remove tracheostomy and intubate stoma
• Once ETT in place (oral or stoma), consider insertion of finger in stoma to apply direct compression of vessel into sternum
If significant hemorrhage and SBP <_ 90 or HR >_ 110 with poor perfusion, see Hemorrhage Control
��i1��Ci����'��.w.
PRO
Bites/Envenomation
• On patient, document time and mark leading edge of skin changes, pain, and/or tenderness
If bite involves extremity
• Remove all jewelry
• Immobilize affected limb at or above the level of the heart
• Do not tightly wrap the affected limb
If stinger is present
• Attempt to brush away with edge of card
Do not disturb the wound site
Consider other protocols as appropriate:
Allergic Reaction/Anaphylaxis
Circulatory Support
Us
Ni"tem, -!It
Hyperthermia/Heat Stroke
• Remove patient from high temperature environment
If Mild symptoms: heat cramps or heat exhaustion; no signs of altered mental status (AMS); temperature <_ 1040 F
• Passive cooling (loosen clothing, fanning)
If available
• PO fluids (use caution if nausea/vomiting)
If Severe symptoms: heat stroke (AMS and temperature >_ 104' F)
Begin active cooling
Use sheets/towels dipped in ice water directly on skin
Ice packs to core (trunk/abdomen)
Request EMS Supervisor for Cold Water Immersion
If shivering begins, mental status improves, or temperature <_ 1020 F
• Cease active cooling measures
If ice water immersion is in progress, do not remove patient until temperature < 1020 F
Mild
Muscle cramps, sweating
If hypotensive, see Circulatory Support
If uncontrolled shivering occurs during cooling
• Mirlowdom
Moderate
Headache, nausea/vomiting, malaise,
dizziness, orthostatic hypotension,
tachycardia
Adult - 2.5 mg IV/IO/IN
Pedi - 0.05 mg/kg IV/IO or 0.1 mg/kg IM/IN
Repeat PRN q 5-min (max total dose 2.5 mg) x 1
Sweating may or may not be present with heat stroke
Severe
AMS and temperature >_ 104' F
Maintain high index of suspicion for heat -related illness if the any of following risk factors are present:
Elderly
Psychiatric medication
Cardiovascular medications (e.g., diuretics, antihypertensives)
Consider other protocols, as appropriate:
Seizures/Status Ebilet)ticus
Toxicology
Circulatory Support
Altered Mental Status
Diabetic Emergencies
Hypothermia
• Remove patient from cold environment, dry and insulate
Handle the patient gently, consider scoop stretcher (excessive movement may induce ventricular fibrillation)
Remove wet clothing
Assist passive warming with blankets and/or heat packs for comfort
• 12-lead ECG
WN
If severe symptomslsigns: AMS, unstable, dysrhythmia, and/or temperature <_ 90' F
• Actively warm patient with heat packs to neck, groin, and axillae
• Carefully assess vital signs, as they may be diminished but adequate
If patient is in cardiac arrest, and AED advises shockable rhythm
• Administer one defibrillation (no further defibrillation until temperature >_ 90' F)
• IV access, as appropriate; warm IV fluids if possible, consider 500 ml NS IV/IO rapid bolus for hypotension,
Repeat PRN up to 2 L total
If patient is in pulseless ventricular tachycardialventricular fibrillation and not previously defibrillated
• Administer one defibrillation (no further defibrillation until temperature >_ 90' F)
• Do not terminate resuscitation
If symptomatic bradycardia (carefully assess vital signs, as they may be diminished but adequate)
• Initiate pacing only for temperature >_ 90' F
0 M M
M
M
M
MEMO
M
0
0 L
0
M
0
M Mimi
M
M
Amputated Bodv Part
Hemorrhage Control
Cover the stump with saline -soaked sterile dressing and wrap with dry dressing
Wrap severed part in saline -moistened sterile dressing
-Place in watertight plastic bag
-Place bag in cooler with ice, if possible
-Do not freeze
-Do not macerate/soak in water
-Transport amputated body part with patient or to the same Emergency Department as the patient as soon as fea-
sible
Acute Pain Management, as appropriate
If hypotension, see Circulatory Support
Burns
Assist airway, as appropriate
• Titrate OZ to SpOZ >_ 94176 or work of breathing
If suspected carbon monoxide (CO)
• Ensure scene safety, and remove patient from toxic environment
• High flow 02 by NRB + NC (15 1pm)
If potential for ongoing burning
�•
• Brush dry chemicals then flush with water
Initiate decontamination, as appropriate
• Remove clothing/jewelry (affected area and distal to burn)
• Flush eyes with copious amounts of water, as appropriate
• Apply dressings to burns
=> If <_ 10916 BSA, use moist dressings
=> If >_ 1017-o BSA, use dry burn sheet or dry sterile dressing and insulate to prevent hypothermia
• Advanced airway management, as appropriate
Maintain high index of suspicion for inhalation injury
Stridor, muffled voice, singed facial/nasal hair, carbonaceous sputum
• Cardiac monitoring and 12-lead ECG for electrical burns
• IV access, as appropriate; consider 500 ml NS IV/IO rapid bolus for hypotension, repeat PRN up to 2 L total
If >_ Partial thickness burn (>10% BSA), fluid resuscitation as follows:
'
Adult - 500 ml/hr NS IV/IO
3-14 years - 250 mL/hr NS IV/IO
0-3 years - 125 mL/hr NS IV/IO
• Acute Pain Management, as appropriate
�
If severe symptomslsigns (>_ 1096' BSA partial thickness, full -thickness, circumferential, involvement of face/hands/feetlgenitals, significant -
chemical or electrical burns, or airway involvement)
• Provide notification and transport to nearest burn center
If unsecured airway
• Transport to the closest full -service hospital
1 V
13
15 '
9 36 9
19 9% 32 9% ,\
9% 32 9%
9%J'15115
% 18 18 18 18
1 17
1-4 5-9 10-14 ADULT
(RULE OF NINES 1
Entrabment/Crush/Traumatic RhabdomwMis
• Bleeding control (direct pressure, tourniquet)
• Remove constricting clothing, jewelry
Field Amputation
If anticipated prolonged entrapmentlextrication, and if potential for worsening of patient condition in the absence of extrication,
• Contact OLMC to activate field amputation process
Cardiac monitoring, 12-lead ECG
IV access,
Adult - NS 20 ml/kg bolus
Pedi - Same as Adult
• Acute Pain Management, as appropriate
If ECG findings of hyperkalemia (peaked T-waves, wide QRS), contact OLMC following initial dose
• Calcium Chloride
Adult - 1 g IV/10, slow push
Pedi - 20 mg/kg (0.2 mL/kg) IV/I0, slow push (max dose 1 g)
• Sodium Bicarbonate
Adult - 1 mEq/kg IV/10 (max dose 100 mEq)
Pedi - same as Adult
General Trauma
• As appropriate:
Hemorrhage Cotnrol
Airway management
Circulatory Support
Prehos ital B100d Administration
Acute Pain Management
Amputated Body Part
Spinal Motion Restriction
• Keep patient warm
• See Trauma Transport Guidelines
If cardiac arrest, see Traumatic Circulatory Arrest
If suspected tension pneumothorax with hypotension, see Needle Thoracostomy Procedure
If hypotensive, see Circulatory Support
Eye Injury
If isolated eye injury
• Irrigate with NS if result of chemical
burn (if appropriate to agent)
• Cover unaffected eye/stabilize impaled
object
If suspected ocular injury
• Do not delay transport
If outside socket
• Cover with NS soaked gauze
Head/Neck Injuries
• Spinal Motion Restriction
• Maintain >_ 94% SpOZ at all times
If respiratory failure
• Ventilate at a rate of 10 bpm, or to
maintain EtCO2 35-45 mmHg
Chest Injuries
• Hemorrhage Control
• Stabilize impaled objects
• Stabilize flail segments
If suspected open pneumothorax
• Partial occlusive dressing
Abdominal/Pelvic Injuries
• Control bleeding
• Pelvic binder
• Stabilize impaled objects
• Evisceration— cover with saline moistened
gauze
Pregnancy Considerations
• Left lateral recumbent (LLR) position
If signs of poor cardiac output
• Manual fundus displacement (to left)
Head/Neck Injuries
S� • EtCO2 between 35-45 mmHg
Chest Injuries
• Tension Pneumothorax— Needle thoracosto-
my
Junctional/Extremity Injuries
• Hemorrhage Control (direct pres-
sure, tourniquet)
o If bleeding uncontrolled by tourniquet
• Pack wound tightly with hemo-
static gauze and kerlix gauze
• Splinting, as appropriate
t • Sterile dressing— open fractures
I• Care for Amputated Body Part
Ventilation Rates for Pediatric Head Injuries
Infants (0-24 months) 25 breaths per minute
> Children (2-14 years) 20 breaths per minute
Adolescents (15 -17 years) 10 breaths per minute
(same as adult)
Blood Pressure Goals for Pediatric Head Injuries
—> 0-2 years of age
SBP of 70
2-10-years of age
SBP = 70 +(age in years x 2)
—> 10 years of age or greater SBP of 90
Spinal Motion Restriction
If penetrating trauma (including to the neck and/or spine with or without neurological deficit)
• Do not initiate Spinal Motion Restriction procedure
If any of the following findings are present: History criteria, midline tenderness, pain or paresthesias on external rotation
• Initiate Spinal Motion Restriction procedure
Spinal motion restriction may be deferred ONLY IF ALL OF THESE FINDINGS ARE ABSENT
History
Age < 12 or >_ 65
Limited ability to sense or communicate pain
AMS, LOC, intoxicated, head trauma, language barrier, mental retardation
Distracting injury
Long bone fracture, visceral trauma (abdomen, pelvis), large laceration, crush injury, large burn
Neurologic deficit
Motorlsensory loss or paresthesia
Dangerous mechanism of injury
Fall >_ 3 feet or 5-stairs
Axial loading injury to the head (diving accidentlsports injury)
Vehicular accident
High speed motor vehicle accident >_ 60 mph
Motorized recreational vehicle accident
Ejection
Bicycle collision with immobile object (tree, parked car)
Struck by large vehicle
Roll-over
Palpation
FMidline cervical tenderness
Active Range of Motion Test
Patient is able to actively rotate neck 45 ° both to left and right with no pain, paresthesia or
motor deficit
If any pain or paresthesia upon rotation, IMMEDIATELY TERMINATE RANGE OF MOTION TEST
If patient unable to tolerate spinal motion restriction
• Attempt less restrictive means (c-collar only ) or use position of comfort and/or allow patient to self -splint
Trauma Transport Guidelines
Major trauma patients may need to be transported to a designated trauma center in a timely manner. It is in the best
interest of the patient to be transported to a designated trauma center if the patient meets certain criteria.
If any of the following criteria are present,
• Transport to the closest age appropriate Trauma Center (Level 1 or 2):
Injury Pattern
Mental Status & Vital Signs
Penetrating injury (e.g. GSW, stabbing) to head, neck, torso,
Unable to follow commands (motor GCS <6 )
upper arm, thigh
� Age 0-9: SBP < 70 + (2 x age years)
—>
Skull deformity, suspected skull fracture
� SBP < 90 (or relative hypotension)
Suspected spinal injury with new motor or sensory loss
Age >_ 65 AND SBP <_ 110
Chest wall instability, deformity, or suspected flail chest
HR > SBP (shock index of >_ 1)
—�
Suspected pelvic fracture
RR < 10 or > 29
Suspected two or more proximal long -bone fractures
Respiratory distress or need for assisted ventilation
Crushed, degloved, mangled, or pulseless extremity
(e.g. BVM, SGA, ETT)
—>
Amputation proximal to wrist or ankle
Room air pulse oximetry <_ 9096
Active bleeding requiring a tourniquet or wound packing
If any of the following criteria are present,
Transport to the closest age appropriate Trauma Center (Level 1, 2, 3, or 4):
Mechanism of Injury
Risk Factors
Fall from height > 10 feet
Low-level falls in children (age < 5) or older adults
� MVC with:
(age >_ 65) with significant head impact
Partial or complete ejection
Anticoagulant use
Significant intrusion (including roof), with any:
Special, high -resource healthcare needs (chronic
> 12 inches occupant side
ventilator dependency, ventricular assist device)
> 18 inches any site
Suspicion for child abuse
Need for extrication of an entrapped patient
� Pregnancy > 20 weeks
Child (0-9) unrestrained or in an unrestrained child safety seat
� Burns in conjunction with trauma
Death in same passenger compartment
Vehicle telemetry data consistent with severe injury
Rider separated from transport vehicle with significant impact
(e.g. motorcycle, ATV, horse, etc.)
Pedestrian or bicycle rider thrown, run over, or with signifi-
cant impact
Pearls & Pitfalls:
--+ Amputations distal to wrist/ankle may be evaluated at closest Trauma Center
Traumatic Circulato
• DO NOT INITIATE MOVEMENT OF THE PATIENT
If suspicion of non -traumatic cause
• Proceed with Cardiac Arrest protocol
If traumatic cause
• Consider Withholding Resuscitative Efforts
• Initiate CPR and place pads
• Rapidly and simultaneously address reversible pathology (H.O.T.T.)
A
Al-.LCJ L
• Promptly expose patient • BVM or, If clinical suspicion
If catastrophic hemorrhage or hemorrhagic shock with suspected pelvic
• Immediate SGA • Needle Thoracostomy
fracture, see Hemorrhage Control • Simple Thoracostomy
• Pericardiocentesis
• POCUS
GOAL: Catastrophic hemorrhage intervention, oxygenation and confirmed ventilation via EtCO2i
and evaluation +/- treatment for tension pneumothorax
7 ROSC?
Yes No
• Prioritize rapid transport while optimizing patient hemody- • After the following resuscitative efforts*:
namics, oxygenation, and ventilation Hemorrhage control interventions
• Hospital pre -notification ASAP —> Oxygenation
Ventilation with confirmed EtCOZ waveform
If significant traumatic or OB related hemorrhage, see +/- Thoracostomy / Pericardiocentesis
Hemorrhage Control Contact OLMC for termination
Pearls:
After in -person assessment by the EMS Supervisor and prior to ALS interventions, if withholding criteria is present and patient is in
asystole, resuscitation efforts can stop.
Patient may be moved for scene conditions or safety.
Chest compressions offer very low probability of benefit in traumatic arrest, but public expectation exists for its performance. As a
result, perform CPR, however do not allow compressions to interrupt attempts to address treatment goals.
Interventions must be completed prior to MCD placement if transport is indicated.
Epinephrine or other medications offer very limited benefit in traumatic arrest: therefore, they are not indicated.
* There is no minimum resuscitation time required before considering termination, only achievement of treatment goals.
There is almost no benefit to transport of traumatic cardiac arrest. Transport in absence of ROSC should be rare.
Despite traumatic event, consider potential for medical cause of arrest, including AMI or commotio cordis.
OB/GYN
Emeraencv Childbirth
• Administer OZ and titrate to Sp02 >_ 94%
• Check for presentation (crowning, limb, breach, cord) and follow procedures, as below
If crowning
• Emergency Childbirth Procedure
If nuchal cord,
• If cord is loose around the neck: Attempt to gently slip cord over infant's head
• If cord is tight around the neck: Clamp cord X 2 (2-inches apart), cut between clamps
If cord presentation
• Position mother in Trendelenburg or in the knee -to -chest position
• Instruct the mother to pant with each contraction
• Gently push presenting fetal part upward off and into the birth canal
• Maintain hand position so as to maintain cord pulse
• Do not attempt to reposition if the cord retracts
• Apply moist sterile dressing to cord
If breech presentation, see Emergency Childbirth Procedure: breech presentation
If single limb, rapid transport
If premature birth
• Emergency Childbirth Procedure
• Dry and cover newborn (start with head, then body)
Cover head and wrap body use dry liner and foil
• Administer blow -by oxygen (humidified, if available) avoid direct OZ flow into neonate's face
• Minimize family member contact with neonate
• Once delivery complete, see Newly Born
If uterine inversion
• DO NOT ATTEMPT TO REMOVE PLACENTA
• Apply pressure to fundus upward through cervix, use fingertips and palm of gloved hand
• Cover with sterile moist dressing if unsuccessful
If suspected pre-eclampsia or eclampsia, see Pre-eclampsia/Eclampsia
If postpartum hemorrhage
• Aggressive fundal massage
• See Hemorrhage Control
N T 1 ll
INUW1V "V111
• Assess and document APGAR score at 1-minute and 5-minutes after birth
• Warm, dry, and stimulate infant.
• Clear secretions as needed
• Assess breathing pattern and palpate pulse rate
If apneic, gasping, or HR < 100 bpm
• Begin assisted ventilation with a BVM without supplemental oxygen at rate 40-60 breaths per minute
If HR < 60 despite 30-seconds of confirmed BVM ventilation
• Begin CPR, 3:1 compressions -ventilation, 120 bpm
If labored breathing or persistent cyanosis
• Position and clear airway
• Supplemental oxygen as needed
• Begin SP02 monitoring (place on right hand)
— Goal timeframe —1 minute
If HR < 100 despite BVM
• Ensure effective ventilation with BVM (chest rise and fall, waveform capnography)
• Invasive airway management, if necessary
If HR < 60 despite 60-seconds of CPR
• IV/IO access
• Epinephrine 1:10,000 - 0.01 mg/kg IV q 5-min
If failure to respond to epinephrine and suspected hypovolemia '
• NS - 10 ml/kg slow IV/10 push (max dose 50 ml), push over 10 minutes
If blood glucose < 50
• Dextrose 10% (25 g/250 ml) - 2 ml/kg IV/10 bolus
• Initiate transport
SP02 slowly increases within the first 10 minute post -birth (see chart)
Routine suctioning for meconium is generally not indicated.
Intraosseous access is only suitable for term infants > 3kg, and requires a slightly more distal approach than in older children
Prevent hypothermia
Targeted Procedural SP02
1 min
60-65 %
2 min
65-70%
3 min
70-75%
4 min
75-80%
5 min
80-85%
10 min
85-95%
APGAR
0
1
2
Appearance
Blue/pale
Blue extremities
Good color
Pulse
Absent
<_ 100
>_ 100
Grimace
No response
Weak cry
Strong cry
Activity
None
Some
Flexed arms/
legs
Respiratory
Effort
Absent
Weak/gasps
Strong (with
strong cry)
Pre-Eclampsia / Eclampsia
Pre-Eclampsia is present in patients between 20 weeks gestation and 6 weeks postpartum with:
• SBP >_ 140 or DBP >_90 with severe features*
or
• SBP >_ 160 or DBP >_ 110 regardless of symptoms
Eclampsia should be considered present for all tonic-clonic seizures in pregnancy or post-partum patients
If SBP >_ 140 or DBP >_ 90 with Severe Features confirmed by correctly fitted cuff on 2 readings 5 minutes apart
• Magnesium Sulfate (10g / 250mL NS) bolus 6 g IV/10 over 15 min; followed by 2 g/hr infusion
• Bolus: rate = 648 mL/hr; total volume = 150
• Infusion: rate = 50 mL/hr
If SBP >_ 160 or DBP >_ 110 confirmed by correctly fatted cuff on 2 readings 5 minutes apart
• Nifedipine 10 mg SL
• Magnesium Sulfate (IOg / 250mL NS) bolus 6 g IV/IO over 15 min; followed by 2 g/hr infusion
• Bolus: rate = 648 mL/hr; total volume = 150
• Infusion: rate = 50 mL/hr
If suspected eclamptic seizure
• Midazolam as per Seizure protocol (only for ongoing seizure)
• Magnesium Sulfate (IOg / 250mL NS) bolus 6 g IV/10 over 15 min; followed by 2 g/hr infusion
• Bolus: rate = 648 mL/hr; total volume = 150
• Infusion: rate = 50 mL/hr
(administered even if seizure stops)
If maternal HR is > 60 and SBP >_ 160 or DBP >_ 110 confirmed by correctly fitted cuff on 2 readings 5 minutes apart and
severe symptoms described above are present
• Labetalol 20mg 17V over 2 minutes, repeat 40 mg IV PRN q 10 minutes
*Severe Features: new onset headache, visual changes, or RUQ pain
Prue
12-Lead ECG
Indications:
Complaints of chest pain or atypical symptoms sugges-
tive of ACS (nausea, palpitations, SOB, dizziness, synco-
pe, weakness) L&
Electrical Injuries
Suspected cardiotoxic overdose V1 V2
Suspected severe electrolyte derangement Vg
Cardiac arrhythmia �� '�� va
• Attach patient to monitor
Shave chest (as necessary)
Apply electrodes II
• Enter demographic information (age, first/last name,
DOB) p FIL L�
• Transmit ECG to the receiving ED ,1M
I
• Download/Attach ECG to the PCR
RA —Right Arm
LA — Left Arm
RL — Right Leg
LL — Left Leg
• Obtain serial 12-lead ECGs
• Continuously monitor ECG
V 1 — 4th intercostal space at right sternal border
V2 — 4th intercostal space at left sternal border
V3 — Directly between V2 and V4
V4 — 5th intercostal space at mid -clavicular line
V4R— Right 5th intercostal space at mid -clavicular line
V5 — Level with V4 at left anterior axillary line
V6 — Level with V5 at left mid-axillary line
If meets ST segment elevation MI (STEMI) criteria
• Transmit to STEMI facility
• STEMI Alert (patient is believed to need emergent PCI)
2 or more continuous leads with:
STE >_ 1 mm limb leads with reciprocal depression and/or
STE >_ 2 mm precordial leads with reciprocal depression and/or
Relative STE <_ 1 mm with reciprocal changes with QRS voltage <_ 5 mm
If STEMI criteria met
• Transport to STEMI facility or call for advanced intercept
If any other interpretation
0 Transport per Patient Destination Policy
Assisted Ventilation/BaLy Mask Ventilation
Indications:
Hypoxia uncorrected by passive
high FiO2
Ineffective minute ventilation
Respiratory insufficiency/failure
BVM ventilation
Contraindications:
Mask— inability to obtain a mask seal
Oral/Facial/mandibular disfigure-
ment
—� Edentulousness with/without ema-
ciation
Adult:
Cardiac Arrest:
• 30:2 compression to breath ratio
Perfusing:
• Titrate to SP02 >_ 94% and
eucapnia (as appropriate)
Pearls & Pitfalls:
If mask ventilating
Ensure EtCO2 waveform for every breath
Reposition patient head if no waveform
Do not utilize BURP/Sellick's maneuver to prevent gastric filling
Position ETSN with 2-hand mask seal to prevent gastric filling
If advanced airway
Ensure EtCO2 waveform for every breath
After initial placement confirmation, avoid excessive ventilation rates/
pressures
Be vigilant for tube migration/dislodgment the duration of placement
and for all patient moves
Disconnect BVM for loading/unloading into the ambulance
Ventilation Rates:
Pediatric:
Cardiac Arrest:
• 15:2 compressions to breath ratio
Perfusing:
• 20 breaths per minute
Procedure
• Position for patency
Ear -to -sternal notch (ETSN)
Up to 2 NPAs -L OPA (as appropriate)
• Obtain strong face -Mask seal
(preferred 2 rescuer technique)
Thenar grip or
E-C "Clamp"
• Squeeze bag
(confirm 4 phase EtCO2 waveform every breath)
If wheezes present
• Continue Albuterol/Ipratropium where applicable in protocol
Neonates:
Cardiac Arrest:
• 3:1 compressions to breath ratio
Perfusing:
• 30-60 breaths per minute
Thenar Grip
EC "Clamp"
Caonoaranh
Indications:
Respiratory distress (dill. breathing, or requiring >_ 2 1pm 02)
Decreased LOC/somnolence
Trending: Perfusion/respiration
Advanced airway use (ETT and SGA)
Narcotic/benzodiazepine/sedative administration
Contraindications:
None
Pearls & Pitfalls:
Clogging of the detector should prompt appropriately
aggressive airway clearance by use of suction (strongly
consider removing any inserted device)
An advanced airway or BLS airway adjunct should be
removed and reattempted if CO2 waveform absent
—> EtCO2 alone cannot detect right main stem intuba-
tion, confirm lung sounds after 4-phase waveform eve-
ry ETT placement
Be vigilant for tube migration/dislodgment the dura-
tion of placement and for all patient moves
Airway in place or During mask ventilation:
Clogged Detector
• Suction airway immediately
• Replace detector
If no noted 4-phase waveform after 1 detector swap
• Remove airway device
• Ventilate by different device/method
Malpositioned tube/no ventilation
0
X
If SGA LT, ETT, OPA, BVM
• Remove device
• Reposition airway
• Ventilate by different device/method
Causes: 0 mmHg EtCO2
1 Loss of airway e.g. apnea, failed tube, dislodged tube
2 Loss of circulation e.g. witnessed cardiac arrest, massive
PE, exsanguination, RV rupture
Side Stream Nasal Cannula
• Connect EtCO2 detector line to machine
• Apply nasal cannula
Bag Mask Ventilation
• Connect EtCO2 detector line to machine
• Insert "in -line" detector between the Bag -Valve and Mask
• Ventilate per Bag Mask Ventilation/Assisted Ventilation Procedure
• Appreciate 4-phase EtCO2 waveform for every breath
"In -Line" EtCO2 with Advanced Airway
• Connect EtCO2 detector line to machine
• Insert "in -line" detector between the Bag -Valve and advanced airway
• Ventilate per Bag Mask Ventilation/Assisted Ventilation Procedure
• Appreciate 4-phase EtCO2 waveform for every breath
Indications:
Temp >_ 104 ° F AND AMS
Contraindications:
Evidence of major trauma
Suspected infectious cause
Cold Water Immersion (CWI)
Pearls & Pitfalls:
In cases of very short transport times, evaluate if the
benefits of rapid transport outweigh delay of CWI
initiation. There may still be a time-lag for setup in
the ED. Provide ED early pre -notification of need
CWI.
—� If ICE bag unavailable, may use patient transport
tarp (MegaMover), stretcher cover or non -medical
plastic tarp/sheet.
Procedure:
• Remove from environment and initiate/continue active cooling measures if not already completed
If ice immediately available on scene
• Proceed with CWI
If ice available in timely manner
• Determine fastest method for obtaining ice:
—> Request EMS or FRO resource with ice
Send clinician to nearby establishment (e.g., gas station, restaurant, grocery) with ice access
—> Detour to nearby establishment with ice access
• Place defibrillation pads and ensure full monitoring
• Place patient in Immersion Cooling Emergency (ICE) bag on the stretcher
• Protect airway and fill ICE bag with ice and cool/cold water or saline (-1-2 L) to cover >_ 2 inches of the pa-
tient's body. Zip bag (or wrap tarp) to mid -chest. Continue to circulate ice bath for maximal cooling.
• Check temperature after 10 minutes
• Criteria to discontinue CWI
—> Core (rectal) temp <_ 1020 F or improved mental status
If uncontrolled shivering occurs during cooling, see Hyperthermia/Heat Stroke
Contact Precautions/Personal Protective Eauiument
Procedure:
• Explain the reason for use of isolation equipment
• Wear gloves, gown, and eye protection
• Wash hands after leaving the care area
• Splash precautions (goggles/face shield) for suction, intubation, nebulizer updrafts etc.
If standard precautions
• Don the following PPE
Disposable exam gloves
Goggles/face shield for any airway procedures or patient with active cough
Impermeable gown for any situation likely to generate splash/liquid exposures
Place surgical mask on patients who are coughing
If contact precautions indicated
• Don the following PPE
Disposable exam gloves
—> Goggles/face shield for any airway procedures or patient with active cough
-� Impermeable gown
If droplet precautions indicated
• Don the following PPE
2 Sets of Disposable Exam Gloves
Disposable surgical mask
-� Goggles/Face Shield
Impermeable gown
If airborne precautions indicated
• Don the following PPE
2 Sets of Disposable Exam Gloves
N95 Respirator
Goggles/Face Shield
Impermeable gown
Utilize viral filter, if available, when performing basic or advanced airway management
If special respiratory precautions indicated
• Don the following PPE
2 Sets of Disposable Exam Gloves
N95 Respirator
Goggles/Face Shield
Impermeable gown
Boot/Shoe covers
If ebolalviral hemorrhagic fever precautions indicated
• Don the following PPE
Gloves
PAPR (Powered Air -Purifying Respirator)
Coverall
PPE
Eme
Indications:
Childbirth/labor
Contraindications:
None
Childbirth
Pearls & Pitfalls:
Inspect perineum for crowning on all pregnant females
reporting symptoms of labor
Prepare for splashing fluids; sterile gloves, gown, mask/
glasses
Childbirth:
• Administer oxygen as appropriate Lithotomy Position
• Place patient in tilted Left Lateral Position if not crowning --- ?
• Visually inspect perineum for crowning
• If delivery imminent or in process, do not initiate or continue transport
• Prepare OB kit and area for delivery and position mother (lithotomy) I
As the head delivers:
• Use a gloved hand to control speed of head delivery
• Suction the mouth then nose with suction bulb if:
Amniotic fluid is not clear
Obvious obstruction to spontaneous breathing or if positive pressure ventilation required
Address umbilical cord around newborn neck if present:
If cord loose around neck: Attempt to pull cord over infant's neck
If cord tight around neck: Clamp cord X 2 (2-inches apart), cut between clamps, and continue
Apply gentle downward traction for the top shoulder to deliver with head sandwiched between both palms
Apply gentle upward traction for the bottom shoulder to deliver with head sandwiched between both palms
If delivery fails to progress after head delivers (suspected shoulder dystocia)
• Hyperflex maternal hips via supine knee -chest position (McRobert's maneuver)
• Apply firm suprapubic (not fundal) pressure to attempt to dislodge shoulder
• After complete delivery place the newborn on maternal abdomen or level with the mother's uterus
• Address umbilical cord
If infant is vigorous and mother is stable: delay cord cutting 30-60 seconds
Clamp and cut the umbilical cord (minimum 6-inches from the neonate 2-inches apart) unless already done
• Dry and cover newborn start with head, then body
If term birth, strong cry, regular respiratory effort, and good tone: Place infant on mother's chest skin -to -skin
• Assess for maternal bleeding, and, assess for signs of placental separation (Lengthening cord, pelvicpain, etc.)
If not already done, encourage the mother to attempt breastfeeding to aid in bleeding control
If bleedingpresent orplacenta delivers perform fundal massage (vigorous massage of fundus watching for uterine tone/decreased
bleeding)
Direct pressure for excessive bleeding from birth canal tears
Breech:
Delivering the legs, abdomen, and umbilical cord:
• Allow fetus to deliver to level of umbilicus
After umbilicus is visualized extract 4-6 inch loop of umbilical cord
• Gently extract legs downward after buttocks are delivered
Delivering the shoulders:
• Gently align the fetus' shoulders anterior -posterior to the mother with the infant's face pointing laterally
• Gently guide fetus upward to deliver the posterior shoulder
• Gently guide fetus downward to deliver the anterior shoulder
Delivering the head/neck:
• Rotate the fetal face or abdomen AWAY from the maternal pubis after the shoulders are delivered
Upon delivery of the neck:
Place gloved finger up into infant's mouth to keep head flexed AND
Apply gentle pressure to the occiput with the other hand to aid in neck flexion AND
Endotracheal Intubation/Video Laryngoscopy (UEScope)
Indications:
—> Respiratory failure
Need for airway protection
Adult cardiac arrest after failed SGA
Contraindications:
Non -cardiac arrest patients if DSI parame-
ters are not met
Pediatric patients per definition
Definition of an Intubation Attempt:
Insertion of a laryngoscope blade into
the mouth with the intent of performing
ETI (regardless of whether a ETT/bougie is
placed in the mouth).
—> Does not include laryngoscopy for foreign
body removal
Pearls & Pitfalls:
Intubation is prohibited if DSI parameters (>_ 94% x 3 min,
SBP >_ 100 mmHg) are not met in non -cardiac arrest
patients, and will not be tolerated.
DSI is required for all intubations not in cardiac arrest
—> Upload of the VL (UEScope) file is required
—> Do not interrupt CPR to intubate
—> Avoid damage to teeth and soft tissue by using gentle, controlled
laryngoscope movements
—> Maintain manual in -line cervical spine precautions if suspected
cervical spine injury, may open c-collar during intubation
SALAD (Suction Assisted laryngoscopy & Airway Decontamina-
tion) technique should be used for all attempts with emesis or
other airway contamination to ensure clear VL optics and visual
field and reduce aspiration.
• Invasive Airway Preparation
• Utilize Intubation Checklist
• External Laryngeal Manipulation (ELM) under guidance from laryngoscopist
• Ensure proper positioning
• Select appropriate UEScope blade for patient size and attach to monitor
• Assure UEScope device is on and recording
• Open patient's mouth using scissor technique (index/thumb)
• Suction airway before blade insertion and PRN during intubation
• Insert blade midline along the tongue and identify the epiglottis
(do not deliver tube if unable to visualize epiglottis)
• Insert blade into vallecula and lift to view vocal cords
Perform head -lift or ELM to maximize view PRN
If continuous emesis or other airway contamination build-up
• SALAD Park maneuver - Remove suction from right side, place catheter into left
side of mouth behind intubator's left hand, place tip in proximal esophagus.
• Deliver bougie and thread ETT over bougie j
If resistance to ETT passage, rotate ETT clockwise or counterclockwise
Check insertion depth and inflate ETT cuff
• Remove bougie first and then VL device
• Confirm placement:
Primary: 4-phase EtCO2 > 5 mmHg for >_ 5 breaths
Secondary Confirmation:
Two -provider visual confirmation
Bougie "hold-up" Modifier! Co,m k-Lehaoe Scale
Epvglattie
Bilateral lung sounds V-1 cn d
Absent/diminished epigastric sounds -
"Misting" in tube
V �—
• Secure ETT and continue to monitor placement with
EtCO2 waveform
Aryt—d caitllage
Grade S Grade 2. Grade 2b Grade 3 Grade 4
External Cardiac Pacin
Indications:
Bradycardia associated with:
Hemodynamic instability
End organ dysfunction
Hypotension
Adult: SBP <_ 90 or relative JBP
Pedi: SBP <_ 70 + (age in years X 2), or 90 if >_ 10 years
Contraindications:
—• Severe hypothermia (core temp < 900 F)
Pearls & Pitfalls:
Consider underlying profound electrolyte disturbance
if unable to achieve capture or if high energy settings
required (seek OLMC for guidance)
As time allows:
Administer sedative agent
(use caution until hypotension is corrected)
• Sedative agent, as appropriate per protocol
• Attach ECG monitoring electrodes (required for demand pacing)
Secure electrodes to wire connector/patient with sturdy tape/kling
• Adjust view to lead with most upright QRS
• Apply pads to patient's chest
+ + +Do not place pads over implanted devices + + +
• Select "PACER" function as per device manufacturer recommendations
• Set pacer rate, as follows:
Age 0-36 Months 36 months - 12 years > 12 years
Rate 120 ppm 100 ppm 70 ppm
• Press/select "START" or depress the "PACER" button
• Increase output in 10 mA increments till capture is noted or maximum output is reached
• Verify both markers of capture present:
• Electrical capture — pacer spike immediately followed by wide QRS complex with tall broad T-wave
• Mechanical capture — palpable carotid and/or femoral pulse; variable presence - pulsatile SpO2 matching
pacing rate and increase in EtCO2
• Increase rate in 10 bpm increments if low cardiac output
• Observe for signs of improved hemodynamics
• Treat other causes for poor hemodynamics
If pacing ongoing at emergency department (ED) handoff
• Do not allow removal of pads/leads or discontinuation of EMS pacing until ED pacing established, or ED clini-
cian determines pacing may be discontinued
• ED staff should apply ED pads, set ED pacer rate above the EMS pacer rate, and then gradually increase ED pac-
er output (mA) until electrical/mechanical capture at higher rate is confirmed, EMS pacing may then be removed.
Anterior/Posterior Pad Placement
Indications:
Gastric distention impeding effective ventilation
Contraindications:
History of esophageal tears
Ingestion of caustic substances
Gastric Tube
Pearls & Pitfalls:
Do not let gastric tube insertion interrupt airway
confirmation
Do not hesitate to remove a SGA if EtCOZ wave-
form is lost
Use with SGA designed to allow gastric tube placement
If suspected gastric inflation
• Remove the gastric tube from the packaging, then, using the tube, measure the distance from: nare-to-ear and
ear -to— xiphoid process, noting the length at which to insert the tube to
• Prior to insertion, thoroughly lubricate gastric tube and partially insert through the gastric lumen
• Follow Supraglottic Airway procedure, ensuring waveform confirmation of placement
• Advance the gastric tube through the gastric lumen to the depth noted by the earlier measurement
• Using a 60 cc `cath-tip' syringe, inject air thought the gastric tube while verifying the presence of "bubble"
sounds over the epigastrium
• Following confirmation of sounds over epigastrium, aspirate with the syringe, looking for gastric contents
If insertion was successful
Secure with tape to the SGA
Attach gastric tube to suction intermittently at 30-40 mmHg
Use with Endotracheal Tube
If suspected gastric inflation
• Remove the gastric tube from the packaging, then, using the tube, measure the distance from: nare-to-ear and
ear -to— xiphoid process, noting the length at which to insert the tube to
• Advance the gastric tube at a downward angle into the oropharynx to the depth noted by the earlier
measurement
• Using a 60 cc cath-tip syringe, inject air thought the gastric tube while verifying the presence of "bubble" sounds
over the epigastrium
• Following confirmation of sounds over epigastrum, aspirate with the syringe, looking for gastric contents
If insertion was successful
• Secure with tape
Attach gastric tube to suction intermittently at 30-40 mmHg
H1Lrhly Contagious Infectious Disease
• Upon notification of a response to or awareness of a patient with HCID
• Don personal protective equipment before entering scene (do not remove until after patient contact ends)
• Minimize potential exposure
Only one EMS provider should approach the patient and perform the initial screening from at least 6
feet away from the patient.
Keep other emergency responders further away, while assuring they are still able to support the pro-
vider with primary assessment duties.
Confirm screening criteria:
1. Does the patient have any of the following symptoms?
a. Fever or chills
b. Headache, joint pain, or muscle aches
c. Weakness or fatigue
d. Stomach pain, diarrhea, or vomiting
e. Abnormal bleeding
AND
2. Recent exposure to an individual with a confirmed HCID and/or travel to a region with a
known outbreak of an HCID, or if known public health emergency (e.g., COVID, Ebola,
Monkeypox).
If patent remains a person under investigation
• Follow agency HCID notification process
• Remove and keep nonessential equipment away from the patient, so as to minimize contamination, on the
scene and in the ambulance.
Medical equipment used on patients should be disposable whenever possible
Including manual BP cuff and manual suctioning (if necessary).
Transfer cardiac monitor and other equipment to supervisor before transporting.
• Follow disease specific Medical Directives regarding the performance of invasive procedures that may be re-
quired for patient stabilization.
Minimize aerosolizing procedures to what is necessary while wearing appropriate PPE for airborne
precautions
If patient is in cardiac arrest contact OLPG immediately for guidance on possible WOR.
• Notify receiving hospital as soon as possible
• Outfit ambulance as per HCID procedure.
• Notify PD to secure scene and keep any exposed persons in same household sequestered until Public Health
assesses
• Documentation of patient care should be done after EMS providers have completed their personal cleaning
and decontamination of equipment and vehicle.
• EMS documentation should include a listing of public safety providers involved in the response and level of
contact with the patient (for example, no contact with patient, provided direct patient care). This documenta-
tion may need to be shared with local public health authorities.
• Stay with the patient in the ambulance until the hospital staff is prepared to receive the patient.
• EMS Personnel will doff PPE at the hospital, using the hospital protocol and monitor.
Influenza Vaccination
Indications:
—� Adults: One dose if vaccinated for the seasonal
influenza in any previous year
Children 6 mo - 9 yr: Two doses separated by at
least 28 days if they have never received a seasonal
influenza vaccination in the past, or if their first
seasonal influenza vaccine was last year and they
only received one dose
Contraindications:
—• Age less than 6 months
—• Any acute illness more severe than a common cold
—• Oral (or equivalent) temperature elevation >_ 101.517
—• History of Guillian-Barre
Serious allergic reaction to previous dose of influenza
vaccine
—> Serious allergic reaction to egg or egg products
Pearls:
Prepare vaccines in a clean, designated medication
area away from where the patient is being vaccinated
and away from any potentially contaminated items.
This is to prevent inadvertent contamination of the
vial through direct or indirect contact with potentially
contaminated surfaces or equipment.
Different manufacturers have additional allergy
contraindications which may include gentamicin,
neomycin, polymyxin, thimersol, gelatin, and latex.
It is ESSENTIAL that anyone utilizing this protocol
understands the packaging insert(s) and
contraindications for the specific manufacturers'
product(s) being used
Procedure:
1.Provide vaccinee appropriate CDC Vaccination Information Statement (VIS)
2.Vaccinee to complete the top section of the Vaccine Administration Record (VAR)
3.Review completed VAR
a.VAR serves as written consent for the vaccination
b.If a potential vaccinee answers "yes" to any of the questions, the potential vaccinee should not receive the
vaccination until cleared by a physician
4.Prepare and verify appropriate dose
a.For persons 3 years of age and older:
1.0.5 mL for all inactivated influenza vaccine products
b.For children 6-35 months of age:
1.0.25 mL for Fluzone Quadrivalent
11.0.5 mL for F1uLaval Quadrivalent
5.The injection site (L or R deltoid or L or R anterolateral aspect of thigh) should be identified and cleansed with
alcohol pad
6.A 21-25 gauge needle 1 inch long should be used for adults
a.In patients less than 60 kg, a 5/8 to 3/4 inch needle is preferred
7.Insert the needle at a 90-degree angle and stretch the skin flat between thumb and forefinger
8.The appropriate dose of vaccine should be delivered in the muscle in a quick, steady manner
Intramuscular (IM) Iniection
Indications (Basic providers):
Severe allergic reaction
Indications (Assist/Advanced):
Medication administration where applicable in protocol
• Select the appropriate administration site:
Thigh Arm Hip
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Deltoid Muscle Dorsogluteal Muscle Ventrogluteal Muscle Vastus Lateralis Muscle
Type: IM Type: IM Type: IM Type: IM
Size: 23 to 25 G, 5/8" to 1" Size: 20 to 23 G, 1 'h" to 3" Size: 20 to 23 G, 1 t/z" to 3" Size: 23 to 25 G, 5/8" to 1 '/,"
Range: 0.5 to 2 mL Range: 1 to 5 mL Range: 1 to 5 mL Range: 1 to 5 mL
• Stretch skin and hold tight. Hold the syringe at a 90 degree angle to the skin and insert the needle into the
muscle tissue with a steady sharp and controlled motion
• Releases the tension on the skin
• Administer correct dose of medication at the proper push rate
11
89
Intraosseous (IO) Access
Indications:
Pearls & Pitfalls:
Cardiac Arrest
, Humeral head is the preferred access site for adults
Severe illness/injury and at risk for cardiac arrest
, Syringe bolus as needed (Adult 20 ml/Pedi 10 ml)
Contraindications:
, If conscious explain the need for the procedure
—>
Available peripheral access
—>
Hemodynamic stability
—>
Fractured extremity (consider alternate site)
—>
Excess tissue/swelling/edema at insertion site
—>
Infection at insertion site (consider alternate site)
—>
Known bleeding disorder
•
Locate appropriate insertion site
1. Humeral Head (Adults)
2. Proximal Tibia
•
Prepare insertion site
Aseptic technique
•
Prepare needle/driver assembly
1'
I
F r
• M • 1
�
�
LL
-- r
Humeral Insertion:
Tibial Insertion:
•
Aim the needle tip laterally into the deltoid at a 45'
• Aim the needle 90' into the medial (flat) surface of
angle toward the patient's feet
the tibia
•
Gradually drill the needle into the arm until the hub
• Gradually drill the needle into the tibia until the hub
is flat against the skin (adjust depth as needed for
is flat against the skin
flow)
(adjust depth as needed for flow)
•
Verify patency:
Syringe bolus 10-20 ml (aspiration of marrow is not recommended)
Use pressure infuser/IV pump to maintain flow
•
Dress the site
Protect from trauma/dislodgment
•
Apply wristband
•
Administer 2% Lidocaine prior to infusion
40 mg slow IO bolus (Adult)
0.5 mg/kg slow IO bolus (Pedi)
Needle size Guide
Pink
Blue
Yellow
15 mm
25 mm
45mm
7-90 lbs
>_ 90 lbs
>_ 90 lbs with excess tissue;
all adult humeral insertions
Intravenous & Central Line Access
Indications:
Need or potential need for
Fluids
Medications
Invasive line Access
, Cardiac arrest
Hemodynamic instability
Currently accessed
Peripheral access (extremity or truncal)
• Apply band tourniquet to extremity
• Identify suitable venipuncture site
Straight vein segment
Intact, healthy skin
• Select an appropriate size angiocatheter
Adult:
Hemodynamic instability, continuous infusions
18 g or larger
Medication administration only
20 g max preferred
Pediatric:
Hemodynamic instability, continuous infusions
18gmax
Medication administration only
22 g max preferred
• Use aseptic technique to clean site
• Apply traction to skin above intended puncture site
• Insert angiocatheter into the vessel
Decrease angle of insertion on noting "flash" of
blood
Advance needle/angiocatheter slightly
• Retract/lock the needle
• Attach line/lock
Flush line/administer fluids
Pearls & Pitfalls:
Utilize other methods after 2 peripheral attempts if
hemodynamically unstable
External Jugular Access
EZ-IO device
Invasive line access
Contact OLMC for access of hemodialysis catheters
External Jugular Vein Access
• Lay patient with head dependent if possible
(raise legs if unable to make head lower than torso)
• Identify the external jugular vein
Examine both sides of the neck
Use flat, straight vein segment
• Select venipuncture site highest point above clavicle
possible
• Select appropriate size angiocatheter
Adult:
18 g or larger
Pediatric:
20 max preferred
• Use aseptic technique to clean site
• Apply traction to skin above intended puncture site
• Insert angiocatheter into the vessel
Decrease angle of insertion on noting "flash" of
blood
Advance needle/angiocatheter slightly
• Retract/lock the needle
• Attach line/lock
Flush line/administer fluids
Peripherally Inserted Central Catheter (PICC) Access
• Select the largest lumen available
• Remove cap on the end of the catheter
• Prep the end of the lumen with an alcohol swab
• Aspirate 10 ml of blood with the syringe and discard
• Flush the lumen with 10 ml normal saline using a 10 ml syringe
• Attach IV administration set and observe for free flow of fluid
• If shock is not present, allow fluid to run at rate of 10 ml/hour
to prevent the central line from clotting
Equipment:
10 ml syringe (empty), 10 ml syringe (normal
saline) and sterile gloves (if available)
Multi -Lumen Catheters
(PICCs and Boviacs can have one, two, or three
lumens)
If unable to aspirate blood
• re -clamp the lumen and attempt to use
another lumen (if present)
If clots are present
• Do not utilize
If catheter does not flush easily
• If unable to flush, clamp line attempt dif-
ferent port (if available)
PICC line will generally flush more slowly and
with greater resistance than a typical intrave-
nous catheter
Invasive Airway Preparation
Indications:
—• Insertion of any invasive airway device
Respiratory failure
Need for airway protection
Position patient:
• HOB @ 30' elevation (non -cardiac arrest)
• Ear -to -Sternal -Notch (ETSN) OR
Neutral position (if suspected trauma)
• Consider ramping shoulders for obese patients
Preoxygenate/denitrogenate (non -cardiac arrest):
• NC at flush rate AND
If adequate respirations
• Set BVM @ flush rate, form tight mask seal, and
allow spontaneous respirations to continue. Ensure
PEEP >_ 5 mmHg.
If inadequate respirations
• Perform Max BVM with assisted ventilations
Pearls and pitfalls:
—> Failure to prepare for intubation puts patients at
unnecessary risk for cardiac arrest.
—> Ensure all needed equipment is out in the airway
manager/assistants field of view to avoid unnecessary
delays in retrieving critical equipment.
Assemble Kit Dump:
Place the following items, within the field of view
• UEScope tested and verified to be recording
• Suction device & catheter
, Tested, catheter tucked under right side of HOB
• Bougie (curved)
• 2 sizes ET tubes (out of packaging, ready for use)
• 2 sizes of laryngoscope blades
(estimated size and next largest)
• 10 mL syringe
• Backup airway device (SGA)
• Tube tamer
• Cricothyrotomy kit or TTV kit (unopened, in view)
• In -line EtCO2 cannula (if not already in use)
• Evaluate airway and identify/palpate surgical cricothyrotomy anatomic landmarks
• Evaluate risk for hypotension during invasive airway management
If hypotensive see,
• Circulatory Support
If high -risk (borderline BP, tachycardia, Shock Index > 1.0)
• Prepare Push Dose Epinephrine (PDE)
If hypotension not anticipated
• Ensure PDE components (i.e., epinephrine, syringe, flush, needle) are readily available
If DSI, see Delayed Sequence Intubation
If RSA, see Rapid Sequence Airway
All clinicians are responsible for ensuring the Intubation Checklist is completed prior to DSI
Indications:
Ventricular Fibrillation
Pulseless Ventricular Tachycardia
Contraindications:
None
Manual Defibrillation
Pearls & Pitfalls:
—� Withhold defibrillation until removed from standing
water/conductive surfaces (metal)
Hands on defibrillation not recommended
Do not place defibrillator pads over implanted devices
• Begin chest compressions
• Apply defibrillator pads
• Continue chest compressions during defibrillator charging
• Count down 10 seconds from intended shock delivery (aloud)
• Inform entire resuscitation team prior to shock
• Allow no more than 3 seconds of interruption prior to, and post, defibrillation
• Immediately resume CPR 2 minutes
During uninterrupted CPR
• Charge defibrillator
• Count down 10 seconds from intended shock delivery (aloud)
• Inform entire resuscitation team prior to shock
• Choreograph team to keep peri-shock pause <_ 3 sec total
• Attempt additional shock after 2 full minutes of CPR as indicated
Double Sequential External Defibrillation (DSED) - Adult Patients Only
• Ensure one set of pads is in Anterior -Lateral (A-L) and another in Anterior -Posterior (A-P) position, and that both defibril-
lators are within reach of a single resuscitation team member.
Application of 2nd pads should be performed after a rhythm analysis and shock/no shock, and should not delay
compressions > 10 sec. Use the CPR puck only from the initial set (typically A-L position) of pads and monitor
capturing EtCO2. Ensure A-P pads do not cover the CPR puck.
IfAED (Rapid Shock) Mode Used (Basic credential level may perform)
• Maintain the "main" defibrillator in AED mode, use the 2nd
defibrillator in manual mode.
• Pre -charge manual mode defibrillator 10 seconds prior to
AED rhythm analysis
• Using a single provider deliver defibrillation sequentially (A
-L followed by A-P) with a 1 sec pause between shocks
• If "no shock advised", dump the manual monitor's charge
Anterior -Lateral
If Manual Mode Used
• Maintain both defibrillators in manual mode
• Pre -charge both defibrillators 10 seconds prior to rhythm
analysis
• Using a single provider deliver defibrillations sequentially (A
-L followed by A-P) with a 1 sec pause between shocks
• If rhythm analysis reveals a non -shockable rhythm a single
provider should dump the charge on both defibrillators
DSED
— Aw
y ��
Mechanical Compression Device (MCD)
Indications: Pearls & Pitfalls:
Adult medical cardiac arrest and any of the following: , Consider withholding MCD placement until
At least 15 min of monitored professional rescuer transport or ROSC if able to maintain quality unin-
CPR has occurred
Transport is necessary terrupted manual CPR
ROSC has been achieved and the device is being , Minimally -interrupted manual CPR is better than
pre -positioned for transport perfect CPR after an unacceptable pause (> 10 sec)
, Critical shortage of manpower prevents adequate
Pit Crew CPR
Contraindications:
Traumatic cardiac arrest w/o ROSC or transport
Application will delay CPR > 10 sec
Patient size prevents proper application
• Follow Pit Crew Procedure to ensure high quality chest compressions prior to placement
Ensure monitor/AED applied and rhythm check i defibrillation occurs prior to MCD placement
• Perform Pre -application Timeout
S: Size - determine if device will fit on patient per manufacturer recommendations
T: Turn on - ensure the device powers on and battery charge is adequate
A: Abort - voice abort procedure; ensure all providers are comfortable with procedure
R: Roles - ensure all providers understand their role in application procedure
S: Strap - abort procedure if neck strap unavailable
• Power on device, prepare, and stage all equipment near patient's head
• Position providers at patient's right and left shoulders, and above patient's head
AT THE NEXT 2 MIN RHYTHM CHECK (DO NOT DELAY CPR > 10 SEC)
• Each provider lift patient by respective shoulder
• Third provider place the back piece below the patient's back, under the armpit
• Resume manual chest compressions immediately
AT THE NEXT 2 MIN RHYTHM CHECK (DO NOT DELAY CPR > 10 SEC)
• Apply device arms to back plate and lock in place
• LUCAS - Swing arm over and clamp on both sides
• DefibTech - Clamp on both sides and insert piston
• ADJUST the piston suction cup down to the midsternum, and lock in place (Manufacturer dependent)
• Activate device using correct compression protocol (30:2) and ensure appropriate rhythm/pulse check every 2
minutes
• Apply neck and wrist straps
• Utilize marker to indicate puck and piston placement on chest
If patient's size not appropriate for MCD application
• Perform high -quality manual chest compressions
• Continue Pit Crew Procedure and other treatment as appropriate
Mechanical Ventilator Procedure (Hamilton-T 1
For patients in cardiac arrest after invasive airway placement and confirmation:
Use CPR mode after adding appropriate sex/height information
Continue to use 30:2 CPR for adults, 15:2 CPR for pediatric patients with ventilations only occurring during pauses
During pause in compressions, press and hold "lung" button for 1 second to trigger ventilation.
Use ratio of 1 second of ventilation, 2 seconds, then repeated 1 second ventilation before resuming compressions.
Confirm full breath is being given by monitoring volume graph:
If volume graph appears to be a vertical line, like an ECG pacemaker spike, the ventilate button is not being held down.
If ROSC occurs, switch patient to ASV mode.
For patients needing non-invasive ventilation:
Use NIV-ST mode after adding appropriate sex/height information
Use default settings with FiO1 100%, PEEP of 5 mmHg and Pressure Support of 15 mmHg.
• For ongoing hypoxia:
Assure FiO2 is 100976. If not, titrate up FiO2
Increase PEEP in 5 mmHg increments
Target SpO2 >94%
• For increased work of breathing or patient discomfort with NIV:
Increase Pressure Support in 2mmHg increments, titrating to comfort and work of breathing
For patients with an invasive airway in place:
Use ASV mode after adding appropriate sex/height information
• For hypoxia:
Assure FiO2 is 100%. If not, titrate up FiO2
Increase PEEP in 5 mmHg increments
Target SpO2 >94%
• For increased work of breathing or patient discomfort with ventilations:
Assure adequate sedation
Increase Pressure Support in 2mmHg increments, titrating to comfort and work of breathing
• For EtCO2 > 60 with history/suspicion of obstructive airway disease:
Increase Minute Volume from 10096 in increments of 20%
Wait at least 5 minutes in between adjustments to allow patient to adapt to new settings
For patients undergoing pre -oxygenation during DSI process:
Use Pre -Oxygenation mode (NIV-ST) after adding appropriate sex/height information
Give Ketamine per DSI protocol
Appropriately position patient in head up position and ear to sternal notch position
Apply NPAs as patient tolerates
Apply nasal cannula with flush -rate oxygen
• For ongoing hypoxia:
Assure FiO2 is 100%. If not, titrate up FiO2
Increase PEEP in 5 mmHg increments
Target maximum SpO2
After achieving physiologic goals and administering paralytic:
Monitor EtCO2 and volume graph to assure ventilator takes over ventilations from spontaneous ventilations as
paralytic takes effect and patient stops breathing
Once ready to begin intubation attempt, place ventilator in standby mode, remove mask while continuing apneic oxygena-
tion at flush rate, and begin intubation attempt.
If attempt is successful:
Attach ventilator circuit (with EtCO2 attached and connected) and place mode in ASV mode, using `last patient'
feature to carry over sex/height settings.
Titrate FiO2 down with goal SpO2 >_94%
If attempt is unsuccessful:
Place mask back on patient, return ventilator to "Pre -Oxygenation" mode and assure appropriate ventilations are
administered.
If ventilations not delivered, default to manual ventilations
Non-invasive Positive Pressure Ventilation (NIP
Indications:
Respiratory distress with resistant hypoxia
Awake, able to cooperate for device application
Ability to wear adult size mask
Contraindications:
Pending respiratory failure
Penetrating chest trauma
Suspected pneumothorax
Uncontrolled/persistent vomiting
Facial deformity (traumatic or anatomic) preventing
mask seal
CPAP-only device (e.g. Flow -Safe II EZ)
• Maximize upright sitting position
• Connect oxygen tubing nipple to oxygen source
• Seal the mask to the patient's face using headpiece
Pearls & Pitfalls:
Utilize EtCO2 monitoring, monitor for duration of
placement
Caution if patient unable to cooperate for procedure
Nausea/vomiting (retching/vomiting episodes)
Anatomic deformity (unable to create mask seal)
Risk of hemodynamic collapse
Consider multiple causes for respiratory distress
(pneumothorax/mediastinum, effusion, PE, etc.)
Monitor trends in waveform capnography, CO2 val-
ues, pulse oximetry, mental status, HR/BP
q < 5 min. reevaluation recommended for all moni-
toring/VS, document appropriately
To increase F102 when using NIPPV, consider addi-
tionally placing NC on patient as well
• Turn on oxygen source
• Secure the face mask snugly to patient's face using head harness
• Slowly increase oxygen flow to roughly 15 1pm
• Check mask fit to patient and device connections for leaks
• Adjust the flowmeter until desired pressure is obtained
BPAP (Bilevel positive airway pressure - e.g. Flow -Safe II+ BiLevel)
• Maximize upright sitting position
• Connect 02 tubing nipple to oxygen source
CPAP-Only Device Flow: -Pressure Reference
Approx. Flow Rate
Pressure
15 1pm
5 cmH2O
201pm
7.5 cmH2O
25 1pm _F
10 cmH2O
• Turn on oxygen source
• Ensure device is in Bilevel mode by rotating the green switch to the Bilevel setting
• Secure the face mask snugly to patient's face using head harness
• Slowly increase oxygen flow to 15 LPM, to achieve goal IPAP of roughly 8-10 cm H2O
• Check mask fit to patient and device connections for leaks
• Adjust EPAP knob until manometer reaches 5 cm H2O during exhalation
— Effective mask seal is required for device to shift into EPAP mode from IPAP mode
If simultaneous bronchodilatorr required
• Maximize upright sitting position
• Connect 02 tubing nipple to oxygen source.
• Seal the mask to the patient's face using headpiece
• Turn on oxygen source
• Ensure device is set in CPAP mode -Green switch is set to CPAP
• Secure the face mask snugly to patient's face using head harness
• Slowly increase oxygen flow to 6 - 8 LPM
• Check mask fit to patient and device connections for leaks
• Adjust the flowmeter until desired pressure is obtained
Flow of 12 - 14 LPM is required to reach CPAP pressure of 8.5 - 10
CPAP on CPAP/BPAP Device Flow: -Pressure
Reference
Approx. Flow Rate Pressure
10 1pm
6-7 cmH2O
15 1pm
11-12 cmH2O
BPAP on CPAP/BPAP Device Flow: -Pressure
Reference
15 1pm
8-10 cmH2O
cm H2O
Pelvic Binder
Indications:
—> Mechanism suggestive of pelvic injury and obvious signs
of pelvic injury/instability on physical exam
AND
Signs of hemorrhagic shock (e.g. SBP < 90 and/or
Shock Index >_ 1)
Contraindications:
Isolated proximal femur fracture (isolated "hip frac-
ture")
Pearls & Pitfalls:
Low energy mechanisms (e.g. falls from standing) rarely cause
unstable pelvic fractures
Do not "rock" or "spring" the pelvis. Gently compress iliac
wings to assess for instability. Palpate for tenderness at pubic
symphysis, iliac wings, sacrum/sacro-iliac joints
In reliable patients with no leg/spinal cord injury and no anal-
gesia, a painless straight leg raise test may exclude a pelvic
injury
Avoid log -rolling, use scoop stretcher or slide techniques
Consider in blunt traumatic arrest with MOI/findings of pelvic
injury
Pelvic binder device
• Remove clothing from patient's pelvic area
• Place the black side up beneath patient at the level of the greater trochanters
• Place black strap through buckle and pulls completely through
Hold orange strap and pull black strap in opposite direction until buckle click is felt and heard (approx. 35
pounds of force)
Maintain tension, immediately press black strap onto surface of the pelvic sling to secure
Areas of Palpation to
Evaluate for Pelvic
Instability/Injury
1. Iliac wings
2. Pubic symphysis
3. Sacroiliac (SI) joints
Improvised Pelvic Binder (no commercial device available)
• Remove clothing from patient's pelvic area
Place the material beneath patient with the ends out to either side at the level of the greater trochanters
Pull each end to the front of the pelvis
If using a sheet and hemostats
• Tuck one end into the opposite side and hold still against force being applied to the other side
• Pull against the sheet on the untucked end with 150 Newtons of force (approximately 35 pounds)
• Maintain tension, secure in place with hemostats at the upper and lower edge of the sheet (ideally at least 2 at
each edge for best securement)
If using a sheet only
• Cross ends over the anterior pelvis gripping the side of the sheet that came from the side you are on
• Mirror this action on both sides
• Pull against your assistant until there is a combined force of 150 Newtons (approximately 35 pounds)
• Maintain tension, twist sheet ends an additional rotation and tuck into the portion encircling the pelvis. Add tape
for improved securement
Pericardiocentesis
Indications:
Traumatic circulatory arrest with suspected cardiac
tamponade
Precautions:
Directing too medially (toward sternum) or too
steep (>45 °) carries a risk of right atrial or intra-
abdominal puncture/injury.
If multiple syringes of blood are removed, check
position as overpenetration into atrial/ventricle may
have occurred.
• Prepare equipment and appropriate PPE
Antiseptic swab
20-mL syringe
18-gauge spinal needle (remove and discard stylet, attach needle to syringe)
• Place on continuous ECG prior to procedure, if time allows
• Position the patient supine
• Expose and locate landmarks (xiphoid process and costal arch)
• Prepare site with antiseptic swab
• Insert needle 1 cm inferior to junction between left costal arch and xiphoid process
• Angle the needle between 15-30°, aimed toward the left shoulder
• Slowly advance needle while continuously aspirating/withdrawing plunger withdrawal stop once fluid aspirated
• Withdraw needle and redirect angle if no fluid aspirated
• Evacuate pericardium until resistance is met or pulses return
• Monitor for signs of tamponade recurrence, repeat procedure x 1 PRN
• Contact OLMC if > 2 pericardiocentesis required
Sternum
,iphoid
rocess
Costal
Arch
............
98
Phvsical Restraint
Indications:
Behavioral health emergency and/or agitation AND all
other calming attempts have failed, which include at a
minimum verbal de-escalation techniques.
Contraindications:
Inadequate personnel to perform restraint process
(including law enforcement)
—> Use of EMS restraints for law enforcement detainment or
arrest purposes only and no medical condition present
Exception:
—> The procedure below does not apply to patients who are
in custody/under arrest and are not experiencing a behav-
ioral health emergency and/or agitation that would re-
quire EMS restraints or sedation. However, precautions
regarding patient positioning and law enforcement officer
presence apply to all patients in rigid restraints.
Procedure:
• Attempt less restrictive means of managing the patient.
Pearls & Pitfalls:
Rigid restraints (e.g. handcuffs, flex cuffs) should generally
be transitioned to commercial restraint devices for com-
bative patients. In the rare situations this cannot be per-
formed, the following requirements will be adhered to:
—> Handcuffs should be double locked (prevents unin-
tended tightening)
Patient shall not he or recline on handcuffs
—> The law enforcement officer must accompany the
patient to the hospital in the transporting EMS
vehicle or be immediately available.
—> Documentation should include:
Efforts attempted prior to use of restraints
Reason for use of restraints
—> Type and position of restraints used
-� Time restraints were placed
—> Continuous monitoring
> Neurovascular checks
—> Patients shall never be restrained or be allowed to
position themselves in the prone position, or in a
position that compromises the airway or constricts the
neck or chest.
—> Do NOT use:
—> Hobble/hogtie (hands and feet tied behind back)
positioning
Devices such as backboards, splints, or other devic-
es placed on top of the patient
Non-commercial restraint devices (e.g. triangular
bandages, bandage rolls)
• Request EMS Supervisor and law enforcement assistance.
• Ensure sufficient personnel available to physically restrain the patient safely.
• Restrain the patient using commercial restraint devices
• Place in a lateral or supine position.
• Restrain the extremities at the wrists and ankles.
• Ensure stretcher straps across the chest allow for adequate chest excursion.
• Elevated the head of the stretcher to 30-degrees or more, if possible.
• Administer oxygen, regardless of SpO2
• Maintain constant observation by a Assist or Advanced provider, which includes:
• Direct visualization of the patient
• Frequent blood pressure and continuous ECG, pulse oximetry and EtCO2 monitoring
• Perform neurovascular checks (pulse, motor, sensation) of the restrained extremities q15-minutes, with first check immedi-
ately after placement.
0 Ensure adequate personnel for transport of the patient
Pit Crew (2 Responders)
COMPRESION NOTES DEFIBRILLATION: AIRWAY
—� "Hover Hands" over patient chest Witnessed Arrest— Immediately apply, ana- Rappidly lace SGA with waveform
(every compressor Q @ all rhythm checks) lyze, and shock (AED) as advised M02 (no PEEP) as soon as feasible
—� Continue Compressions during Charge Ventilate only during 30:2 pause
—> Rate: 30:2 @ 100-120 cpm Unwitnessed— 2 minutes CPR THEN analyze EtCO2 verification with first and
—= Depth: 2-2.5 in every breath
—� Pauses: < 10 sec.
—� Lean:0 �------
/ NO OBSTACLE ZONE
/ Move patient to suitable location
/ Right
/
Position 1
• Assess LOC (<_ 3 seconds)
• Begin CPR
• At compressor change, place SGA if
1•••
not already completed
1
I
I � 1
I I
1 I
1 �
1 �
1 t
1 Monitor
1 Compression monitoring
device for all manual CPR
After every 2 minutes of CPR
Position 1 &2 alternate compressor and ventilator roles
♦ Medication deferred until > 2 providers on -scene
♦ Rhythm Analysis
` "No Shock Advised" or Asystole/ "Shock Advised" or VFIB/VT
` PEA • Resume CPR
• Immediately resume CPR • Charge defib.
• Clear patient
• Deliver shock
• Immediately resume 2 min.
CPR
11116
COMPRESION NOTES
—> "Hover Hands" over patient chest
(every compressor Q @a all rhythm checks)
—> Continue Compressions during Charge
—� Rate: 30:2 (a 100-120 cpm
Depth: 2-2.5 in
—> Pauses: < 10 sec.
—> Lean:0
i
i
i
i
i
i
i
i
i
i
i
/
Pit Crew (3 Responders)
DEFIBRILLATION: AIRWAY
Witnessed Arrest— Immediately apply, ana- Immediate SGA placement
lyze, and shock (AED) as advised Do not stop CPR to place SGA
Ventilate only during 30:2 pause
Unwitnessed— 2 minutes CPR THEN analyze EtCO2 verification with first and
every breath
oo
Position 3
• Immediately place SGA ••
*Do not interrupt compressions
*Confirm EtCOZ q breath
• Ventilate with compression pause
.. ..... .....
NO OBSTACLE
ZONE
Right �
Move patient to suitable loca-
-t
\
♦
After every 2 minutes of CPR
Position 1 &2 alternate compressor role
(additional resources on -scene may rotate into Position 1 &2)
Medication as indicated per protocol
Rhythm Analysis
"No Shock Advised" or Asystole/ I "Shock Advised" or VFIB/VT
PEA • Resume CPR
• Immediately resume CPR • Charge defib.
• Clear patient
• Deliver shock
• Immediately resume 2 min.
CPR
Pit Crew (4 Responders)
DEFIBRILLATION:
Witnessed Arrest— Immediately apply, ana-
lyze, and shock (AED) as advised
Unwitnessed— 2 minutes CPR THEN analyze
AIRWAY
Immediate SGA placement
Do not stop CPR to place SGA
Ventilate only during 30:2 pause
EtCO2 verification with first and
every breath
Position 3
• Immediately place SGA
i *Do not interrupt compressions •�
♦ *Confirm EtCO, q breath
♦ • Ventilate during compression pause
NO OBSTACLE ZONE
/ Move patient to suitable location \
/ Right
/ Position 2
• Attach monitor/defib in AED mode
Position 1 Keep within arms reach and ..
VeAssess LOC (<_ 3 seconds) visible to all clinicians
n CPR • Assist osition 3
not interrupt CPR for airway airway/equipment)
• Prepare to relieve Position 1
1 �
1 /
1 /
Position 4
• ALS procedures
• Medication per Cardiac Arrest
protocol.
• Coordinates shock pause/defib.
"On 2's"
• Time keeper
/
Monitor
Compression monitoring
device for all manual CPR
40
i
i
i
Rhythm Analysis
"No Shock Advised" or Asystole/ "Shock Advised" or VFIB/VT
PEA • Resume CPR
• Immediately resume CPR • Charge defib.
• Clear patient
• Deliver shock
• Immediately resume 2 min.
CPR
After every 2 minutes of CPR
Position 1 &2 alternate compressor role
(additional resources on -scene may rotate into Position 1 &2)
Pit Crew (5 + Responders)
COMPRESION NOTES DEFIBRILLATION: AIRWAY
—� "Hover Hands" over patient chest Witnessed Arrest— Immediately apply, ana- Immediate SGA placement
(every compressor 0 @ all rhythm checks) lyze, and shock (AED) as advised Do not stop CPR to intubate/place SGA
—� Continue Compressions during Charge Ventilate only during 30:2 pause
—> Rate: 30:2 @ 100-120 cpm Unwitnessed— 2 minutes CPR THEN analyze EtCO2 verification with first and every
—= Depth: 2-2.5 in breath
—� Pauses: < 10 sec.
—� Lean: 0 ' — —
Position 3
01 1 • I d' t 1 1 SGA
A
NO OBSTACLE ZONE
.... Move patient to suitable location
Position 4 Code Assistant
• Assist Position 3 with airway
• Assist with code activities
DSED
Swapping compressors
MCD placement after 15 mins
pause
Right
Position 1
• Assess LOC (<_ 3 seconds)
• Begin CPR
• Place MCD after 15 minutes
• Do not interrupt CPR for airway
Position 6
Intervention Paramedic
• ALS procedures
• Medication per Cardiac Arrest protocol
Position 5
Code Commander
• Utilize Code Commander TAC Sheet
• Coordinate all positions
• Gather PMH and HPI
Down time
Cause of the arrest
• Coordinates shock pause/defib. "On
2's"
• Time keeping
Position 7 Family Liaison
(if available)
• Stay with family
• Keep them informed of resuscita-
tion efforts
• Set expectations
• Handle death notification if nec-
essary
Position 2
• Attach monitor/defib in AED mode
Keep within arms reach and
visible to all clinicians
• Prepare to relieve Position 1
jo Monitor manager
• Place MCD after 15 minutes
I
1
I
t
Monitor t
Compression monitoring
device for all manual CPR
i
i
After every 2 minutes of CPR
Position 1 &2 alternate compressor role
(additional resources on -scene may rotate into Position 1 &2)
Medication as indicated per protocol
Rhythm Analysis
"No Shock Advised" or Asystole/ I "Shock Advised" or VFIB/VT
PEA • Resume CPR
• Immediately resume CPR • Charge defib.
• Clear patient
• Deliver shock
• Immediately resume 2 min.
CPR
mme is e y p ace
*Do not interrupt compress
*Confirm EtCO2 q breat
• Ventilate only during compr
Spinal Motion Restriction
AMBULATORY and 1. Place cervical collar
2. Bring stretcher as close as possible
Neurologically Intact 3. Assist patient with pivoting & laying down in position
of comfort (may elevate HOB if no thoracic/lumbar
spine tenderness)
• Already self -extricated 4. Secure patient to stretcher
• Already standing
• No Thoracic or Lumbar spinal tenderness
OR .•
ALL OTHERS 1. Place cervical collar
2. Use device (KED/Vacuum Splint/Scoop stretcher/
backboard*) to move patient to stretcher
3. Move patient with as little movement as possible, main-
tain in -line stabilization
4. Secure patient SUPINE to stretcher (tape & seat belts)
DO NOT leave EXTRICATION DEVICE in place
*Backboards and Scoop Stretchers are patient movement devices ONLY. DO NOT LEAVE IN PLACE FOR TRANSPORT
Suction
Indications:
Pearls & Pitfalls:
—> Oral/nasal secretions and/or vomitus unable to be
—> Avoid prolonged suction intervals, oxygenate if
cleared by the patient themselves associated with any
possible between attempts at clearing the airway
condition
—> Avoid contaminating deep suction catheters
> Meconium aspiration of non -vigorous neonate
Rinse catheter often
Avoid inducing vomiting with oral suction, especially
(respiratory distress/persistent cyanosis)
for patients who are partially alert
—> Utilize commercial bite block or suction catheter
between the molars when inserting hands in patient's
mouth
Nasal Suction (French catheter)
• Insert catheter (same technique as for nasal trumpet insertion)
Stop insertion at depth of suspected location of blood/secretions/vomitus
• Apply suction
• Apply suction and spin the catheter while withdrawing
(Slow removal when a pool of liquid is encountered until cleared) �.
Suction Devices
Perfusing
CPR in progress
(no CPR in progress):
(or unable to roll patient):
• Drain patient mouth
• Open the patient's mouth
Roll patient to side (maintain in -line cervical sta-
Scissor technique (thumb and index finger)
bilization PRN)
0 Pinch/remove large or obvious foreign matter with
Remove large or obvious foreign matter with
gloved hand
gloved hand
• Suction mouth and pharynx on removal
• Sweep or scoop bulk material if visible in mouth
• Suction mouth and pharynx on removal
Tracheal Suction (ETT and Tracheostomy)
• Measure catheter from stoma/adapterto two fingers past sternal notch
• Insert catheter to premeasured depth
• Apply suction and withdraw in a spiral/spinning motion
Supraglottic Airway - Air-Q3
Indications:
First -line for adult and pediatric cardiac arrest
Respiratory failure
Need to protect airway
Contraindications:
Known laryngectomy
Indications for Removal:
> Inability to confirm ventilation in <_ 5 -breaths with
waveform EtCOZ
> Significant gastric contents, secretions, or vomitus in
the ventilation port, with absent EtCO, waveform
Definition of an Attempt
Insertion of a supraglottic airway into the mouth
Pearls & Pitfalls:
Most patients not in cardiac arrest should have
RSA performed with ketamine +/- paralytic. In
patients without gag and who are severely ob-
tunded, RSA medications may be deferred.
Assist/Advanced providers may opt to use the device
as a primary airway.
Endotracheal tube placement through Air-Q3 is
prohibited
Make best attempt at achieving SP02 >_ 94% prior
to insertion (non -cardiac arrest)
SIZE GUIDE
Ideal Body Weight
Air-Q3
Max Gastric
(IBW)
Size
0
Tube Size
<2kg
5Fr
2-4kg
0.5
6Fr
imilI
7-17kg
1.5
8Fr
17-30kg
2
10Fr
30-60kg
3
14Fr
_ g
• Place patient in ear -to -sternal notch or neutral head position
• Suction airway as needed
• Lubricate external surface of device including the mask and ridges
• Consider pre -loading gastric tube into appropriate channel in device
• Open mouth and elevate the tongue (using mandibular lift)
• Place the front portion of the Air-Q3 mask between the base of the tongue and soft palate at slight angle
• Continue to insert the device into position within pharynx by gently applying inward/downward pressure
• Continue to advance until fixed resistance felt
• Confirm ventilation with 4-phase waveform EtCOZ for every breath (use subjective confirmation techniques as
appropriate)
• Secure Air-Q3 using commercial tube tamer (use tape if proper tamer size unavailable)
• Place (or if pre -loaded, advance) gastric tube and connect to suction
• Continue to monitor placement with EtCO2 waveform
*AirQ3 is shorthand for the Air-Qsp3G
Surgical Airway & Transtracheal Ventilation
Indications:
—. Failure to oxygenate and ventilate
Procedure Selection:
• Surgical airway: patient greater than 35 kg body
weight or does not fit Broselow tape
• Transtracheal ventilation: patient less than 35 kg or
Broselow tape size green or smaller
Definition of an Attempt
Insertion of a needle or scalpel through the neck
Pearls & Pitfalls:
Follow Advanced Airway Preparation Procedure
Utilize aseptic technique for all invasive procedures
Continue to attempt to maintain oxygenation by
BVM during the procedure
Surgical Airway
• Position supine-45° head elevation, head extended upward/backward
• Stabilize the larynx with non -dominant hand (index finger and thumb)
• Stabilize the thyroid cartilage with the provider's non -dominant hand
Feel for the depression at the bottom border of the thyroid cartilage
Stabilize the wrist/forearm of the incising hand on top of the patient's chest
• Make a vertical incision to the skin on the midline of the trachea large enough to identify the cricothyroid mem-
brane with your finger
• Make a vertical stab incision into the cricothyroid membrane, maintain the scalpel position inside the incision
• Rotate the scalpel horizontally, and incise the cricothyroid laterally to the patients left and right side, leaving the
scalpel inside the incision
• Pass a Bougie alongside the scalpel pointing the tip toward the patient's feet feeling for hang-up to confirm tra-
cheal placement
• Slide a size 6.0 endotracheal tube over the bougie, rotating at the cricothyroid membrane if unable to pass, until
just past the tracheal cuff
• Inflate the cuff via pilot balloon
• Secure with a commercial securing device
• Ventilate and confirm ventilation using EtCO,; listen for lung sounds to rule out right main stem intubation
Transtracheal Ventilation (Pediatric ONLY)
• Position supine-45° head elevation, head extended upward/backward
• Stabilize the larynx with non -dominant hand (middle finger and thumb)
• Stabilize the thyroid cartilage with non -dominant hand (index finger)
Feel for the depression at the bottom border of the thyroid cartilage
Stabilize the wrist/forearm of the inserting hand on top of the patient's chest
• Puncture the cricothyroid membrane with a size 16-18G IV catheter, perpendicular to the trachea
• Maintain manual control of the IV catheter
• Orient the needle tip towards the patient's feet and advance the catheter until the hub is reached
• Attach the endotracheal tube connector from a size 3.0 ET tube
• Ventilate using an infant bag -valve -mask device
• Maintain manual control of the catheter until arrival at the hospital
• Attach ETCOZ and confirm presence of waveform
• Deliver breaths until chest rise is noted, allow time for complete exhalation before next breath
KIYI
Synchronized Cardioversion
Indications: Pearls & Pitfalls:
Tachycardia resulting in: Withhold defibrillation until removed from standing
—> Hemodynamic instability water/conductive surfaces (metal)
End organ dysfunction Hands on defibrillation can result in energy transfer to
Hypotension; SBP < 90 or relative JBP the provider
Contraindications: Avoid implanted devices with defibrillator pads
Unsustained/intermittent tachycardias As time allows:
Remove hair from pad
Administer sedative agent
(use caution until hypotension is corrected)
• Attach ECG monitoring electrodes (required for demand pacing)
• Adjust view to lead with most upright QRS
• Apply pads to patient's chest
Use anterior -posterior placement for pediatrics
+ + +Do not place pads over implanted devices + + +
• Activate the "SYNC" function
• Adjust the monitored lead until a marker is above each QRS
• Charge to the appropriate energy setting:
Adult
Highest energy setting available
No change (CPR or energy) for shocks from ICD
Pediatric/Infant
0.5-1.0 joules/kg initial shock
Then
2 joules/kg Shock
• Clear entire resuscitation team audibly
• Depress and hold the shock/discharge button till shock is delivered (expect delay)
• Evaluate rhythm/hemodynamic status, repeat as needed
• Treat other causes of hemodynamic instability
• Observe for signs of improved hemodynamics
• Treat other causes for poor hemodynamics
Anterior/ oster'or Pad lacem nt*
Anterior Pad
7-
J
* variations o exist, use as appropriate for
situation
KID,
Taser Removal
Indications:
Embedded Taser probes
Contraindications:
Probes located in:
Face
Eye
Neck
Nipple/areola
Genitals or perineum
Any probe in the provider's judgment requiring excessive
force to remove
Procedure:
• Ensure crew and patient safety
• Stretch skin surrounding the probe site till tight
Pearls & Pitfalls:
Risk communication with Law enforcement:
Underlying etiologies which prompted Taser use may
result in any of the following, and patient may still be at
risk for in -custody death:
Hyperactive Delirium with Severe Agitation Ar-
rhythmia/sudden cardiac arrest
Rhabdomyolyis/kidney injury -failure
If the traditional probe was used
• Pull probe out of the skin in the opposite direction that it penetrated (use firm grip ± gauze)
If the flat probe style was used
• Use the probe removal tool pulling straight out the opposite direction the probe punctured the skin (do not pry
the probe out against the skin)
Once removed successfully
• Clean and bandage puncture wound
j
• Discard probe in sharp safe container
M
109
Thoracostomy - Needle
Indications: Precautions:
Suspected tension pneumothorax with signs of poor Insertion too low can cause trauma to the liver,
ventilation/cardiac output spleen, bowel or diaphragm
Traumatic cardiac arrest with blunt or penetrating inju- Do not delay the procedure when indicated
ry to the torso
• Prepare equipment: 14 G (3-inch long) angiocatheter
• Apply monitor before if time allows; ECG, Waveform EtCO2, NIBP every 2-minutes
• Palpate the 5th-intercostal space, at the infra -mammary line (just below the nipple line)
• Insert the needle at a right angle to the chest wall, at the mid-axillary line, over the top of the lower rib
• Insert until a rush of air is heard or the hub of the needle is reached
Decompress the other side as appropriate
• Remove the needle
• Leave catheter in place and open to air
If patient in traumatic cardiac arrest:
• Consider procedure bilaterally
.'age Appropriate C'athrter Sixes.
110
Thoracostomv - Simule (Finger
Indications:
Traumatic circulatory arrest (TCA) or multiple failed
needle decompressions
Precautions:
For TCA - Perform as initial approach if CCP is
immediately available, or after an unsuccessful nee-
dle thoracostomy prior to CCP care.
Always err on placement higher (towards head) if
landmarks uncertain. Location should be near un-
derarm hair
Cupping technique for landmark identification:
Place your hand into axilla, 4th/5th webspace ap-
proximates insertion location
• Prepare equipment and appropriate PPE
Antiseptic swab
Scalpel
Curved "Kelly" hemostat
Gauze dressing
• Apply monitor before if time allows; ECG, Waveform EtCO,, NIBP q2 min
• Position supine (arrest) or if non -arrest 45 ° upright, place or secure arm on side of procedure above patient's head
• Expose and locate landmarks within triangle of safety (4th or 5th intercostal space anterior-axillary line)
• Prepare the incision site with antiseptic swab
• Make a 1-2 cm horizontal incision over superior rib border at appropriate site
• Bluntly dissect with index finger through subcutaneous tissues until intercostal muscles are reached and identify
the rib above and below
• Grip clamps with thumb and index finger 1-2 cm from the tip and while sliding OVER the rib puncture into
pleural space
• Open/spread hemostats while withdrawing them from the pleural cavity
• Insert finger into the pleural space and sweep 360' (may omit if suspected displaced rib fracture)
• Loosely cover site with non -occlusive gauze
• Reevaluate clinical status
If signs of recurrent pneumothorax
• Remove gauze and resweep pleural space
Anteriorly
Lateral edge of pectoralis major
ral edge of pectoralis major
e of the axilla Superiorly
Inferiorly Base of the axilla
8y the line at level of nJpple
ral edge of latissimus dorsi (commonly 5th intercos
i intercostal space
Laterally
Anterior edge of latissimus dorsi
ME
Tourniquet
Indications: Pearls and Pitfalls:
Extremity bleeding cannot be controlled If the joint is the 2"-3" above the bleed, place the tourniquet above the
with direct pressure joint.
Placing the tourniquet in direct contact with the skin is preferred.
Contraindications: Tourniquets can be placed over clothes but avoid placement over pockets
• Wound over joint containing any items.
• Junctional wounds Caution to find the most proximal wound(s) on the extremity and place
the tourniquet above, if in doubt place as high on the extremity as possi-
ble
—> Do not wait for hemodynamic instability to apply a tourniquet
Damage to the limb is unlikely if removed within several hours �•
• Place commercial tourniquet 2"-3"inches above the wound or as high as possible
• Tighten until hemorrhage stops and distal pulses are no longer palpable
• If initial tourniquet fails ensure tightness and placement of first tourniquet and consider placing second tourniquet more
proximal or if no room below and as close to the first one as possible.
• Document time of tourniquet application
• Do not cover tourniquet
• Dress wounds and consider hemostatic agent or wound packing
• Reassess for bleeding frequently
• Consider pain management
• Do not remove or loosen once hemostasis achieved
Tracheostomy Replacement Procedures
Indications: Pearls & Pitfalls:
BVM Utilize PPE for all tracheostomy care
Respiratory failure (acute or chronic) Positioning is critical, tracheostomies are initially
Cardiac arrest
Suspected airway obstruction placed in hyperextended neck positioning
For exchange/replacement
Failure of 3'Cs of troubleshooting to establish tracheostomy
patency
Complete tracheostomy dislodgement
Massive tracheostomy hemorrhage and uncuffed tracheostomy
Contraindications for exchange/replacement:
--* Fresh Tracheostomy (<7 days)
BVM Ventilation
• If tracheostomy patent:
• Assisted Ventilation/BVM Procedure
• Position airway in slight extension
• If bagging via face
• Perform Max BVM
• Gently occlude tracheostomy stoma to prevent air
leak
If using bougie, trim/cut off coude (hooked) tip
Decision to replace/exchange should weigh risks/
benefits (age of tracheostomy, anticipated difficulty)
Fresh tracheostomies have significant risk of false -tract
creation with reinsertion attempts
If bagging via stoma (tracheostomy removed and failure of venti-
lation or laryngectomy)
• Use pediatric mask (ideally circle) and adult sized reser-
voir/bag
• Apply mask over the trach stoma
• May need to hold mouth/nose closed to prevent air
leak from upper airway
• Squeeze bag (confirm 4-phase EtCO2)
Tracheostomy Replacement/Exchange
• Preoxygenate to SpO2 >_ 94% if possible
• Position the patient supine with neck hyperextended, consider padding under shoulders
If no device in -situ
• Maintain sterility of equipment as possible
If replacement tracheostomy available
• Remove inner cannula if present and insert tracheostomy obturator
• If cuffed tracheostomy, assess integrity of cuff
• Lubricate tracheostomy
• Consider "preloading" tie or securing device to one side of tracheostomy
• Gently insert tracheostomy initially at a 90-degree angle and then slowly rotate back to a neutral position and curve
downward into the trachea in a sweeping motion
• Mild resistance as balloon passes through stoma may occur
If resistance, consider
• Repositioning and inspection of tracheostomy
• Smaller sized tracheostomy (back-up trach)
• Do not advance tracheostomy and discontinue if marked resistance.
• Insert trach gently until seated level with skin
• Inflate cuff with 10 mL (or manufacturer recommended volume)
• Remove obturator and replace inner cannula (if present and required)
If replacement tracheostomy unavailable
• Utilize 6.0 ETT or size appropriate for patient and lubricate tube
• Insert until thick black line just deep to the skin
• Inflate cuff with l Occ of air and gently withdraw the bougie
• Secure device and verify placement with EtCO2 and bilateral breath sounds
If tracheostomy is in -situ to facilitate exchange
• Prepare equipment tracheostomy or ETT as above
• No obturator required
• Insert bougie through original tracheostomy, do not insert fully
• While maintaining bougie remove original trach
• Insert new device over Bougie
• Inflate cuff, as appropriate
Traction Splint (Sager)
Indications:
Mid -shaft femur fracture
Contraindications:
• Injuries close to the knee or involving the knee itself
• Hip or pelvic injuries
• Lower leg or ankle injuries
• Partial amputation or avulsion with bone separation
while only marginal tissue connects the distal limb •.
• After exposing the injured area, check the patient's pulse and motor and sensory function. Adjusts the thigh strap
so that it lies anteriorly when secured
• Estimate the proper length of the splint by placing it next to the injured limb
• Fits the ankle pads to the ankle
• Places the splint at the inner thigh, apply the thigh strap at the upper thigh, secure snugly
• Tighten the ankle harness just above the malleoli. Snug the cable ring against the bottom of the foot
• Extend the splint's inner shaft to apply traction at about 10% of body weight
• Secures the splint with elasticized cravats
• Checks pulse, motor, and sensory functions.
Pliart-i-iac.<)1�C'1�
Acetaminophen
Analgesic/Antipyretic
Indications: I Contraindications: I
Acute Pain Management
Fever
Protocol, Dosage, and Administration
Acute Pain Management,
Adult: 1 g PO
Pedi: 15 mg/kg PO (Max dose 1 g)
Adult: 15mg/kg IV (Max dose 1 g)
Pedi > 2 years of age: Same as Adult
Fever, >_ 100.4
Adult: 1 g PO
Pedi: 15 mg/kg PO (Max dose 1 g)
Adult: 15mg/kg IV (Max dose 1 g)
Pedi > 2 years of age: Same as Adult
Active and severe hepatic disease
Severe hepatic impairment
Hypersensitivity to acetaminophen
10It
Adenosine
Endogenous Nucleoside
Indications: Contraindications:
Conversion of SVTTAT to sinus rhythm , Irregular wide complex tachycardia
Identification of supraventricular rhythms (SVT:PAT vs. A. Flutter) Second or third degree block
Hypersensitivity to adenosine
Protocol, Dosage, and Administration
Tachvcardias: Stable, Regular, Narrow Complex
Adult: 12 mg rapid IV/IO
Repeat PRN,18 mg x 1
Pedi: 0.1 mg/kg rapid IV/IO
Repeat PRN 0.2 mg/kg (max 12 mg) x 1
117
Sympathomimetic, bronchodilator, beta-2 agonist
Indications: Contraindications:
Treatment of bronchospasm , Hypersensitivity to albuterol
Wheezing
Protocol, Dosage, and Administration
Allergic Reaction Anavhvlaxis: Wheezing/Bronchospasm
Adult: 2.5 mg with 0.5 mg ipratropium in 3 mL NS nebulized
Repeat PRN x 2
Pedi: Same as Adult
RestUiratory Sunvort: Asthma, COPD, Wheezing, Reactive Airway Disease
Adult: 2.5 mg with 0.5 mg ipratropium in 3 mL NS nebulized
Repeat PRN x 2
If persistent wheezing/respiratory distress after 3 albuterol/ipratropium doses
7.5 mg in 9 mL NS (continuously nebulized)
Pedi: Same as Adult
Amiodarone
Antidysrhythmic
Indications: Contraindications:
Suppression of VF/pulseless VT refractory to defibrillation , Medication induced ventricular dysrhythmias
Suppression of stable VT , Second or third-degree block
Hypotension
Bradycardia
Torsades de Points
Narrow Complex (QRS < 0.12 sec)
—• Hypersensitivity to amiodarone
Protocol, Dosage, and Administration
Preparation:
Bolus: 150 mg in 100 mL of NS
Cardiac Arrest: VF
Adult: 300 mg IV/IO push after second defibrillation
If persistent or recurrent VI NT 150 mg IV/IO x 1
Pedi: 5 mg/kg IV/IO (max 300 mg) after second defibrillation
If persistent or recurrent VI NT Repeat PRN x 2 q 4-minutes
Tachycardias: Stable Wide Ventricular Tachycardia
Adult: 150 mg IV/IO bolus over 10 min (600 mL/hr)
Repeat PRN x 1
Pedi: 5 mg/kg IV/IO (max 150 mg) bolus over 10 min
Tachycardia - Pedi
Kg:
Volume (mL) to infuse
over 10 min:
2.5
8
5
17
10
33
15
50
20
67
25
83
30
100
35
100
119
Anti-inflammatory, platelet inhibitor
Indications: Contraindications:
Chest pain or anginal equivalents suggestive of ACS —> Gastrointestinal bleeding
—> Hypersensitivity to NSAIDs
Protocol, Dosage, and Administration
Acute Coronary Svndrome/STEMI
Adult: 324 mg PO chewed
Pedi: N/A
120
Indications:
Hemodynamically unstable bradycardia
Organophosphate poisoning
Nerve agent antidote
Protocol, Dosage, and Administration
Svmt:)tomatic Bradvcardia
Adult: 1 mg IV/IO
Repeat PRN to max dose 3 mg
Contraindications:
Tachycardia
Hypovolemic shock
Hypersensitivity to atropine
Pedi: 0.02 mg/kg IV/IO (minimum dose 0.1 mg and max single dose 1 mg)
Repeat PRN x 1
Toxicolo--v: Organophosphate poisoning
Adult: 2 mg IV/IM/IO
Repeat PRN 2 mg q 3 minutes until signs of significant atropinization
Pedi: 0.02 mg/kg IV/IM/IO (max single dose 2 mg)
Repeat PRN until signs of atropinization
121
Buprenorphine
Opioid partial agonist
Indications: Contraindications:
Detoxification from opioids
Maintenance therapy for opiate use disorder
Protocol, Dosage, and Administration
Known or suspected GI obstruction
Respiratory depression
Acute alcohol or benzodiazepine intoxication
Adrenal insufficiency
Hepatic insufficiency
Pregnancy
Severe hypersensitivity
Opiate Use Disorder
Adult; 8 - 24 mg buccal (SL strips or tabs) per physician order
repeat 8 - 16 mg (max 32 mg) q 15 minutes PRN x 1 COWS score >8 or symptoms not resolved
Pedi: N/A
122
Calcium Chloride
Parenteral Mineral
Indications: Contraindications:
Calcium channel blocker overdose , Suspected digitalis toxicity
Hyperkalemia
Protocol, Dosage, and Administration
Cardiac Arrest: Hyperkalemia, Calcium Channel Blockers
Adult: 1 g IV/IO slow push
Pedi: 20 mg / kg (0.2 mL/kg) IV/10, slow push (max dose 1 g)
SvmUtolnat�ic B_rVictrdia: Hyperkalemia, Calcium Channel Blocker Overdose
Adult: 1 g IV/ O s ow push
Pedi: 20 mg / kg (0.2 mL/kg) IV/IO, slow push (max dose 1 g)
Toxicolo-y: Calcium Channel Blocker Overdose
Adult: 1g IV/IO slow push
Pedi: 20 mg / kg (0.2 mL/kg) IV/IO, slow push (max dose 1 g)
Entr a /Crush((Trauma�* Rhabdomvolvsis: Hyperkalemia
�uT g IV/IO slow push
Pedi: 20 mg / kg (0.2 mL/kg) IV/IO, slow push (max dose 1 g)
123
Dexamethasone
Adrenal Glucocorticoid
Indications: Contraindications:
Asthma
Wheezing
Pediatric anaphylaxis
Barking cough/stridor
Protocol, Dosage, and Administration
Allergic Reaction/Ananhvlaxis
Adult: 10 mg IV/IM
Pedi: 0.6 mg/kg (max dose 10 mg) IM/IV/PO
Circulatory Sunnort: Addison Disease / Adrenal Insufficiency
Adult: 10 mg IV/IM
Pedi: 0.6 mg/kg (max dose 10 mg) IM/IV/PO
Resniratory Sunnort: Asthma/COPD/Wheezing/Croup
Adult: 10 mg IV/IM
Pedi: 0.6 mg/kg (max dose 10 mg) IM/IV/PO
Advanced glaucoma
Systemic fungal infection
Hypersensitivity to dexamethasone
124
Carbohydrate, Altered mental status
Indications: Contraindications:
Hypoglycemia
Altered mental status
Protocol, Dosage, and Administration
Diabetic Emergencies
Adult: 100 mL IV/IO bolus
Repeat PRN up to 50 g (500 mL)
Pedi: 5 mL/kg IV/IO bolus
Repeat PRN up to 25 g (250 mL)
OB/GYN - Newly Born: Blood Glucose < 50 mg/dL
Newborn: 2 mL/kg IV/IO bolus
125
Indications: Contraindications:
Control of rapid ventricular rates caused by atrial fibrilla- Hypotension
tion or atrial flutter during interfacility transports or by Second or third-degree block
order from Hospital at Home (HaH) Physician
Wide complex tachycardia
Cardiogenic shock
Protocol, Dosage, and Administration
Tachvcardias: Stable, Narrow Complex, Regular or Irregular
Adult: 0.25 mg/kg IV/IO, slow push
Repeat PRN x 1
Pedi: N/A
126
Diphenhydramine
Antihistamine, Anticholinergic
Indications: Contraindications:
Allergic reaction
Anaphylaxis
Acute dystonic reactions
Protocol, Dosage, and Administration
Allergic Reaction/Anat)hvlaxis:
Adult: 25-50 mg PO
Pedi: PO N/A
Adult: 50 mg IV/IM/IO
Pedi: 1 mg/kg IV/IM/IO (max dose 50 mg)
Toxicolo--v: Dystonia reaction
Adult: 50 mg IV/IM/IO
Pedi: 1 mg/kg IV/IM/IO (max dose 50 mg)
Hypersensitivity to diphenhydramine
127
Dopamine Antagonist
Indications: Contraindications:
Behavioral Emergency/Agitation
Refractory Nausea/Vomiting
Cannabinoid Hyperemesis Syndrome
Atraumatic Headache
Protocol, Dosage, and Administration
Unconsciousness
Parkinson's Disease
Hypersensitivity to Droperidol
Behavioral Emergencies/Agitation: RASS 2 + to 3 + (Moderate Agitation)
Adult: 5 mg IV/IO/IM
Repeat PRN 2.5 mg q 10-minutes xl
Pedi: Contact OLMC 0.05 mg/kg IV/IO/IM
Behavioral Emergencies/Agitation: RASS 3+ to 4+ (Severe Agitation) / RASS 4+ (Violent Agitation with Delirium)
Adult: 10 mg IM
Repeat PRN 5 mg q 10-minutes xl
**For patients >_65 years old: Decrease to half the original dose for dosages >_ 5 mg**
Pedi: Contact OLMC 0.1 mg/kg IV/IO/IM
Repeat PRN 0.05 mg/kg q 10-minutes xl
Nausea and Vomiting: Despite odansetron, or gastroparesis / cyclical vomiting syndrome
Adult: 1.25 mg IM or Slow IV/IO
Repeat PRN 0.625 mg q 10-minutes xl
Pedi: N/A
Atraumatic Headache
Adult: 1.25 mg IM/slow IV/IO
Repeat PRN 0.625 mg q 10-minutes xl
Pedi: N/A
128
Epinephrine
Indications
Cardiac arrest
Anaphylaxis
Shock/hypotension
Severe allergic reaction
Asthma
Symptomatic Bradycardia
Protocol, Dosage, and Administration
Preparation:
Push Dose Epi (PDE): 1 mL 1:10,000 / 9 mL NS Flus
(Solution = 10 mcg/mL)
Infusion: 1 mg (10 mL) 1:10,000 / 250 mL NS
1 mg (1 mL) 1:1,000 / 250 mL NS
(Solution = 4 mcg/mL)
CA Push: 1 mg (1 mL) 1:1,000 / 9 mL NS
(When 1 mg 1:10,000 not available)
CA Infusion: 2 mg (20 mL) 1:10,000 / 250 mL NS
Allergic Reaction/Anaphylaxis: Severe Signs/Symptoms
Adult: 0.5 mg (1:1,000) IM
Repeat PRN q 5 min x2
Pedi: 0.01 mg/kg (1:1,000) IM (max dose 0.5 mg)
Repeat PRN q 5-10 min x2
Allergic Reaction/Anaphylaxis: Signs of Anaphylaxis/Shock
Adult: PDE 10 mcg (1 mL)
Repeat PRN q 5 min,
(max total dose 50 mcg or 5 mL)
Pedi: PDE 1 mcg/kg (max dose 10 mcg)
Repeat PRN q 5 min,
(max total dose 50 mcg or 5 mL)
Adult: Epi Infusion 5 mcg/min
Titrate to MAP > 65
Pedi: Epi Infusion 0.1 mcg/kg/min
Titrate by 0.1 mcg/kg/min q 2 min to age
appropriate goals
Cardiac Arrest: All Initial Rhythms
Adult: 1 mg (1:10,000) IV/IO x 1
Pedi: 0.01 mg/kg (1:10,000) IV/IO
Repeat q 5 minutes x 2
Cardiac Arrest: Initial non -Shockable Rhythm
Adult: Infusion 67 mcg/min or 540 mL/hr
Pedi: Infusion N/A
Sympathomimetic
Contraindications:
Hypertension
Hypothermia
Trauma (push -dose only)
Circulatory Support
Adult: PDE 10 mcg (1 mL)
Repeat PRN q 5 min, (max total dose 50 mcg or 5 mL)
Pedi: PDE 1 mcg/kg (max dose 10 mcg)
Repeat PRN q 5 min, (max total dose 50 mcg or 5 mL)
Adult: Epi Infusion 5 mcg/min
Titrate to MAP > 65
Pedi: Epi Infusion 0.1 mcg/kg/min
Titrate by 0.1 mcg/kg/min q 2 min to age
appropriate goals
Respiratory Support: Asthma only with impending failure
Adult: 0.5 mg (1:1,000) IM
Repeat PRN q 5 min xl
Pedi: 0.01 mg/kg (1:1,000) IM (max dose 0.5 mg)
Repeat PRN q 5 min xl
Symptomatic Bradycardia
Adult: N/A
Pedi: 0.01 mg/kg IV/IO (max dose 0.1 mg) xl
Symptomatic Bradycardia: Beta Blocker Overdose
Adult: Epi Infusion 5 mcg/min
Titrate to MAP > 65
Pedi: Epi Infusion 0.1 mcg/kg/min
Titrate by 0.1 mcg/kg/min q 2 min to age
appropriate goals
Toxicology: Beta Blocker Overdose
Adult: Epi Infusion 5 mcg/min
Titrate to MAP > 65
Pedi: Epi Infusion 0.1 mcg/kg/min
Titrate by 0.1 mcg/kg/min q 2 min to age
appropriate goals
129
Esmolol (Adult)
Beta Blocker
Indications: I Contraindications:
Cardiac arrest
Protocol, Dosage, and Administration
Preparation•
Bolus - push
Infusion - premixed 2,500 mg / 250 mL (10 mg / mL)
Cardiac Arrest: VF/V I"
Adult: 0.5 mg / kg IV/IO bolus (50 mg max) then
Hypertension
Infusion 0.05 mg / kg / min (5 mg/min max)
Pedi: N/A
Analgesic, Opioid
Indications: Contraindications:
Pain
Protocol, Dosage, and Administration
—� Intolerance / Hypersensitivity
Respiratory depression
Hemodynamic instability (relative)
—> Active labor (relative)
Acute Pain Management
Adult: 1 mcg/kg IV/IN/IM (max single dose 100 mcg)
Repeat PRN, titrate to pain relief and respiratory/hemodynamic status
Pedi: Same as Adult
131
Glucagon
Antihypoglycemic, Pancreatic hormone, Insulin antagonist
Indications: Contraindications:
Hypoglycemia --+ Hyperglycemia
Beta-blocker overdose
Insulinoma
Hypersensitivity to glucagon
Protocol, Dosage, and Administration
Cardiac Arrest: Beta-blocker overdose
Adult: 1 mg IV/IO slow push over 1 min
Repeat PRN 1 mg IV/IO x 1
Pedi: 0.1 mg/kg IV/IO slow push over 1 min (max single dose 1 mg)
Repeat PRN 0.2 mg/kg IV/IO x 1 (max single dose 1 mg)
Diabetic Emereencies
Adult: 1 mg IM
Pedi: 0.1 mg/kg IM (max dose 1 mg)
Svmt)tomatic Bradvcardia: Beta-blocker overdose
Adult: 1 mg IV/IO slow push over 1 min
Repeat PRN 1 mg IV/IO x 1
Pedi: 0.1 mg/kg IV/IO slow push over 1 min (max single dose 1 mg)
Repeat PRN 0.2 mg/kg IV/IO x 1 (max single dose 1 mg)
Toxicology: Beta-blocker overdose
Adult: 1 mg IV/IO slow push over 1 min
Repeat PRN 1 mg IV/10 x 1
Pedi: 0.1 mg/kg IV/IO slow push over 1 min (max single dose 1 mg)
Repeat PRN 0.2 mg/kg IV/IO x 1 (max single dose 1 mg)
132
Antihypoglycemic
Indications: Contraindications:
Conscious patient with suspected hypoglycemia , Decreased level of consciousness
Unable to swallow/maintain own airway
Nausea and vomiting
Protocol, Dosage, and Administration
Diabetic Emergencies
Adult: 15 g buccal
Pedi: 7.5 g buccal
133
Dopamine Antagonist
Indications: Contraindications:
Behavioral Emergency/Agitation
Refractory Nausea/Vomiting
Psychiatric Disease
Protocol, Dosage, and Administration
Unconsciousness
Parkinson's Disease
Hypersensitivity to Haloperidol
Behavioral Emer—aencies/Agitation: RASS 2+ to 3+ (Moderate Agitation)
Adult: 5 mg IV/IO/IM
Repeat PRN 2.5 mg q 10-minutes xl
Pedi: Contact OLMC 0.05 mg/kg IV/IO/IM
Behavioral Emer--encies/A--itation: RASS 3+ to 4+ (Severe Agitation) / RASS 4+ (Violent Agitation with Delirium)
Adult: 10 mg IM
Repeat PRN 5 mg q 10-minutes xl
"For patients >_ 65 years old: Decrease to half the original dose for dosages >_ 5 mg*
Pedi: Contact OLMC 0.1 mg/kg IV/IO/IM
Repeat PRN 0.05 mg/kg q 10-minutes xl
Nausea and Vomiting: Despite odansetron, or gastroparesis / cyclical vomiting syndrome
Adult: 1.25 mg IM or Slow IV/IO
Repeat PRN 0.625 mg q 10-minutes xl
Pedi: N/A
134
Hydroxocobalamin
Indications: Contraindications:
Suspected cyanide poisoning None
Protocol, Dosage, and Administration
Preparation
Bolus infusion: 5 g / 200 mL NS (25 mg/mL)
ToxicoloLv:
Adult: 5 g IV/IO over 15 minutes,
Repeat PRN x 1
Pedi: 70 mg/kg IV/10 over 15 minutes,
Repeat PRN x 1;
Contact OLMC following initial dose
Toxicology - Pedi
Volume (mL) to infuse
Kg: over 15 min:
2.5 7
5 14
10 28
15 42
20 56
25 70
30 84
35 98
135
Ibuprofen
Nonsteroidal Anti-inflammatory Drug
Indications: Contraindications:
Pain , Intolerance / Hypersensitivity
Active peptic ulcer disease
—� Active bleeding / bleeding disorder
Advanced chronic kidney disease with or without dialysis
Renal Transplant
Trauma
Pregnancy or breastfeeding
Protocol, Dosage, and Administration
Acute Pain Management
Adult: 600 mg PO
Pedi > 6 months: 10 mg/kg PO (mas dose 600 mg)
Fever
Adult: 600 mg PO
Pedi > 6 months: 10 mg/kg PO (mas dose 600 mg)
136
Ipratropium Bromide
Bronchodilator, Anticholinergic
Indications: Contraindications:
Asthma
COPD
Emphysema
Acute bronchospasm
Protocol, Dosage, and Administration
—� Hypersensitivity to atropine or its derivatives
Hypersensitivity to ipratropium bromide
Allergic Reaction/Anat)hvlaxis: Wheezing/Bronchospasm
Adult - Mix 0.5 mg with 2.5 mg Albuterol in 3 mL NS and nebulize
Repeat PRN x 2
Pedi - Same as Adult
Resviratory Sunnort: Asthma/COPD/Wheezing/Reactive airway disease
Adult - Mix 0.5 mg with 2.5 mg Albuterol in 3 mL NS and nebulize
Repeat PRN x 2
Pedi - Same as Adult
137
Isopropyl Alcohol (inhaled)
Indications: Contraindications:
Nausea and vomiting
Protocol, Dosage, and Administration
Nausea and Vomiting
Adult: 3-pads, Repeat PRN x I
Pedi: Same as Adult
Hypersensitivity to isopropyl alcohol
Instruct patient to hold pads 1-2 cm from nose and inhale deeply as frequently as required to achieve nausea relief.
138
Ketamine
Anesthetic Adjunct
Indications: I Contraindications:
Analgesia
Sedation for procedures or post -airway management
—> Induction agent in intubation
Protocol, Dosage, and Administration
Preparation
Push
Infusion: Adult - 200 mg / 100 mL NS
Pedi - 50 mg / 100 mL NS
Delayed Sequence Intubation (DSI)
Adult: 2 mg/kg IV/IO (max 200 mg)
Repeat PRN x 1
Pedi: N/A
Rapid Sequence Airway (RSA)
Adult: 2 mg/kg IV/IO (max 200 mg)
Repeat PRN x 1
Pedi: Same as Adult
Hypersensitivity to ketamine
Post -Invasive Airway Management: Immediately after invasive airway secured or 15 min after rocuronium given or RASS goal
Adult: 2 mg/kg IV/IO
Repeat PRN q 15 min or more frequently to maintain RASS goal of -5
Pedi: Same as Adult
Post -Invasive Airway Management: Infusion if RASS goal not met or signs of awakening, movement, or discomfort
Adult: 1 mg/min, titrate by 1 mg/min to goal RASS
Pedi: 10 mcg/kg/min, titrate by 5 mcg/kg/min to maintain goal RASS
Acute Pain Management: Moderate to severe acute pain
Adult: IV/IO: 0.3 mg/kg in 100 mL NS over 10 min (max single dose: 30 mg), repeat PRN q 10-min x 1
IM: 0.6 mg/kg (max single dose 50 mg), repeat PRN q 10-min x 1
Pedi: Same as Adult
Behavioral Emergencies/Agitation: Violent agitation with delirium (RASS +4)
Adult: 4 mg/kg IM (max single dose 400 mg)
Pedi:1 mg/kg IV Or 2 mg/kg IM
Cardiac Arrest: Signs/symptoms of CPR induced consciousness
Adult: 1 mg/kg IV/IO slow push (max single dose 200 mg)
Pedi: Same as Adult
Symptomatic Bradycardia: Sedation prior to/during pacing if time permits and if adequate respiration
Adult: IV/IO: 0.3 mg/kg slow push (max single dose: 30 mg), repeat PRN q 10-min x 1
IM: 0.6 mg/kg (max single dose 50 mg), repeat PRN q 10-min x 1
Pedi: Same as Adult
Tachycardia: Sedation prior to/during Cardioversion if time permits
Adult: IV/IO: 0.3 mg/kg slow push (max single dose: 30 mg), repeat PRN q 10-min x 1
IM: 0.6 mg/kg (max single dose 50 mg), repeat PRN q 10-min x 1
Pedi: Same as Adult
139
Ketorolac
Nonsteroidal Anti-inflammatory Drug
Indications: Contraindications:
Pain , Intolerance / Hypersensitivity
Active peptic ulcer disease
—� Active bleeding / bleeding disorder
Advanced chronic kidney disease with or without dialysis
Renal Transplant
Trauma
Pregnancy or breastfeeding
Protocol, Dosage, and Administration
Acute Pain Management
Adult: 15 mg IV or 30 mg IM
Pedi: 0.5 mg/kg IV/IM (max single dose 15 mg)
140
Antihypertensive, Beta Blocker
Indications: Contraindications:
—> Maternal Hypertension Hypotension
Severe hypersensitivity
Asthma
Overt cardiac failure
Severe bradycardia
Protocol, Dosage, and Administration
Pre-Eclamosia / Eclamosia: maternal HR > 60 and SBP >_ 160 or DBP >_ 110 with severe symptoms
Adult; 20mg IV over 2 minutes,
repeat 40 mg IV PRN q 10 minutes
Pedi: N/A
MIH - HaH Program
Adult: Dosing per HaH physician order
Standard dosing 200-400 mg every 12 hours
Pedi: 1-3 mg/kg/day divided every 12 hours; not to exceed 1200 mg/day
Indications: Contraindications:
—> IO access
Protocol, Dosage, and Administration
Procedure: Intraosseous (IO) Access
Adult: 40 mg slow IO bolus prior to infusion
Hypersensitivity to lidocaine
Pedi: 0.5 mg/kg slow IO bolus prior to infusion
MIH-HaH: program dosing per HaH physician order
Adults: 296 Topical Standard dosing
Apply to the affected area 3-4 times daily
Max single application dose 5g for 2% concentration, or 6 inches for 5% concentration
Pedi: Dose is based on body weight and must be determined by physician
`Y,
Magnesium Sulfate
Indications:
, Torsades de Pointes
, Asthma
—> Pre-eclampsia
—> Eclamptic seizure (peri or postpartum)
Protocol, Dosage, and Administration
Preparation:
Bolus: slow push
Infusion: 10 gin 250 mL NS
Medical Cardiac Arrest: Torsades de Pointes
Adult: 2 g IV/IO slow push
Pedi: 25-50 mg/kg (max 2 g) IV/IO slow push
Electrolyte
Contraindications:
Heart block
Renal disease
Respiratory Support: Severe Asthma/COPD/Wheezing
Adult: 2 g over 15 min (rate 200 mL/hr, total volume 50 mL)
Pedi: 40 mg/kg over 15 min (max 2 g)
PreEclampsia / Eclampsia: Suspected preeclampsia or eclamptic seizure
Adult: 6 g IV over 15 min
Follow with 2 g/hr IV infusion
Respiratory- Pedi
Kg:
Volume (mL) to in -
fuse over 10 min:
2.5
2.5
5
5
10
10
15
15
20
20
25
25
30
30
35
35
143
Midazolam
Short -acting benzodiazepine, CNS depressant
Indications: Contraindications:
Sedation —• Depressed vital signs
Sympathomimetic overdose Shock
Behavioral emergencies Hypersensitivity to midazolam
Seizures Musculoskeletal spasms
Protocol, Dosage, and Administration
Toxicology: Sympathomimetic intoxication
Adult: 2.5 - 5.0 mg Slow IV/IO
Repeat PRN q 5 minutes (max total dose 10 mg)
Pedi: 0.05 mg/kg (max dose 2.5 mg) IV,
Repeat PRN q 5 min x 1
Behavioral Emergencies/Agitation: RASS + 1
Adult - 2.5 mg IV/IO/IM/IN
Repeat PRN q 10-min x 1
Pedi - 0.05 mg/kg (max dose 2.5 mg) IV/IO/IM/IN
Repeat PRN q 10-min x 1
Behavioral Emergencies/Agitation: RASS > + 1 and non -pharmacological interventions unsuccessful
Adult - 5 mg IV/IO/IM
Repeat PRN q 10-min
Pedi - 0.1 mg/kg (max dose 5 mg) IV/IO/IM
Repeat PRN q 10-min
Seizure/Status Epilepticus: If actively seizing, or in status epilepticus
Adult: 10 mg IM/IN; or 5 mg slow IV/IO, (IM is first -line route if IV not already established)
Repeat PRN q 5 min x 2
Pedi: 0.15 mg/kg Slow IV/IO/IM (max dose 2.5 mg),
Repeat PRN q 5 -min x 1
Hyperthermia/Heat Stroke; If shivering during cooling
Adult: 2.5 mg IV/IO/IN
Pedi: 0.05 mg/kg IV/IO or 0.1 mg/kg IM/IN
Repeat PRN q 5-min x 1 (max total dose 2.5 mg)
144
Opioid antagonist
Indications: Contraindications:
Opiate overdose with CNS depression, miosis, and respira-
tory depression (all 3)
Coma of unknown origin
Protocol, Dosage, and Administration
Cardiac arrest with no evidence of opiate overdose
Use with caution in narcotic dependent patients
Use with caution in neonates of narcotic -addicted moth-
ers
Hypersensitivity to naloxone
Opiate Use Disorder: suspected opiate intoxication with respiratory and CNS depression
Adult: 2 mg IN (1 mg in each nostril)
Repeat PRN q 5-minutes x 1
0.5 mg IV/IO,
Repeat PRN q 5 min (max total dose 4 mg)
Pedi: 0.5 mg IN
Repeat PRN q 5-minutes (max total dose 2 mg)
IV/IO Same as Adult (max total dose 2 mg)
145
Antihypertensive, Calcium channel blocker
Indications: Contraindications:
Patients between 20 weeks gestation and 6 weeks post , Hypersensitivity to nifedipine
partum meeting blood pressure criteria for preeclampsia
Protocol, Dosage, and Administration
PreEclamosia / Eclampsia : SBP >_ 160 or DBP >_ 110 confirmed by correctly fitted cuff on 2 readings 5 minutes apart
Adult: 10 mg SL
Pedi: N/A
146
Nitroglycerin
Nitrate, Coronary vasodilator
Indications: Contraindications:
Acute angina
Ischemic chest pain
Congestive heart failure pulmonary edema
Protocol, Dosage, and Administration
Recent use of erectile dysfunction medications
Hypotension
Hypovolemia
Intracranial bleeding/head injury
Hypersensitivity to nitroglycerin
Acute Coronary Svndrome/STEMI
Adult: 0.4 mg SL q 5 min, titrate to SBP >_ 100 and signs/symptoms
Pedi: N/A
SCAPE
Adult: 0.4 mg SL q 5 min, titrate to goal SBP < 180
Pedi: N/A
Adult: Bolus - 1 mg Slow IV push
Pedi: N/A
Adult: Infusion - 100 mcg/min, titrate rapidly down as blood pressure drops, goal SBP < 180
Pedi: N/A
MIH - HOM Program: Angina Pectoris or Congestive Heart Failure
Adult: 2916 Topical, Dosing per H@H physician order
Standard - 1.5 inches every 4 hours (increase by 0.5-1 inch up to 4 inches)
147
Norepinephrine
Indications:
Hypotension
Protocol, Dosage, and Administration
Preparation:
Infusion: 4 mg / 250 mL NS
Sympathomimetic, Vasopressor
Contraindications:
TargetBP goals:
• TBI/Stroke: > 110 mm Hg
• Blunt Trauma: = 100 mm Hg (max 500 mL)
• Hemorrhagic Shock or Penetrating Trauma: SBP = 90 mm Hg (max 500 mL)
• Other patients:
Adult - MAP > 65 (or SBP > 90 mm Hg if manual measurement)
Pedi - SBP > 70 mm Hg + (age in years x 2) or > 90 mm Hg for age 10 or greater
Circulatory Support
Adult - 5 mcg/min, titrate to goals
Pedi - 0.1 mcg/kg/min, titrate to goals
Post ROSC
Adult - 5 mcg/min, titrate to MAP >_ 65
Pedi - 0.1 mcg/kg/min, titrate to age appropriate goals
Dial -a -Flow
Dose and Rate
*For Pump Failure Only*
mcg / min
mL / hr
2
7.5
3
11
4
15
5
19
6
22.5
7
26
8
30
9
34
10
37.5
15
56
20
75
25
94
30
112.5
`Cf:
Indications: Contraindications:
Nausea and vomiting
Protocol, Dosage, and Administration
Nausea and Vomitin--
Adult: 4 mg ODT
Repeat PRN q 10-min x 1
Pedi: 8-15 kg: 2 mg ODT
Repeat PRN q 10-min x 1
16-30 kg: Same as Adult
Nausea and Vomiting
Adult: 4 - 8 mg IM/IV
Repeat PRN q 10-min xl
Pedi: 0.15 mg/kg (max dose 4 mg) IM/IV
Hypersensitivity to ondansetron
149
Oxymetazoline (Afrin)
Indications: Contraindications:
Epistaxis --* Hypersensitivity to drug or ingredients
Protocol, Dosage, and Administration
Hemorrhage Control: if ongoing epistaxis despite direct pressure, blow nose then:
Adult: 2 squirts to affected nare(s)
Pedi: Same as adult
150
Pituitary hormone, Uterine stimulant
Indications: Contraindications:
Postpartum hemorrhage --+ Hypersensitivity to oxytocin
Protocol, Dosage, and Administration
Hemorrhage Control: if significant OB related hemorrhage following complete placental delivery
Adult: 10 units IM followed by 20 units / 1 L NS IV, run wide open
Pedi: N/A
151
Phenylephrine
Vasoconstrictor
Indications: Contraindications:
Hypotension refractory to norepinephrine , Ventricular tachycardia
Severe hypertension
—� Closed angle glaucoma
Severe hypersensitivity
Protocol, Dosage, and Administration
Preparation
Push Dose: 10 mg / 100 mL NS; 100 mcg / mL
Circulatory Support
Adult: 50 mcg (0.5 mL) q 3 minutes; titrate to target BP goals
Pedi: N/A
152
Racemic Epinephrine
Indications: Contraindications:
Moderate to severe croup Hypersensitivity to epinephrine
Protocol, Dosage, and Administration
Respiratory Support - Pediatric
Pedi: < 10 kg - 0.25 ml (1/2-ampule) mixed with 3 ml NS, nebulized
Repeat PRN x 1
> 10 kg - 0.5 ml (1-ampule) mixed with 3 ml NS, nebulized
Repeat PRN x 1
153
Non -depolarizing Neuromuscular Blocker
Indications: Contraindications:
—> Paralysis for intubation
Protocol, Dosage, and Administration
Delaved Sequence Intubation (DSI)
Adult: 1.5 mg/kg IV/IO x 1 (max 150 mg)
Pedi: N/A
Rapid Sequence Airwav (RSA)
Adult: 1.5 mg/kg IV/IO x 1 (max 150 mg)
Pedi: Same as Adult
Hypersensitivity to rocuronium
154
Sodium Bicarbonate
Indications: Contraindications:
Known or suspected acidosis
TCA overdose
Hyperkalemia
Alkalosis
Hypocalcemia
*WARNING* This medication cannot be mixed with other drugs. Flush line prior
to and after administration this drug to prevent crystallization and loss of IV access.
Protocol, Dosage, and Administration
Cardiac Arrest: Medical CA not witnessed by bystander, Metabolic acidosis etiology (e.g. DKA), Hyperkalemia,
Tricyclic Antidepressant Overdose
Adult: 1 mEq/kg IV/IO (max dose 100 mEq)
Pedi: Same as Adult
Svmptomatic Bradvcardia: Hyperkalemia (if suspected acidosis)
Adult: 1 mEq/kg IV/IO (max dose 100 mEq)
Pedi: Same as Adult
Toxicolo--v: Tricyclic Antidepressant (TCA)
Adult - 1 mEq/kg IV/IO (max dose 100 mEq)
Pedi - Same as Adult
Entrapment/Crush/Traumatic Rhabdomvolvsis: ECG findings of hyperkalemia
Adult - 1 mEq/kg IV/IO (max dose 100 mEq)
Pedi - Same as Adult
155
Opioid partial agonist
Indications: Contraindications:
Detoxification from opioids
Maintenance therapy for opiate use disorder
Protocol, Dosage, and Administration
Known or suspected GI obstruction
Respiratory depression
Acute alcohol or benzodiazepine intoxication
Adrenal insufficiency
Hepatic insufficiency
Pregnancy
Severe hypersensitivity
Opiate Use Disorder
Adult; 8 - 24 mg buccal (SL strips or tabs) per physician order
repeat 8 - 16 mg (max 32 mg) q 15 minutes PRN x 1 COWS score >8 or symptoms not resolved
Pedi: N/A
Suboxone is buprenophine + naloxone and the naloxone is chemically inactive when taken SL/oral. Either is
acceptable and supply may vary based on availability. Dosing is the same between the two agents.
156
Tranexamic Acid (TXA)
Indications:
Significant tracheostomy hemorrhage
Ongoing epistaxis
Postpartum hemorrhage
Traumatic hemorrhage (if traumatic cardiac arrest, ad-
minister only if ROSC achieved)
Protocol, Dosage, and Administration
Hemostatic agent
Contraindications:
Hypersensitivity to TXA
—� >_ 3 hours since injury
Hemorrhaze Control: ongoing epistaxis despite direct pressure
Adult - 2 g topical on cotton ball to affected nare(s)
Pedi - Same as Adult
Early pregnancy
Signs of DIC
Upper or lower gastrointestinal bleeding
Hemorrhaze Control: significant traumatic, OB, tracheostomy hemorrhage and SBP <_ 90 or HR >_ 110 with poor per-
fusion
Adult - 2 g IV/IO, slow push over 1 min
Pedi - N/A
Prehosoital Blood Administration
Adult - 2 g IV/IO, slow push over 1 min
Pedi - N/A
157
Indications: Contraindications:
Hypotension refractory to norepinephrine , Coronary artery disease
Protocol, Dosage, and Administration
Preparation
Infusion: 20 units / 100 mL NS (0.2 units / mL)
Circulatory Support: hypotension refractory to norepinephrine
Adult: 0.04 units / minute infusion (12 mL / hr)
Pedi: N/A
158
Indications: Contraindications:
—> Congestive heart failure Hypersensitivity to Lasix
—> Pulmonary edema Hypersensitivity to sulfa drugs
Protocol, Dosage, and Administration
MIH - Congestive Heart Failure
3-5 lbs over: double PO Lasix x 3 days
> 5 lbs over: administer double the patients PO dose of Lasix as IVP x 1
159
Potassium
Indications:
, Hypokalemia
Electrolyte
Contraindications:
Hyperkalemia
Protocol, Dosage, and Administration
MIH - CHF
K+ 2.5-2.9
Increase by 50% for length of time patient has increased Lasix dosing
K+ 3.0-3.4
Increase by 25916' for length of time patient has increased Lasix dosing
K+ 3.5-5.0
No change
K+ 5.1-5.4
Discontinue supplement
MIH-HaH program dosing per HAaH physician order
Standard dosing
Adults: 20-100 mEq PO gDay in divided doses
Pedi > 1 month: 2-5 mEq/kg PO in divided doses
160
$VPPLLWNTAL IFT PROTOCOL, AND PROCIEhURE
1.7
'Chest Tube Management Procedure
1. Inspect the patient's chest wall to ensure that all connections are tight and that the tubing is not kinked. Also check the
skin around the insertion site for subcutaneous emphysema. Be sure that all connections are tight and that all connections
between the tube and the chest drain system are secured with non -porous tape.
2. Note color, consistency and amount of drainage.
3. Note any air leak in the water chamber. Ask the sending facility staff RN if there has been a prior leak.
4. Mark Pleur-evac (or other drainage system) with a pen at the current level of drainage in the system.
Be alert to sudden changes in the amount of drainage.
A sudden increase indicates hemorrhage or sudden patency of a previously obstructed tube.
A sudden decrease indicates chest tube obstruction or failure of the chest tube or drainage system.
5. Adjust wall suction to create a gentle rolling of bubbles in the water seal chamber or until suction indicator in
appropriate range. Vigorous bubbling results in water loss. Note that some systems do not include a water seal chamber
and therefore may not bubble.
6. Verify the level of the suction control chamber is at the level prescribed by the physician (usually -20 cm).
7. Do not clamp the patient's drainage tube at any time during travel. The water seal in the unit prevents backflow of air,
whether or not suction is applied.
8. Position patient in semi -fowlers (if condition allows) to enhance air and fluid evacuation. NEVER raise the chest tube
above the chest or the drainage will backup into the chest. Avoid any dependent loops as drainage problems and tube
obstruction may occur. The tubing should be coiled flat on the bed and from there fall in a straight line to the chest
drainage system.
9. After placing the patient in the ambulance, place the Pleur-evac next to the cot and secure with 3" tape so that it is kept
upright during transport.
10. Dislodgment of the chest tube - If the chest tube falls out or is accidentally pulled out, it is important to quickly seal off
the insertion site. Use a gloved hand until petroleum gauze is available. Petroleum gauze is necessary to prevent air from
entering the pleural cavity. Apply 4-sided petroleum gauze occlusive dressing. If respiratory distress and/or signs of tension
pneumothorax, remove one side of the dressing in an attempt to burp the chest.
11. Dislodgment from the drainage system (Pleur-evac) - If the chest tube becomes disconnected from the Pleur-evac or
other collection device, clamp the chest tube (using Kelly clamps) until corrective action can be taken.
IFT Extracorporeal Membrane Oxygenation (ECMO) Procedure
ECMO accredited staff must be present to manage and maintain changes during transport.
Unlike standard cardiopulmonary bypass which provides cardiopulmonary support following cardiac surgery or cardiac ar-
rest, ECMO provides longer -term support, typically over 3-10 days.
Prevention of complications is fundamental to successful ECMO care. Ensure and document the following prior to initiation
of transport.
1. Securing Cannula: All ECMO lines MUST be secured at 2 points with properly adherent skin dressings. Initial securing
is the responsibility of the cannulator (physician) and cannot be delegated.
2. Prior to transport, ensure that backup components of critical items are available
3. Cannula positions: Cannula position must be confirmed radiographically by medical staff prior to transport.
4. ECMO Cannula dressings: Sterility must be maintained and insertion sites kept unsoiled.
5. Patient Movement: Prevent tension or torsion to the ECMO circuits during patient movement.
During transport:
1. Monitor — vitals every 15 minutes and document all pertinent labs (i.e. INR, PLT) and medications.
2. Contact transferring physician or OLMC for additional guidance or concerns.
IFT Hemodvnamic Monitoring Procedure
All patients who are transported by a Critical Care Paramedic that have invasive pressure lines will be monitored continu-
ously with the use of a cardiac monitor. All pulmonary artery catheters will be monitored during transport. The following
standards will be achieved on all patients meeting the criteria for hemodynamic monitoring.
1. Assess the pressure waveform displayed on the sending facility monitor.
2. Obtain a pre -transport strip of waveform from sending facility's monitoring equipment as well as a post- transport strip
from receiving facility's monitoring equipment.
3. Obtain current pressure readings from the monitor and patient care records.
4. The CCP will evaluate the pressure transducer for compatibility with the CCP equipment. If the line is not compatible,
the pressure line must be changed to facilitate monitoring by the CCP unit during the transport.
5. Flush the invasive line prior to changing over to CCP equipment to ensure patency.
6. Once line has been changed over, flush any visible air out of line via stopcock before flushing to patient.
7. The pressure bag will be inflated to 300 mmHg.
8. The pressure cable will be connected to the monitor and the patient end will be connected to the transducer port on the
pressure tubing.
9. The transducer will be placed at the Phlebostatic axis (4th intercostal space, mid -chest level) line and taped securely.
10. All excess tubing will be coiled and taped in an orderly fashion.
11. The pressure line will be zeroed and calibrated to the monitor.
12. The waveform will be identified by the labels provided in the monitor (PA, ART).
13. The waveform will be assessed on the monitor, a pressure reading will be obtained and a strip will be printed showing
the waveform. The strip will be identified as to the type of tracing.
14. Pulmonary artery pressures will be documented in conjunction with the secondary
survey, as well as every 10 minutes for the duration of the transport. The pulmonary artery catheter should never be
wedged during transport.
15. Arterial pressures will be documented in conjunction with the secondary survey, as well as every 10 minutes for the du-
ration of the transport.
16. All distal pulses, capillary refill times, skin temperature, and sensation will be assessed and documented on extremities
used.
IFT Pulmonary Artery Catheter Procedure
Check and document PCWP at sending facility ONLY. Check PA systolic, diastolic and mean pressures at sending fa-
cility and every 10 minutes.
The Pulmonary Artery Capillary Pressure (PCWP) will only be obtained at the sending facility
a. Normal Mean Values:
i. Pulmonary Artery Pressure (PAP) Systolic 15-30 mmHg Diastolic 4-12 mmHg
ii. Pulmonary Artery Capillary Pressure (PCWP): 4-10 mmHg
iii. Central Venous or Right Atrial Pressure (CVP): 0-12 mmHg
(Therapeutic ranges may be somewhat higher than the above values)
b. Exceptions:
i. The optimal mean PCWP (wedge) may be 15-20 mmHg in patients with compromised left ventricular
function, post -op stress or post MI.
ii. For patients with COPD and respiratory failure, expect PCWP pressures in the range of 30-50 mmHg.
PCWP should be normal in pure pulmonary hypertension.
2. Trends in PAP and PCWP pressures are the most significant factors in detecting significant physiological changes in the
patient's condition. Be sure to obtain history of these values prior to transport.
3. Inspect and document the insertion site. Note and document the PA insertion depth.
4. Calibrate the transducer at the beginning of the transfer before the patient is transferred over to the stretcher and with
any major position changes.
5. Maintain pressurized flush system at 300 mmHg.
6. If change in waveform occurs, contact Medical Control for direction.
7. Follow set parameters for specific IV vasoactive drips as ordered by transferring physician or see protocol for IV vasoac-
tive pharmaceutical titrations and/or communicate with the online physician.
8. CCP must document all interventions that take place regarding PA catheter.
9. Label all pressure tracings and document the tracings on the patient care report.
IFT- ransvenous Pacemaker Procedure
1. Place a new battery in the temporary pacemaker and test it prior to use.
2. Connect pacer wires to Temporary Pacemaker Cables with leads/heartwires - the patient cable with lead or heartwire
plugs into socket on top of unit. In the absence of patient cables, temporary transvenous leads plug directly into the
two smaller sockets.
3. Match the positive (+) and negative (-) leads to the positive (+) and negative (-) sockets or clips (as applicable). There
may be instances where the leads are reversed in polarity to obtain capture. CCP will connect in the same manner as
the sending facility.
4. Set the pacemaker controls
a. Set the sensitivity (the highest number is least sensitive; the lowest is most sensitive)
5. Demand mode - (withholds its pacing stimulus after sensing a spontaneous depolarization) set the sensitivity value to
detect intrinsic activity.
a. Set pacemaker's rate 10 bpm slower than patient's intrinsic rate (the sense indicator will flash regularly)
b. Reduce milliamps (output) to the minimum value (this avoids risk of competitive pacing).
c. Sensitivity should be set at its lowest value necessary to ensure mechanical capture, and should be increased only
to the point of stopping any oversensing.
d. Restore original pulse generator rate and output values.
6. If asynchronous mode is indicated (stimulates at a fixed, preset rate independently of the electrical and/or mechanical
activity of the heart) turn sensitivity dial to ASYNC (not the preferred mode for critical care transport).
a. Set the rate and milliamps (output)
b. Set the milliamps (output) at 5 and the rate at 60 or as directed by the physician orders.
7. Turn the pacemaker ON
8. Check the monitor to ascertain that capture (depolarization of the atria and/or ventricles) is obtained- if not, increase
the milliamps slowly until capture is obtained, this is the threshold (minimum electrical stimulus needed to consistently
elicit a cardiac depolarization). Then set the milliamps at two (2) x the threshold.
Setting stimulation threshold:
1. Ensure the patient is connected to pacemaker and being monitored on EKG.
2. Set pulse generator rate at least 10 ppm faster than the patient's intrinsic rate (The pace indicator will be flashing regu-
larly at the set rate).
3. Decrease the milliamps (output) until 1:1 capture is lost (the pace and sense indicators will be flashing intermittently).
4. Increase the milliamps (output) to restore 1:1 capture. This value is the stimulation threshold for the chamber being
paced. (The pace indicator will be flashing; and the sense indicator will have stopped flashing.)
5. Set output value to 2-3 times the threshold value. This safety margin will allow for threshold variation while maintain-
ing capture.
6. Restore original pacemaker rate value (60 or physician prescribed rate).
Ventricular Assist Device Procedure (all others)
While some VADs produce pulsatile flow, most VADs use continuous flow technology, thereby creating a non -pulsatile
continuous flow. This means most patients with a VAD will not have a palpable pulse and, therefore, taking a blood pres-
sure with a manual cuff and stethoscope will rarely allow you to auscultate a pressure. It is imperative that the type and
model of VAD be identified (i.e. HeartWare HVAD vs Jarvik 2000 FlowMaker). Important aspects of transport include
allowing a family member to ride along with the patient because the family member can be an invaluable resource. They
are often trained in the operation of the equipment and know how to handle an emergency, and can also be a comfort to
the patient.
Refer to device specific manual for setup and troubleshooting or questions. Verify you are using the most current procedure
manual before operation.
If patient not responsive to pain and has capillary refill >_ 3 seconds (inadequate perfusion)
If CPR and defibrillation can be performed on the patient (see VAD reference or documentation)
• See, Cardiac Arrest
If CPR and defibrillation are contraindicated
1. Check controller for alarms. (i.e. low battery, driveline malfunction, pump stopped.)
2. Auscultate and feel left upper abdominal quadrant for a continuous whirring sound and vibrations.
3. Determine if there is a "hand pump" or external device to utilize.
4. Remember not to perform chest compressions because they could dislodge the pump, making the patient bleed
to death. (Unless the patient is in obvious cardiac arrest and the pump isn't working. Use the assistance of the
VAD coordinator to figure this out before starting any compressions).
5. Perform all other BLS/ACLS protocols as written.
6. Avoid kinking or twisting driveline when strapping the patient onto the stretcher.
7. Keep batteries and controller in reach and secured to the patient during transport. Keep them dry.
8. Take the patient's emergency travel bag when leaving the scene. (It has an extra controller, batteries and the
VAD coordinator's emergency contact number.) Access back up controller and power sources as needed.
9. Monitor and document all IBP (in hospital), ECG, and Wave form EtCO2 and ventilator settings every 15
minutes.
10. Contact online medical control for further instructions.
*If feasible, transport the patient to their implant hospital. If not, transport to the nearest most appropriate
hospital.
If patient is out -of -hospital and hemodynamically stable
1. If available, utilize doppler device to auscultate blood pressure. The first sound heard is approximately equivalent to the
mean arterial pressure (normal Doppler pressure range is 60-90 mmHg). A pressure of 60-90 mmHg is considered
acceptable. Note that you may or may not hear normal heart tones with a stethoscope.
2. Assess the patient's EtCO2, mental status, skin, and lips to assess perfusion status.
3. Take the patient's emergency travel bag when leaving the scene. It may have an extra controller, batteries, and the
VAD coordinator's emergency contact number.
4. Ensure the controller and battery packs are close to the patient and aren't dangling off the side of the cot. Be sure that
the driveline (the power cord of the pump) isn't pulled, kinked, or cut.
IFT Ventricular Assist Device Procedure (IABP)
Procedure:
1. Review the most recent 12-lead ECG. Select lead with greatest R-Wave amplitude. Place patient in this lead on cardiac moni-
tor for continuous monitoring during transport. Limit chest artifact. ECG leads for the IABP will be secured with tape to the
patient's chest and maintained during transport. Lead selection may need to be changed in order to get the best R wave and
capture on the balloon pump (if ECG triggered).
2. Arterial line shall be maintained on the IABP. If a transducer is used, ensure that it is directly connected to the pump and in
working order. Maintain adequate arterial tracing. If radial site is used, secure arm with arm board to protect site during
transport. Secure tubing.
3. Evaluate balloon insertion site. Note balloon size in the medical record. Check dressing site appearance. Monitor site frequently
(every 15 minutes and as needed) during transport. Instruct patient to keep affected leg straight. Ensure that a knee immobi-
lizer is in place prior to transport for additional reinforcement.
4. Establish baseline condition. Evaluate hemodynamics and clinical condition.
5. Hemodynamic assessment will include: temperature; blood pressure; respiration rate and quality; heart rate and rhythm; arteri-
al blood pressure; Augmented pressures, MAP; CVP; PAP; augmented diastolic pressure (ADP). Document findings including
patients weight.
6. Evaluate pulses, both radial sites as well as posterior tibial and dorsalis pedis to facilitate subsequent localization during
transport, also capillary filling times and extremity temperature.
7. Review lab values and trends.
8. Maintain H.O.B. at lowest point tolerated by patient, never to exceed 30 degrees.
9. Evaluate and closely monitor urinary output. All patients will have an in -dwelling urinary catheter.
10. Maintain IABP at prescribed timing/ratio (i.e.: 1:1; 1:2; 1:4). Evaluate effects.
11. Document hemodynamics. Document: IABP type, model and trigger (ECG, A -Line)
Precautions
— Never leave balloon pump inactive in patient for more than 20-30 minutes (i.e., not inflating and deflating). Throm-
bosis formation could occur after 30 minutes. Utilize 60 ml syringe to manually fill and deflate balloon.
Balloon leak: Observe tubing for blood. If blood is observed in the pneumatic tubing, shut off the balloon pump and
leave intact. Maintain sterile technique and notify the physician and receiving facility immediately.
IABP Failure: Evaluate patient's condition and hemodynamics. Troubleshoot the device and make every effort to cor-
rect the problem and maintain the patient's safety. If IABP is inoperable for greater than 20-30 minutes, inflate IABP
manually with 60 cc syringe every 3-5 minutes to avoid clot formation (Inflate with 10cc less than balloon size).
Ensure IABP battery is charged and Helium tank level is sufficient for transport. The balloon pump should be plugged
into the ambulance inverter or generator outlets during transport.
Ensure there is ample tubing length for transfer and loading the patient into the ambulance. Secure the IABP tubing at
patient end and stretcher end, but not mid -line. Put loops in tubing if length permits.
If bleeding is observed at the insertion site, apply direct pressure to the site until bleeding stops
—> If CPR is required, the IABP should be switched to "pressure trigger" mode
IFTVentricular Assist Device Procedure (Im
The Impella is intended for partial circulatory support using an extracorporeal bypass unit, for periods from 6 hours
(Impella 2.5) to 2 weeks (Impella 5.0).
1. Confirm that Impella placement has been verified with echocardiography. Document position of the Impella as reported by send-
ing facility. If possible, bring reports and/or imaging studies that document confirmation of placement.
2. Verify the patient's Activated Clotting Time (ACT) has been checked and is between 160-180 seconds.
a. If the ACT is not verified, ensure it is evaluated before transport.
b. If the ACT is < 160 or > 180 seconds, request that it is addressed before transport per the sending facility guidelines.
3. Evaluate and confirm Impella settings. Document and monitor:.
a. pump performance level (P2-P9)
b. flow G. I to 5.3 L/min {device dependent})
c. placement signal pulsatile [mmHg] (red waveform)
d. purge pressure 300-1100 mmHg
e. motor current < 1000 and pulsatile (green waveform)
f. pump position
g. purge fluid infusion rate (2-30 mL/hr)
4. Ensure the Tuohy -Borst on the Impella catheter is tight to prevent catheter migration (tighten completely to the right).
5. Evaluate insertion site for signs of bleeding, swelling or hematoma, and catheter on initial assessment, following each patient
transfer, and frequently (every 15 minutes and as needed) during transport. Document findings following each evaluation.
6. Evaluate pulses, capillary filling time, and temperature of affected lower extremity on initial assessment, following each patient
transfer, and frequently (every 15 minutes and as needed) during transport.
7. Evaluate urine output and color on initial assessment and monitor during transport. Changes in urine color may indicate hemoly-
sis.
8. Establish the patient's baseline condition. Evaluate hemodynamics and clinical progression.
9. Patients should remain flat throughout transport. Under no conditions is head of bed (HOB) elevation to exceed 30°.
10. Instruct the patient to keep the affected leg straight. Apply knee immobilization device if needed to prevent movement.
11. During transport, maintain pump performance level and flow rate at ordered levels. If unable to maintain ordered flow rate at or-
dered levels, contact OLMC for guidance.
12. If alarms occur during transport, follow on -screen troubleshooting guidance for resolution. If alarms not resolved following trou-
bleshooting, contact OLMC for further guidance.
13. If purge solution requires replacement during transport replace with D 10 solution or solution provided by sending facility.
14. Refer to the hemodynamic monitoring protocol for arterial line maintenance.
Impella Precautions: Next Page
Ventricular Assist Device Procedure (Impella)
Precautions:
Verify the battery charge level before unplugging and moving the Impella controller. A fully charged battery will sup-
port the system for approximately 60 minutes. The Impella controller should always be plugged in for transport.
Place the Impella controller must on a flat surface, where the screen is easily visible during transport. The controller
must be secured during transport to avoid accidental dislodgement of the sheath and to prevent the controller from
becoming a dangerous projectile. Consider using the bed mount as a loop through which to secure the device with
straps.
Movement of the HOB is the primary cause of migration of the Impella during transport. Do not move the HOB from
its initially established position.
Keep the stopcock on the peel -away introducer or repositioning sheath in the closed position. Significant bleeding can
occur if the stopcock is in the open position.
Do not decrease pump performance (P) level below P2 as long as the pump is in the ventricle. Below P2, retrograde
flow will occur across the aortic valve.
CPR should be initiated immediately per MedStar protocol if indicated. When starting CPR, reduce the Impella flow
rate to P2. If return of spontaneous circulation, return the flow rate to the previous P-level, by increasing one P-level
every 30-60 seconds and assess placement signals on the controller.
Infusion through the side port of the introducer can be done only after all air is removed from the introducer. If per-
formed, the infusion should be done for flushing purposes only and NOT for delivering therapy or monitoring blood
pressure or MAP.
Base the management of the patient's hemodynamic status on MAP readings from an arterial line. Target MAP to
> 65 mmHg or level ordered by sending facility.
--. If there are any changes in the patient's condition during transport or there are unresolved Yellow or Red alarms, con-
tact the receiving facility with updated information so they can prepare for the proper interventions before patient arri-
val.
Contact the 24-hour clinical support line at 1-800-422-8666 with any questions or concerns during transport. Use only
for general information about the device functionality only. For any orders needed for patient management, contact
OLMC. the receiving facility with updated information so they can prepare for the proper interventions before patient
arrival.
IFT-Ventriculostomv Monitorine Procedure
1. Maintain patient's head position per physician's order (usually 30 degrees).
2. Check and document dressing site and appearance.
3. Confirm level of drain and any other patient specifics in regards to monitoring, as follows.
a. Review physician's order to place ventriculostomy to either drain or monitor.
i. If ventriculostomy is placed to drain
• Verify that the stopcock at the zero level is opened to the drainage bag side. The drip chamber is placed so
that the zero level is at the foramen of Monroe (Point of communication between the 3rd and lateral ventri-
cles of the brain). Anatomical landmark for foramen of Monroe is the external auditory canal. Ensure the Bu-
retrol is moved so that the pressure line is at the ordered level of drainage.
ii. If ventriculostomy is set to monitor
• Do not collect measurements during transport.
4. The system must be secured on a pole at all times. The system is adjusted to obtain the zero level.
5. If tubing becomes occluded during transport, do not flush or manipulate line. Notify receiving staff upon arrival.
6. Document on PCR drainage amount, color, ICP and any other pertinent information.
MOBILE INTEGRATED HEALTHCARE
Co
0-
MOBILE INTEGRATED HEALTHCARL
estive Heart Failure (CHF) Protocol
This protocol is to be used by an appropriately credentialed Mobile Integrated Health (MIH) Provider as standing orders for patients
enrolled in an approved Mobile Integrated Health program. This protocol may be used in visits requested by partner agencies or 911
calls from program clients. The primary point of contact for all patient consultations is that individual's PCMH primary provider con-
tact or, if unavailable, contact OLMC.
Contact appropriate partner agency staff
Review relevant patient clinical record and lab values
Measure and document vital signs (BP, weight, OZ, pulse)
• Perform 12-lead ECG
Considerations for Patient Education
• Educate patient on appropriate dietary and medication compliance.
• Encourage ingestion of food or milk to reduce GI upset if increasing potassium dose.
• Have patient record weight daily.
Interpret 12-lead ECG
Perform and interpret i-STAT (ensure sample not hemolyzed)
Hypokalemia
If K+ < 2.5 mEq/L or ECG findings consistent with hypokalemia
• Administer patient's Potassium - 40 mEq PO
• Request ambulance for transport to ED
Hyperkalemia
If there are any ECG changes consistent with hyperkalemia
• Request ambulance for transport to ED, and treat for hyperkalemia (see treatment box)
If K+ > 7.0 mEglL (regardless of ECG changes)
• Request ambulance for transport to ED, and treat for hyperkalemia (see treatment box)
If there are no ECG changes consistent with hyperkalemia
If K+ > 5.0 - 6.0 mEglL, AND if the most recent K+ > 5.0 mEglL (within the last 72 hrs)
Contact partner agency staff / OLMC for further guidance to discuss plan of care, to potentially include:
• Stop oral potassium supplementation for 2 days
• Recheck potassium at least daily until <5 mEq/L
If the patient is not taking oral potassium AND is not scheduled for urgent diuresis
• Request ambulance for transport to ED
If K+ > 5.0 - 6.0 mEglL, AND if the most recent K+ < 5.0 mEq/L (within the last 72 hrs)
• Request ambulance for transport to ED
If K+ 6.0-7.0 mEq/L (independent of previous K+ value)
• Request ambulance for transport to ED
If Creatinine > 3 mg/dl
• Contact PCMH
If patient is on warfarin (Coumadin)
Urgent/Emergent Treatment of HyUerkalemia
Calcium Chloride - 1 g IV slow push
Sodium Bicarbonate - 1 mEq/kg IV/IO (if sus-
pected acidosis)
• Review patient's PT/INR, when available, with the
PCMH, who will provide instructions for changes in dosing and follow-up
• Adjust diuresis and potassium dosing per CHF Protocol Dosing Schedule
Contraindications
• Weight gain of less than 2 lbs. over baseline.
• Potassium of < 2.5 or > 5.5 mEq/L (transport if present)
• Acute clinical changes such as chest pain, dyspnea, or signs of acute decompensation (transport if present)
• If in the MHP's clinical judgment the patient requires transport/ED evaluation
173
MOBILE INTEGRATED ETHC
Congestive Heart Failure (CHF) Protocol (Dosing Schedules)
Diuresis Dosing Schedule
over
-
• Double PO furosemide or torsemide for 3
• Administer double the patients sin le PO dose of
days.
furosemide as IVP xl.
Refer to K+ dosing schedule below
(e.g. Patient on 40 mg PO twice daily = 80 mg IVP)
Refer to K+ dosing schedule below
• MIH-P follow-up in 24 hours.
• MIH-P follow-up in 4 hours (can be phone call).
• 24 hour follow-up in person
• PCP notification
• Extensivist / PCP follow up in 48 hours.
• Extensivist / PCP follow up in 48 hours.
Potassium Dosing Schedule:
Increase by 50% for the Increase by 25% for the
length of time patient has length of time patient has No Change Refer to protocol
increased Lasix dosing. increased Lasix dosing.
PEARLS:
Furosemide (Lasix), Torsemide (Bumex)
If diuresis is performed more than 3-visits in a row refer to an Advanced Heart Failure Clinic.
MOBILE INTEGRATED HEALTHC,AR$ 0M
COPD/Asthma Protocol
This protocol is to be used by an appropriately credentialed Mobile Integrated Health (MIH) Provider as standing orders for patients
enrolled in an approved Mobile Integrated Health program. This protocol may be used in visits requested by partner agencies or 911
calls from program clients. The primary point of contact for all patient consultations is that individual's PCMH primary provider con-
tact or, if unavailable, contact OLMC.
• See Respiratory Support
• Initiate transport if the patient fails to respond to nebulizer therapy
If patient has a positive response to nebulizer therapy
• Contact PCMH to arrange appropriate follow-up
MOBILE INTEGRATED HEALTHC,AR$
Diabetes Protocol
This protocol is to be used by an appropriately credentialed Mobile Integrated Health (MIH) Provider as standing orders for patients
enrolled in an approved Mobile Integrated Health program. This protocol may be used in visits requested by partner agencies or 911
calls from program clients. The primary point of contact for all patient consultations is that individual's PCMH primary provider con-
tact or, if unavailable, contact OLMC
If patient is obtunded, unconscious, or altered
• See Diabetic Emergencies and request ALS transport
If patient is conscious
• Measure Blood Glucose
If blood glucose <_ 60 mgldl and symptomatic
• Oral Glucose - 15 g buccal (if intact gag reflex and able to tolerate)
• Recheck blood glucose
• Contact PCMH for any suggested changes in dosing and/or for appropriate follow up
If blood glucose > 300 mg/dl and asymptomatic
• Verify with appropriate partner agency that patient is on insulin sliding scale
• Teach and assist patient with insulin self -administration
If patient is unable to administer insulin
• Contact PCMH for any suggested changes in dosing and/or for appropriate follow up
If blood glucose > 300 mgldl and symptomatic (e.g. AMS, signs of hypovolemia, suspected DKA or hyperosmolar state)
• Perform i-STAT
If CO2 <_ 16 or anion gap > 20
• NS - 1 L IV bolus
• Contact PCMH and recommend ambulance transport to ED
MOBILE INTEGRATED HEALTHCAR-L
High Utilizer Group (HUG) Protocol
This protocol is to be used by an appropriately credentialed Mobile Integrated Health (MIH) Provider as standing orders for
patients eligible for, or enrolled in, the High Utilizer Group program. Patients with frequent utilization of the 911 EMS or hos-
pital Emergency Department system are eligible for the High Utilizer Group (HUG) program. Patient will either be referred
internally or by partner agencies. MedStar will conduct a series of home visits to help enable patients to navigate themselves
through the healthcare system. The primary point of contact for all patient consultations is that individual's PCMH primary
provider contact or, if unavailable, contact OLMC.
Referral Criteria
High Utilizer Group patients may include individuals who meet the following criteria:
Requested 15 or more 911 ambulance responses during the past 90-days, OR
Referred by a partner agency for avoidable visits to the Emergency Department during the past 12-months
AND
Live in the MIH service area
Possesses mental capacity to support navigational assistance
Willing to participate in the program and allow MIH Providers into their home for assessment and follow-up
Initial Home Visit/Patient Assessment
Conduct initial assessment of barriers to the patient's care, which may include:
Living environment
Social barriers to appropriate engagement in care
Transportation
Access to primary care
Disease management
Facilitate the development and implementation of a care plan by the PCMH, which may include:
Primary Care Provider (PCP) assignment (if necessary)
Series of home visits to educate the patient and family on appropriate care management
Assistance with navigation through the patient's primary care network/resources
Provision of 24/7 non -emergency number to request mobile healthcare provider support during the dura-
tion of the program enrollment
Scheduled Home Visits
Enrolled patients will receive a series of home visits to educate:
The patient and family on appropriate ways to manage their disease process
The patient on how to navigate the healthcare system
Unscheduled Home Visits
The patient will be provided a non -emergency phone number in the event they would like a phone consultation or an
unscheduled home visit between scheduled visits.
911 Responses
Enrolled patients will be tracked in the computer aided dispatch (CAD) system, and in the event of a 911 call to their
residence, a 911 ambulance response will be initiated, along with an MIH provider who will be dispatched to the scene.
Once on -scene, the MIH provider may be able to intervene and navigate the patient to an alternate source of care, in-
cluding PCMH, urgent care, self -care, or by employing the use of the Disease Management MIH protocols.
Care Management Protocols (CMP)
The primary point of contact for all patient consultations is that individual's PCMH primary provider contact or, if
unavailable, contact OLMC. In consultation with the PCMH, patients with conditions including, Diabetes, COPD, or
CHF can either have their medications adjusted in the field, or they may receive in -home therapy through Care
Management Protocols, with an in -office follow-up appointment to minimize any unnecessary transport to the Emer-
gency Department. Refer to the appropriate CMP (e.g. Diabetes, CHF, COPD/Asthma)
177
MOBILE INTEGRATED HEALTHCARE
High Utilizer Group (HUG) Protocol
Program Length
Term of program will be a minimum of 30-days and a maximum of 90-days after acceptance into the program, based on
patient compliance and meeting established program goals.
Record Keeping
Patients enrolled in the program have a continual electronic medical record (EMR) that allows all care providers mobile ac-
cess to the patient's entire course of assessments and treatments during enrollment, including care notes, lab values, vital
signs, ECG tracings and treatments initiated. These records can be provided to caregivers in accordance with the Treatment
Payment Operations (TPO) definitions of Health Insurance Portability and Accountability Act (HIPAA).
178
MOBILE INTEGRATED HEALTHCARE
Hospice Patients
This protocol is to be used by an appropriately credentialed Mobile Integrated Health (MIH) Provider as standing orders
for patients enrolled in an approved Mobile Integrated Health program. This protocol may be used in visits requested by
partner agencies or 911 calls from program clients.
If concernlcomplaint related to hospice care
• Responding ambulance crew should remain on -scene and only transport if it is unsafe to wait for a MIH provid-
er to arrive.
Upon arrival on scene, the MIH provider will assist in addressing the family/patients concerns. The MIH provid-
er will help to ensure the patient's comfort and may use the hospice supplied in -home comfort -pack if required
once they have consulted with hospice provider or, if unavailable, OLMC.
The responding MIH provider will remain with the family/patient until the hospice nurse arrives or until the
family and patient are comfortable with the patient's status.
If the patientlfamily insists on being transported to the ED
• Attempt to arrange for a direct admit to an inpatient hospice care facility
If complaint not associated with the patient's hospice diagnosis
• Responding ambulance crew should transport only if acuity/condition is unsafe to wait for MIH provider to ar-
rive
• Upon arrival on -scene, the MIH provider will work with the patient/family to ensure their wishes are carried out
and the appropriate care is provided, while awaiting the arrival of a hospice representative.
If the patient/family insists on being transported to the ED and are unwilling to wait or discuss the situation with the
responding Hospice representative
• Facilitate transportation by ambulance to the appropriate acute care facility.
EL_ MOBILE INTEGRATED HEALTH
Insulin Titration
This protocol is to be used for patients with hyperglycemia or hypoglycemia on the second home visit who have recently been released
from the hospital and have not seen their new PCP or their PCP has been contacted twice (on two subsequent visits) without a re-
sponse.
• Contact appropriate partner agency
• Measure blood glucose
If hyperglycemia present (blood glucose >_300 mgldl prior to short acting insulin treatment and asymptomatic)
Hyperglycemia
• Perform iStat and calculate anion gap
If anion gap < 12
• Glucose 300-400 mg/dl increase long -acting insulin by 2 units on next dose
• Glucose 400+ increase long -acting insulin by 4 units on next dose
If hypoglycemia present
• For symptomatic with hypoglycemia see, Diabetic Emergencies and if no transport consider Insulin Titration
Fasting or overnight
Blood glucose < 54
Blood glucose 55-70 and
Blood glucose 55-70 and
Reduce long -acting insulin dose
Reduce long -acting insulin by 4
Reduce evening intermediate insulin
by 40916
units or 10% (whichever is greater)
dose by 2 units
Daytime and corresponds with sliding scale or set pre -prandial insulin dosage
(use sliding scale insulin dosage given 30 minutes-6 hours prior to hypoglycemic episode)
Blood glucose <_ 54
Blood glucose 55-70
Reduce sliding scale or pre -prandial insulin by 4096
Reduce sliding scale insulin dosage
If sliding scale < 10 units reduce by 2 units
If sliding scale 11-20 units reduce by 4 units
If sliding scale > 20 units reduce by 8 units
Daytime & Does Not Correspond with Sliding
Blood glucose <_ 54
Blood glucose 55-70 and
Blood glucose 55-70 and
long -acting insulin
intermediate insulin
Reduce long -acting insulin dose
Reduce long -acting insulin by 4
Reduce morning and evening
by 40%
units or 10% (whichever is greater)
intermediate insulin dose by 2 units
Fasting or Overnight and Daytime & Corresponds with Sliding Scale
Blood glucose <_ 54
Blood glucose 55-70 and
Blood glucose 55-70 and
long -acting insulin
intermediate insulin
Reduce long -acting insulin dose
Reduce long -acting insulin by 4
Reduce morning and evening
by 40916
units or 10% (whichever is greater)
intermediate insulin dose by 2 units
Fasting or Overnight and Daytime & Does Not Correspond with Sliding Scale
Blood glucose <_ 54
Blood glucose 55-70 and
Blood glucose 55-70 and
long -acting insulin
intermediate insulin
Reduce long -acting insulin dose
Reduce long -acting insulin by 4
Reduce morning and evening
by 40976
units or 10% (whichever is greater)
intermediate insulin dose by 2 units
Pearls:
Intermediate -acting insulins (examples): Humulin N, Insulin NPH, Novolin N
Long acting insulins (examples): Insulin glargine, insulin detemir, insulin degludec
For this protocol basal insulin is any intermediate or long -acting insulin
180
MOBILE INTEGRATED HEALTHCARE
i-STAT Procedure
Precautions:
Avoid the Following Circumstances:
• Drawing a specimen from an arm with an I.V.
• Stasis (tourniquet left on longer than two minutes before venipuncture)
• Extra muscle activity (fist pumping)
• Hemolysis (alcohol left over puncture site, or a traumatic draw)
• Time delays before filling cartridge, especially lactate, ACT, and PT/INR
Criteria For Specimen Rejection:
• Evidence of clotting
• Specimens collected in vacuum tubes with anticoagulant other than lithium or sodium heparin
• Specimens for ACT or PT/INR collected in glass syringe or tube or with anticoagulant of any kind
• Incompletely filled vacuum tube for the measurement of ionized calcium or PCO2
• Other sample types such as urine, CSF, and pleural fluid
Procedure:
Cartridges:
A single -use disposable cartridge contains microfabricated sensors, a calibrant solution, fluidics system, and a
waste chamber. A whole blood sample of approximately 1 to 3 drops is dispensed into the cartridge sample
well, and the sample well is sealed before inserting it into the analyzer. An individual cartridge may be used
after standing 5 minutes, in its pouch, at room temperature. An entire box should stand at room temperature
for one hour before cartridges are used. Cartridges may be stored at room temperature (18 to 30' C or 64 to
86' F) for 14 days. Cartridges should not be returned to the refrigerator once they have been at room tempera-
ture, and should not be exposed to temperatures above 30' C (86' F). If the pouch has been punctured, the
cartridge should not be used. Write the date on the cartridge box or individual cartridge pouches to indicate
the two -week room temperature expiration date. Cartridges should remain in pouches until time of use. Do
not use after the labeled expiration date.
Testing:
Press the Power button to turn on the Handheld.
DO NOT insert the cartridge to start the test.
Sean er Enter Scan or Enter
Press the "T' button to start a new test. Follow the Dperater W Patient 1D
handheld prompts. For "Operator ID," enter your
MedStar ID number. For "Patient ID," enter the
run number for the call.
Screen 2 Screen 3
181
MOBILE INTEGRATED HEALTHCARE
i-STAT Procedure
Scan the Lot Number on the cartridge pouch. Posi-
tion the barcode 3-9 inches from the scanner window
on the handheld. Press and hold "Scan" to activate
the scanner. Align the laser light to cover the entire
barcode. The handheld will beep when it reads the
barcode successfully. If you cannot scan the barcode,
enter the lot number using the numbered keys, ig-
noring any letters. DO NOT open cartridge pouch
before scanning the barcode.
Remove cartridge from pouch. Handle the cartridge
by its edges. Avoid touching the contact pads or ex-
erting pressure over the center of the cartridge.
Mix blood and collection tube additives by inverting a tube
gently at least ten times. Following thorough mixing of
the sample, use a plastic capillary tube, pipette, or syringe
to transfer sample from a tube to a cartridge. Direct the
dispensing tip containing the blood into the sample well.
Dispense the sample until it reaches the fill mark on the
cartridge and the well is about half full. Close the cover
over the sample well until it snaps into place. (Do not
press over the sample well.)
Scan or €nter
Cartridge
Lot Number
Screen F
..,
;f-t,, 4
11- r <31
IE YA
MOBILE INTEGRATED HEALTHCARE
i-STAT Procedure
Insert the cartridge into the cartridge port on the analyzer until it clicks into
place. The analyzer must remain horizontal during the testing cycle. Never at-
tempt to remove a cartridge while the LCK or "Cartridge Locked" message is
displayed.
Wait until testing cycle is complete. Results are displayed numerically with their
units. Electrolyte, chemistry and hematocrit results are also depicted as bar
graphs with reference ranges marked under the graphs.
To print the results, turn printer on if green power light is not on. Align IR windows of
analyzer and printer. Display results. Press the Print key.
Do not move analyzer or printer until printing is complete.
Note: Results printed on thermal paper will fade with time and are therefore not ac-
ceptable as a permanent chartable record.
To print a stored test record(s), select "Print Results" from the Stored Results menu.
Select records to be printed by pressing the Key(s) corresponding to the numbers beside
the record(s). Press the numbered key again to deselect a record. Then press the PRT
Key. Do not move the analyzer while "Printing" is displayed.
Suppressed Results
There are three conditions under which the i-STAT System will not display results:
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i-STAT
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Screen 4 Screen S
1. Results outside the System's reportable ranges are flagged with a < or > , indicating that the result is below the lower
limit or above the upper limit of the reportable range respectively. (See the table of Reportable Ranges.) The < > flag
indicates that the results for this test were dependent on the result of a test flagged as either > or <.
Cartridge results which are not reportable based on internal device problem are flagged with ***. Action: Analyze the
specimen again using a fresh sample and another cartridge. If the specimen integrity is not in question, the results that are
not suppressed should be reported in the usual manner.
3. A Quality Check message will be reported instead of results if the analyzer detects a problem with the sample, cali-
brant solution, sensors, or mechanical or electrical functions of the analyzer during the test cycle. The device should be
serviced as soon as possible.
The following should be used as a guideline to determine appropriate actions when any of the following are
identified:
Abnormal Lab Values - When Chem 8 values are
abnormal, but not "critical", notification to client's
physician's office must be made prior to terminating
visit. This may be telephone or email but must also be
documented in the client record.
Critical Lab Values - When Chem 8 values report in
the "critical range" (as below) patient's physician must
be consulted immediately. If consultation with the
patient's physician cannot be completed, the Office of
the Medical Director on -call physician, or delegate,
must be consulted. Consider transport to appropriate
facility as needed.
NOTE: For End -stage Renal Disease (ESRD)
patients on dialysis who have received regularly
scheduled dialysis and have a normal potassium,
an abnormal creatinine or BUN value does not
require contact.
Test
Reference Range
Critical Levels
Sodium (Na)
138-146 mEq/L
< 120 or > 160
Potassium (K)
3.5-4.9 mEq/L
<2.5 or >6
Chloride (Cl)
98-109 mEq/L
<90 or > 120
Ionized Calcium (iCa)
4.5-5.3 mg/dl
<4 or >6
Total CO, (TCOz)
24-26 mEq/L
< 10 or >40
Glucose (Glu)
10-105 mg/dl
>400
Urea Nitrogen (BUN)
8-26 mg/dl
<2 or >80
Creatinine (Crea)
0.6-1.3 mg/dl
>2.8
Hematocrit (Hct)
38-51916 PCV
<20 or >60
Hemoglobin (Hgb)
12-17 g/dl
<6 or >20
FAnion Gap (Agap)
10-20 mEq/L
>20
183
MOBILE INTEGRATED HEALTHCARE
Non -Compliant HUG Protocol
This protocol is to be used by an appropriately credentialed Mobile Integrated Health (MIH) Provider as standing orders for
patients who are found to be non -compliant with the High Utilizer Group program.
Non -Compliant Evaluation
When an agency official believes that an individual HUG patient may be chronically and inappropriately utilizing the 911
EMS system, a report shall be provided to the OMD with the following information:
Identity of the individual
911 utilization before and during enrollment in the HUG program
Chief Complaint when calling 911
Past Medical History
Any previous history of enrollment in MIH programs, and the outcomes of those enrollments
History of Police utilization during prior 911 responses or patient visits
—> Frequency of hospital visits
Contact information for any known PCMH or other outpatient care providers (including mental health providers), and
details of prior service requests, interactions, and discussions regarding facilitation of a care plan
Assigned home hospital
—> Copies of patient record forms completed by all EMS providers who have previously interacted with the patient
Non -Compliant Assignment
The Medical Director will review the report. If the individual is deemed non -compliant, the patient will be registered as
such, and a Client Specific Care Plan will be issued.
Calls to 911
All 911 requests for Non -Compliant HUG patients shall receive an appropriate 911 response.
If identified as a Non -Compliant HUG patient during 911 call -taking process
• Communications Center will initiate a concurrent MIH response
If not identified as a Non -Compliant HUG patient during 911 call -taking process
• Responding crew shall:
• Perform and document a careful assessment on all patients
• Initiate an MIH response via radio or phone request
If the crew identifies an emergent or possible life -threatening condition
• Initiate 911 treatment and transport, as appropriate
If identified as a Super Non -Compliant HUG patient during the 911 call -taking process
• Communications Center will initiate a non -transport response as per the Client Specific Care Plan
MIH Response, Management, and Disposition
• Respond, if available
• Assign themselves to the CAD incident, if not already done so by the Communications Center
• Respond in non -emergency mode
• Access the client's information, if available
• Take a verbal report from the responding 911 crew to obtain the following:
Current complaint
Vital signs
Significant history and examination findings
• Complete a thorough assessment
• Evaluate the patient for possible navigation to an alternative source of care, or initiate 911 transport to the ED
iI-E
MOBILE INTEGRATED HEALTHCARE
Non -Compliant HUG Protocol
If patient is a candidate for alternate source of care
• Contact OLMC for discussion of treatment, transport modality, and disposition
• Facilitate transport and allocation of additional resources, which may include:
Bus pass
Taxi voucher
Follow-up home visit
Assisting client to schedule visit with a doctor or urgent care
If patient does not necessitate ED transport, or alternate source of care
• Contact OLMC, and if agreement, assign disposition of Medical Director Refusal
Documentation
• Complete ePCR and sign as the primary paramedic, and include summary of OLMC disposition
• Attempt to have the client sign the authorization section, acknowledging the assessment provided and assigned
disposition
• If the client refuses to sign, place the client's name in the appropriate field and mark that the client
"refused to sign"
• Attempt to obtain a witness signature
Quality Assurance
• A file will be maintained on each OMD registered Non -Compliant HUG patient, including ePCR documentation of all
transports and non -transports
• All cases will be reviewed every 6-months for renewal of Non -Compliant HUG status
• Patients whose 911 utilization falls below 1/3 of their original usage may have their non -Compliant status removed
IR
MOBILE INTEGRATED HEALTHCARE
Observation Avoidance Protocol
This protocol is to be used by an appropriately credentialed Mobile Integrated Health (MIH) Provider as standing orders for patients
eligible for, or enrolled in, the Observation Avoidance program. Patients are referred by the Emergency Department case manager or
any member of the care team. The MIH Provider initially consults with care providers and evaluates patients while in the ED. The
MIH Provider then performs scheduled home assessment follow-up visits until patient care is transitioned to the PCMH, within 7-
days. The primary point of contact for all patient consultations is that individual's PCMH primary provider contact or, if unavailable,
contact OLMC.
Referral Criteria
To be eligible for enrollment into the Observation Avoidance Program, the patient must:
Be referred prior to discharge, and be present in the ED when the MIH Provider arrives
Possess mental capacity to provide informed consent for treatment and management
Be willing to participate in the program and allow MIH Providers into the home for assessment and follow-up
Live in the MIH service area
Be eligible for a follow-up visit within the next 7-days
Program Length
Completion of program is based on the patient's care being successfully transitioned to the PCMH. Term of program will be a mini
mum of 1-day and a maximum of 7-days.
Enrollment
To enroll patients into the program, the MIH Provider will:
• Perform an initial visit and assessment in the ED
• Meet with the patient and referring physician to discuss patient's management following discharge and prior to PCP or
specialist follow-up
• Schedule an appointment with the follow-up care provider within 7-days.
• Explain to the patient the service that will be provided
• Schedule an in -home visit
• Provide the non -emergency contact number to the patient for episodic needs while enrolled in the program.
Any change in the patient's condition, or consultation regarding the patient's condition or treatments, will be communicated •'
to the referring Emergency Department physician or PCMH, for inclusion in the patient record.
Follow-up
The MIH coordinator or Triage Nurse will provide a report to the follow-up provider's office, including the patient's assess-
ment, treatments provided, and any written documentation.
The MIH coordinator or ECNS Nurse will confirm the time of the patient's appointment, remind the patient of the appoint-
ment time, and ensure that the patient has transportation to the follow-up provider's appointment
Unscheduled Home Visits:
The patient will be provided a non -emergency phone number for MIH in the event they would like a phone consultation or an
unscheduled home visit between scheduled visits.
911 Responses
Enrolled patients will be tracked in the computer aided dispatch (CAD) system, and in the event of a 911 call to their resi-
dence, a 911 ambulance response will be initiated, along with a MIH-P who will be dispatched to the scene.
Once on -scene, the MIH-P may be able to intervene and navigate the patient to an alternate source of care, including PCMH,
urgent care, self -care, or by employing of the use of the appropriate CMP protocols.
Record Keeping
Patients enrolled in the program have a continual electronic medical record (EMR) that allows all care providers mobile access to the
patient's entire course of assessments and treatments during enrollment, including care notes, lab values, vital signs, ECG tracings and
treatments initiated. These records can be provided to caregivers in accordance with the Treatment Payment Operations (TPO) defini-
tionsof Health Insurance Portability and Accountability Act (HIPAA).
MOBILE INTEGRATED HEALTHCARE
Oropharyngeal / Nasopharyngeal Swab Procedure
Indications:
Clinical concern for strep pharyngitis
Clinical concern for COVID-19 +/- influenza
Contraindications:
, Recent facial trauma / fracture / surgery
, History of bleeding disorders
, Nasal septal or palate defect
Procedure:
Pearls & Pitfalls:
—> Up to 20% of asymptomatic school -aged children
and 2 5 % of asymptomatic household contacts of chil-
dren with strep throat are colonized with Group -A
Strep
Patients who have recently tested positive for
COVID-19 may remain positive for weeks to months
Wear appropriate PPE for droplet precautions: face mask, gloves, protective eye wear
Ensure patient is in a comfortable position.
Nasopharyngeal Swab
—> Hold swab with a pencil grip and insert horizontally into one nostril parallel to the palate. Insert to
the following depth, or until resistance is met:
1 cm if <2 years
1.5 cm if 2-6 years
2 cm if 6-12 years
2-3 cm if > 12 years
Rotate swab 5 times against the nasal wall.
Remove Swab and insert into transport medium or vial.
Oropharyngeal Swab
Using a tongue depressor, flatten tongue and insert swab. Swab tonsillar beds and back of throat,
avoiding tongue. Rotate tip of swab for 3-5 seconds.
Remove Swab and insert into transport medium or vial.
187
MOBILE INTEGRATED HEALTHC,AR$�
Peak Flow Procedure
This protocol is to be used by an appropriately credentialed Mobile Integrated Health (MIH) Provider as standing orders for patients
enrolled in an approved Mobile Integrated Health program. This protocol may be used in visits requested by partner agencies or 911
calls from program clients. The primary point of contact for all patient consultations is that individual's PCMH primary provider con-
tact or, if unavailable, contact OLMC.
Indications:
Patients with limited or severely restricted expiratory flow
Patients on bronchodilator therapy
Patient able to understand and physically able to attempt the test
Contraindications:
Age or cognition does not enable ability to comprehend or cooperate
Facial condition or neurological condition that alters their ability to do the test.
Respiratory distress level to point patient could deteriorate with testing
Procedure:
• Ensure indicator is at the bottom of the number scale
• Position patient in an upright sitting or standing
• Instruct the patient to hold the peak flow meter horizontal being careful not to block the opening
• Instruct patient to inhale as deeply as possible and then place mouth firmly around the mouthpiece making a
tight seal.
• Instruct patient to blow out as hard and fast as they can through the mouthpiece
• Move the indicator back to the bottom of the scale, and repeat steps 2-5 for two more attempts
• Instruct the patient to repeat this maneuver three times (if able to do so)
• Document the highest reading as the peak flow
*** Please contact the ordering community partner with the results of Peak Flow test***
Zones
Signs & Symptoms
JL�No
No asthma symptoms
Green
nighttime cough
(80% of predicted)
Normal activities
No need for rescue medications
Yellow
Some asthma symptoms
(50-80% of predicted)
Decreased peak flow
Increased asthma symptoms
• •
Decreased in peak flow
Poor or no response to rescue medications
IR
0 MOBILE INTEGRATED HEALTHC,AR$
Admission/Readmission Avoidance Protocol
This protocol is to be used by an appropriately credentialed Mobile Integrated Health (MIH) Provider as standing orders for pa-
tients eligible for, or enrolled in, the Admission/Readmission Avoidance program. Patients at risk for admission/readmission are
referred by the patient's Case Manager or PCMH. The MIH Provider will conduct a series of home visits to educate the patient
and family on appropriate healthcare management, coordinate in -home therapy, schedule a follow-up appointment with the
PCMH, or facilitate emergency transport or navigation to an alternate source of care.
Referral Criteria
To be eligible for enrollment into the Admission/Readmission Avoidance Program, the patient must:
Be referred during an inpatient admission or be at high risk for a preventable readmission
Possess mental capacity to make informed decisions regarding their disease management
Be willing to participate in the program and allow the MIH Providers into their home for assessment and follow-up
—� Have an established relationship with a PCMH
Must live in the MIH service area
Patient may be deemed ineligible for the program if, for example, they are:
Stage-3 or 4 Chronic Kidney Disease (CKD) without an attending nephrologist
—� Pregnant
Age 18-years or younger
Living outside the MIH service area
Currently receiving chemotherapy and/or radiation therapy
Homeless and not living in a shelter
Previously non -adherent with an MIH program
Any case, at any time, may be deemed ineligible and excluded from the MIH program after review by OMD. All reasonable ef-
forts will be made by the MIH Provider to notify the client, PCMH, and home health partners of the client's status.
Scheduled Home Visits
Enrolled patients will receive a series of home visits by an MIH Provider to:
• Educate the patient and family on appropriate management of their disease process, including:
Diet and weight management
Medication compliance
Healthy lifestyle changes
• Educate the patient on how to navigate their primary/specialty care network for the purpose of managing their
disease process, including:
—> When to call for an appointment
—> Important information to share with providers
Unscheduled Home Visits
The patient is provided a non -emergency phone number for MIH in the event they would like a phone consultation or
an unscheduled home visit between scheduled visits.
911 Responses
Enrolled patients will be tracked in the computer aided dispatch (CAD) system, and in the event of a 911 call to their
residence, a 911 ambulance response will be initiated, along with a MIH-P who will be dispatched to the scene.
Once on -scene, the MIH-P may be able to intervene and navigate the patient to an alternate source of care, including
PCMH, urgent care, self -care, or by employing of the use of the appropriate CMP protocols.
In consultation with the patient's PCMH, patients with a Care Management Plan (CMP), e.g. Diabetes, CHF, COPD/
Asthma, can either have their medications adjusted in the field, receive in -home therapy through their CMP, or with the
PCMH. Refer to the appropriate CMP.
IRK
MOBILE INTEGRATED HEALTHCARE
Admission/Readmission Avoidance Protocol
Program Length
Term of program will be a minimum of 30-days and a maximum of 90-days after acceptance into the program, based on
patient compliance and meeting established program goals.
Record Keeping
Patients enrolled in the program have a continual electronic medical record (EMR) that allows all care providers mobile access to the
patient's entire course of assessments and treatments during enrollment, including care notes, lab values, vital signs, ECG tracings and
treatments initiated. These records can be provided to caregivers in accordance with the Treatment Payment Operations (TPO) defini-
tions of Health Insurance Portability and Accountability Act (HIPAA).
MOBILE INTEGRATED HEALTHCARL
Suture/Staple Removal Procedure
This protocol is to be used by an appropriately credentialed Mobile Integrated Health (MIH) Provider as standing orders for
patients enrolled in an approved Mobile Integrated Health program. This protocol may be used in visits requested by part-
ner agencies or 911 calls from program clients.
Indications: Request from a clinician to remove staples or a known type of suture
Contraindications: Signs of wound complications, dehiscence (wound edges do not meet), or infection
Procedure -
Visually assess the wound for uniform closure of the wound edges, absence of drainage, redness, and swelling
Utilize non -sterile gloves and cleanse site with alcohol prep prior to beginning
Simple Interrupted Suture Removal
• Gently grasp the knot or the tail of suture with forceps and raise slightly off skin
• Place the curved tip of the suture scissors directly under the knot or on the side, close to the skin
• Gently snip the suture and remove it with forceps. Never snip both sides of the knot.
• Ensure all suture material is removed and placed on sterile gauze
• Remove every second suture until the end of the wound line.
Assess for signs of dehiscence after each removal (if present see below)
Continue removal until all sutures removed
Staple Removal
• Place the lower jaw of the staple remover under a staple
• Squeeze the handles completely to close the device bending the staple in the middle and pulling the edges of the
staple out of the skin
• Gently move the staple away from the wound once both ends are visible
• Relax pressure on the staple remover's handles to release the staple onto clean gauze. Consider staple disposal
into a sharps container.
• Remove every second staple until the end of the wound line
• Assess for signs of dehiscence (if present see below)
• Continue removal until all staples removed
Post -removal care
• Apply sterile wound strips to reduce likelihood of dehiscence
• Advise patient of ongoing self -care and warning signs for infection
MOBILE INTEGRATED HEALTHCARL
Urinary Catheter (Foley) Malfunction
This protocol is to be used by an appropriately credentialed Mobile Integrated Health (MIH) Provider as standing orders for
patients enrolled in an approved Mobile Integrated Health program. This protocol may be used in visits requested by part-
ner agencies or 911 calls from program clients.
• Review clinical record
• Consult with appropriate partner agency.
• Flush the catheter or remove as necessary
• Re-insert new urinary catheter
If two unsuccessful attempts
Contact appropriate partner agency staff or, if unavailable, contact OLMC
notMOBILE INTEGRATED HEALTHCAR$
Wound VAC Malfunction Protocol
This protocol is to be used by an appropriately credentialed Mobile Integrated Health (MIH) Provider as standing orders for
patients enrolled in an approved Mobile Integrated Health program. This protocol may be used in visits requested by part-
ner agencies or 911 calls from program clients.
• Review clinical record
• Contact appropriate partner agency staff or, if unavailable, contact OLMC
• Remove Wound VAC
• Pack wound with wet to dry dressings
• Cover dressing with 4 X 4 or abdominal pad and secure with tape.
• Notify appropriate partner agency staff
Clititcal Policies
Ambulance Capabilites
1. Purpose. This policy defines the use and designation of all ambulances in the Fort Worth
Regional EMS System (System) to facilitate reliable response to all levels of ambulance calls
and outlines the use of non -transport emergency vehicles.
Scope. This policy applies to EMS ambulance operations, outlining the designation, staffing, and use of BLS
and MICU ambulances, Critical Care non -transport units, and use of non -transport emergency vehicles for
transport under extenuating circumstances.
Unit Inventory and Staffing Requirements.
3.1. BLS Ambulances are "Basic Life Support with MICU Capability" units.
3.1.1. Such units shall be equipped and staffed as required by the Texas Department of State Health
Services EMS Provider License regulations, contractual requirements, and FWOMD requirements.
They must be equipped, at a minimum, to support the Basic level of protocol.
3.1.2. Basic credentialed personnel may be assigned to work on BLS Ambulances with at least a Basic
credentialed partner and may function within stated policy, protocol, and credentialed scope of
practice.
3.2. MICU Ambulances are "MICU Ambulance" units.
3.2.1. Such units shall be equipped and staffed as required by the Texas Department of State Health
Services EMS Provider License regulations, contractual requirements, and FWOMD requirements.
3.2.2. Paramedic credentialed personnel may be assigned to work on MICU Ambulances with at least a
Basic credentialed partner and may function within stated policy, protocol, and credentialed scope
of practice.
3.3. Critical Care non -transport units.
3.3.1. Such units shall be equipped and staffed as required by agreement and FWOMD requirements.
3.3.2. CCP credentialed personnel may be assigned to work on critical care non -transport units and may
function within stated policy, protocol, and credentialed scope of practice.
4. Appropriate use of Non -Transport Emergency Vehicles
4.1. Non -transport emergency vehicles may be used under the following circumstances in the transport of
patients when concern for emergent transport exists and a transport unit is not immediately available:
4.1.1. MCI with > 10 patients
4.1.1.1.Alternate transport considerations have been exhausted
4.1.1.2.Intercept with responding transport unit should be attempted (including Air Medical)
4.1.1.3.An attendant should be present during transport when available
4.1.1.3.1.Attendant should have the highest appropriate level of EMS or other medical licensure
or certification available if possible
4.1.1.4.Transport patient to the closest appropriate hospital
4.1.1.5.Patient should be transported in an enclosed environment as available
4.1. L6.Patient should be appropriately restrained in the vehicle if it will not compromise patient well-
being
4.1.2. All other situations
4.1.2.1.Contact On-line Medical Control for further transport guidance
Ambulance Capabilites
5. Appropriate use of BLS Ambulances
5.1. BLS Ambulances may be used for BLS eligible patients described by the protocol and operate under the
Basic protocols and procedures.
6. Appropriate use of MICU Ambulances
6.1. MICU Ambulances may be used for any patient and operate under the Paramedic protocol and
procedures.
7. Appropriate use of Critical Care non -transport units
7.1. Critical Care non -transport units may be used to supplement BLS and ALS ambulance personnel as
described by protocol and operate under the CCP protocols and procedures.
Changes in Patient Condition While Engaged in Transport.
8.1. Any treatment beyond the clinician's credentialed scope of practice must be ordered by direct on-line
medical direction. In case the condition of a patient deteriorates, personnel should provide the indicated
stabilization within their scope, immediately notify Medical Control, and request appropriate orders. If it
is an inter -facility transfer that originated at a hospital, the team should return to the facility if still near
the sending facility; otherwise, transport should continue to the receiving facility. In extreme cases,
proceed to the nearest appropriate facility for additional evaluation of the patient.
Comprehensive Clinical Management Program
1. Purpose. This policy addresses the Comprehensive Clinical Management Program (CCMP) for the Fort
Worth Regional EMS System (System). Additionally, it addresses credentialed provider eligibility,
tracking, and approval of the CCMP renewal option with Texas Department of State Health Services
(DSHS).
Scope. This policy applies to System personnel credentialed within the System for at least six months.
Procedure
3.1. Definitions
3.1.1. CCMP - Comprehensive Clinical Management Program is a recertification / relicensure training
program coordinated by the Fort Worth Office of the Medical Director (FWOMD) for System
credentialed personnel employed by or affiliated with the System in meeting the recertification
or re-licensure requirements outlined in TAC §157.34(b)(5).
3.1.2. CCMP Participation — All credentialed FWFD providers are eligible to participate in the
CCMP.
3.1.3. Renewal- The renewal process for a system provider to renew their DSHS EMS certification.
3.2. CCMP Professional Development Hours
3.2.1. The System will provide, at a minimum, the following amounts of professional development
hours per year: Paramedic -24 hours, AEMT -20 hours, EMT -16 hours, and ECA -10 hours.
3.2 Eligibility
3.2.1. Any System personnel who meet the FWOMD Credentialing Requirements policy and have
been credentialed for a minimum of six months within the system.
4. Process
4.1 Process
4.1.1. Upon credentialing, System providers will receive a credentialing letter stating the date of
credentialing as well as the date of CCMP participation eligibility. CCMP eligibility date will
be six months post -credential date.
4.1.2. The System will provide annually the number of professional development hours listed in 3.2.1
to comply with the CCMP program and this policy.
4.1.3. A 90-day certification expiration report will be generated at the end of each month. CCMP
Coordinator will verify biennial maintenance credentialing requirements per OMD
Credentialing Requirements policy and DSHS approved EMS Jurisprudence course have been
completed.
4.1.4. Upon completion of the biennial maintenance requirements, a letter will be sent on behalf of
the System Medical Director to the individual stating their current participation in the
CCMP.
4.1.5. Individuals will submit a renewal application, selecting the CCMP Recertification Option,
including their CCMP participation letter to DSHS.
4.1.6. All continuing education programs provided or sponsored by the System must be approved
by the FWOMD to ensure consistency with the System Medical Director's practice of
medicine and alignment with current protocol, procedure, and quality improvement
initiatives.
Credentialing Requirements
Purpose: This policy describes the initial and maintenance requirements of credentialing for Fort Worth
Regional EMS System (System) clinicians to provide patient care.
2. Scope: This policy applies to all state -licensed personnel that provide clinical care within the EMS System
Definitions
3.1. DSHS - Texas Department of State Health Services
3.2. IBSC — International Board of Specialty Certification
3.3. PRM - Protocol Review Module
3.4. PIM - Process Improvement Module
3.5. System CE — continuing education provided by FWOMD or System providers in support of licensure
maintenance
3.6. FTO — agency assigned field training officer who mentor and evaluate individuals for credentialing
3.7. Skills competency assessment — psychomotor skills evaluation to be conducted by FWOMD or Agency
FTO
3.8. Clinical competency verification — the agency's established field training in verifying FWOMD clinical
competencies conducted by an agency FTO
3.9• MegaCode evaluation — scenario -based protocol application assessments of a medical, trauma, adult,
pediatric, and infant resuscitation
3.10. Clinical Credentialing Interview (CCI) — table -top case presentation conducted by FWOMD as the final
evaluation step to credentialing of EMT provider
3.11.Mock interview — table -top case presentation conducted by FWOMD to assess readiness for Medical
Director Interview
3.12.Medical Director Interview (MDI) — table -top case presentation conducted by a Medical Director or
designated EMS Fellow as the final evaluation step to credentialing of Paramedic, Mobile Health
Paramedic, and Critical Care Paramedic provider
4. Process
4.1. On -boarding
4.1.1.Notify FWOMD of new hire and level of credential to be pursued
4.1.2.Individual must hold a current, verified by FWOMD, DSHS or National Registry
(EMT/Paramedic)
4.1.2.1. Must hold board certification from IBSC in Critical Care or Community Paramedic for
the critical care or mobile health paramedic credential
4.1.3.Individual must complete an on -boarding process that includes, at a minimum, a comprehensive
orientation process consisting of the services, policies and procedures, treatment and transport
protocols, safety precautions, and the quality management process of the EMS System and their
specific agency.
4.1.4. Prior to Field Training, the individual must:
4.1.4.1. Hold a current, verified, DSHS and, if needed, critical care or mobile health paramedic
certification for the credential level sought
4.1.4.2. Complete FWOMD Clinical NEOP
4.1.4.3. Complete FWOMD approved cardiac resuscitation course
4.1.4.4. Complete clinical knowledge assessment
4.1.5.Other components of credentialing may be accomplished in field training or lab
4.1.5.1. Skills competency assessment
4.1.5.2. Clinical competency verification
4.1.5.3. MegaCode evaluation as required
4.1.5.4. Patient contacts that include ambulance transport
4.1.6.Final interview and recommendation
4.1.6.1. Upon completion of all components of credentialing, a recommendation for credentialing
is to be submitted to FWOMD by the training officer
Credentialing Requirements
4.1.6.1.1. For Paramedic, MHP, and CCP credentialing, upon receipt of the recommendation
for credentialing, a Medical Director interview will be scheduled
4.1.7.The agency is required to maintain a copy of all documentation of the components of credentialing
4.1.8.FWOMD will provide and maintain a letter of credentialing to the agency for documentation
purposes upon verification of successful completion of all components of credentialing
4.2. Maintenance
4.2.1. FWOMD will conduct monthly audits to validate compliance with maintenance requirements of
credentialing to include verification of current state certification
4.2.2.Providers must maintain an FWOMD approved card course certification or successfully complete
the appropriate MegaCode assessment for their respective discipline
4.2.3.By state regulations, providers must complete an annual PRM on Allergic Reaction/Anaphylaxis
4.2.4.Every two years (biennial), credentialed providers must complete the required maintenance of
credentialing components listed within their respective credential level
4.2.4.1. The agency will submit active roster and all credentialing documentation upon
FWOMD request
4.2.5.All PIMs must be completed within the designated timeframe during the maintenance period, all
other components must be completed by the end of the two-year maintenance cycle
4.3. See FWOMD policy, Examination and Testing, for requirements regarding skill assessment, clinical
competency verification, and MegaCode evaluation along with retesting and credentialing interviews
Emergency Care Attendants (ECA)
5.1. Initial Requirements:
5.1.1. Current ECA by the DSHS
5.1.2.Completion of FWOMD approved cardiac resuscitation course
5.1.3.Completion of agency specific on -boarding process to include:
5.1.3.1. Completion of all Basic PRMs
5.1.3.2. Completion of National Registry EMR skills assessment
5.2. Maintenance requirements:
5.2.1. Current ECA by the DSHS
5.2.2.Current FWOMD approved cardiac resuscitation course
5.2.3.Completion of all Basic PRMs
5.2.4.Current with all PIMs
5.2.5. Completion of National Registry EMR skills assessment
6. Basic (EMT-B, A -EMT, or EMT-P/LP)
6.1. Initial Requirements:
6. 1. 1. Current EMT-B (or above) by the DSHS
6.1.2.Completion of FWOMD approved cardiac resuscitation course
6.1.3. Completion of agency specific on -boarding process to include:
6.1.3.1. Completion of FWOMD clinical NEOP
6.1.3.2. Completion of Basic clinical knowledge assessment
6.1.3.3. Completion of the Basic skills competency assessment
6.1.3.4. Completion of clinical competency verification program (Field Training)
6.1.3.4.1. Includes patient contacts with ambulance transport
6.1.4.Completion of CCI by FWOMD.
6.2. Maintenance requirements:
6.2.1. Current EMT-B (or above) by the DSHS
6.2.2.Current FWOMD approved cardiac resuscitation course
Credentialing Requirements
6.2.3.Completion of all Basic PRMs
6.2.4.Current with all PIMs
6.2.5.Completion of the Basic skills competency assessment
7. Paramedic (EMT-P/LP)
7.1. Initial requirements:
7. L L Current Paramedic (EMT-P/LP) by the DSHS
7.1.2.FWOMD approved cardiac resuscitation course
7.1.3. Completion of agency specific on -boarding process to include:
7.1.3.1. Completion of FWOMD clinical NEOP
7.1.3.2. Completion of the Paramedic skills competency assessment
7.1.3.3. Completion of System MegaCodes
7.1.3.4. Completion of clinical competency verification program (Field Training)
7.1.3.4.1. Includes patient contacts with ambulance transport
7.1.3.5. Completion of mock interview by FWOMD
7.1.4.Completion of MDI by a Medical Director or designated EMS Fellow
7.2. Maintenance Requirements:
7.2.1. Current Paramedic (EMT-P/LP) by DSHS.
7.2.2.Current FWOMD approved cardiac resuscitation course
7.2.3. Completion of all PRMs
7.2.4. Current with all PIMs
7.2.5. Completion of System MegaCode verification
7.2.6. Completion of the Paramedic skills competency assessment
Mobile Healthcare EMT — MH-EMT (EMT, EMT -I, EMT-P/LP)
8.1. Initial requirements:
8.1.1. Meet Basic level credentialing requirements.
8.1.2. Completion of an approved Mobile Healthcare Paramedic Course
8.1.3. Completion of all MIH PRMs
8.1.4. Completion of the MIH skills competency assessment
8.1.5.Completion of clinical competency verification program (Field Training)
8.1.6.Completion of MH-EMT MDI by FWOMD
8.2. Maintenance Requirements:
8.2.1.Meet Basic credential maintenance requirements
8.2.2.Completion of all MIH PRMs
8.2.3. Current with all MIH PIMs
8.2.4.Completion of the MIH skills competency assessment
9. Mobile Healthcare Paramedic — MHP (EMT-P or LP)
9.1. Initial requirements:
9.1.1.Meet Paramedic level credentialing requirements.
9.1.2.Completion of an approved Mobile Healthcare Paramedic Course
9.1.3.Hold IBSC Community Paramedic certification (CP-C)
9.1.4. Completion of all MIH PRMs
9.1.5. Completion of the MIH skills competency assessment
9.1.6.Completion of MHP clinical competency verification program (Field Training)
9.1.7.Completion of mock interview by FWOMD
9.1.8. Completion of MHP MDI by a Medical Director
Credentialing Requirements
9.2. Maintenance Requirements:
9.2.1.Meet Paramedic credential maintenance requirements
9.2.2.Current Community Paramedic certification (CP-C)
9.2.3. Completion of all MIH PRMs
9.2.4. Current with all MIH PIMs
9.2.5. Completion of the MIH skills competency assessment
10. Critical Care Paramedic - CCP (EMT-P or LP)
10.1. Initial requirements:
10.1.1. Meet Paramedic level credentialing requirements.
10.1.2. Completion of an approved Critical Care Paramedic Course
10.1.3. Hold IBSC Critical Care Paramedic certification (CCP-C or FP-C)
10.1.4. Completion of CCP PRMs
10.1.5. Completion of CCP clinical knowledge exam
10.1.6. Completion of the CCP skills competency assessment
10.1.7. Completion of CCP clinical competency verification program (Field Training)
10.1.8. Completion of mock interview by FWOMD
10.1.9. CCP-MDI and recommendation by a Medical Director.
10.2. Maintenance Requirements:
10.2.1. Meet Paramedic credential maintenance requirements
10.2.2. Current Critical Care Paramedic certification (CCP-Cor FP-C)
10.2.3. Completion of any assigned continuing education
10.2.4. Completion of all CCP PRMs
10.2.5. Current with all PIMs
10.2.6. Completion of the CCP skills competency assessment
11. Extended Absence — Return to Work Re-credentialing
11.1. <_ 60-days absent
11.1.1. Current required certification(s)
11.1.2. Complete any new PRMs
11.1.3. Complete any new PIMs
11.1.4. Complete any new skill assessment
11.2. > 60 to 120 days absent
11.2.1. Current required certification(s)
11.2.2. Complete all PRMs
11.2.3. Complete all current PIMs
11.2.4. Complete new skills assessment
11.2.5. Complete MegaCode verification
11.2.5.1. Failure of MegaCode will result in FTO time with specific objectives to be
accomplished prior to MegaCode reverification
11.2.6.
11.3. > 120 to 365 days absent
11.3.1. Complete initial requirements of credentialing for desired level with exception of credentialing
interview
11.3.2. Complete all current PIMs
Credentialing Requirements
11.4. > 365 Days
11.4.1. Complete the initial requirements of credentialing for desired level
11.4.2. Complete all current PIMs
Deceased Patient Transport
1. Purpose. To address the procedure for patients who are declared deceased while in an ambulance or where
scene factors are unsafe or inappropriate to leave the body on scene. Transport of patients who do not
respond to appropriate resuscitative efforts presents risks to crew safety, consumes critical ED/hospital
resources, provides false hope for patient's families, and leads to unnecessary expenses.
Scope. This policy applies to all FWOMD-credentialed providers.
Inclusion criteria
3.1. Patients who have all the following criteria
3.1.1. An online medical control physician has as given an order to terminate resuscitative efforts.
3.1.2. The body is in an ambulance OR a location that is deemed by Incident Command and Law
Enforcement to be either unsafe or inappropriate to leave on scene.
3.1.3.Death occurred in Tarrant County Medical Examiner's District jurisdiction
3.1.4. Death felt likely to be determined by ME staff to be ME case:
3.1.4.l.Traumatic arrest
3.1.4.2.Death by, or suspected to be by, suicide.
3.1.4.3.Medical arrest not under direct care of a physician (e.g., hospice, home health care)
4. Exclusion criteria
4.1. Death not in Tarrant County Medical Examiner District
4.2. Death occurred in health care institution (hospital, nursing facility)
4.3. Death in any location where it is safe & appropriate to leave body on scene
5. Procedure
5.1. Ensure all inclusion and no exclusion criteria are met
5.2. Contact the Medical Examiner Forensic Investigator at 817-920-5700, option 5 and discuss the case
and confirm it is appropriate to transport to ME office.
5.2.1.If Forensic Investigator approves:
5.2.1.1. Transport body without lights and sirens to ME office at 200 Feliks Gwozdz Pl. Fort
Worth, TX 76104
5.2.2.If Forensic Investigator declines:
5.2.2.1. Contact the closest appropriate hospital via phone and speak with the ED charge nurse to
inform them that an online medical control physician has declared the patient deceased
and the body is being transported without resuscitative efforts to their ED due to on scene
circumstances.
5.2.2.1.1. Note: Approval by hospital staff is not required, this is a courtesy report.
5.2.3.Transport the body without further resuscitative efforts and without use of lights & sirens to the
hospital report was called to.
5.3. Contact EMS Supervisor for any concerns or disputes.
Do Not Resuscitate
1. Purpose. Chapter 166 of the Health and Safety Code establishes Out -of -Hospital Do -Not -
Resuscitate (OOH DNR) Orders. The chapter allows the development of a local DNR policy that
complies with the State-wide DNR protocol adopted by the Board of Health.
2. Scope. This policy applies to all System providers and in all cases of out -of -hospital events including
cardiac arrests that occur during inter -facility transports.
DNR Form and Identification of Patients.
3.1. EMS personnel may only accept the original or a copy of the standardized OOH DNR Order
3.2. EMS personnel may accept an approved OOH DNR bracelet or necklace (identification device) as
proof that an OOH DNR order form has been executed by or issued on behalf of the person wearing
the identification device.
3.3. When presented with a "DNR Order," EMS personnel should make every effort to identify the
patient as the person for whom the OOH DNR Order has been executed or issued. Relatives, friends,
neighbors, documents, ID bracelets, or other identification may be used as sources of identification.
4. Honoring an OOH DNR Order.
4.1. When presented with a DNR Order, EMS personnel are to review the form to make sure that it is
correctly completed and signed as required by the Health and Safety Code. If the order appears valid,
the OOH DNR Order shall be honored.
4.2. EMS personnel are not required to honor an OOH DNR Order that does not comply with the Health
and Safety Code.
Revocation of an OOH DNR Order.
5.1. The patient may revoke an OOH DNR Order, or the patient may direct someone in his or her
presence to destroy the order and remove the patient's identification device.
5.2. A qualified relative, legal guardian or patient's agent having medical power of attorney (or a
person acting on behalf of any of these persons) may revoke the OOH DNR Order.
5.3. The patient's physician may revoke the OOH DNR Order.
5.4. In case of a revocation of the OOH DNR Order, EMS personnel shall document the name of the
person who revoked the order, the date, time, and location of the revocation.
5.5. Upon revocation of the OOH DNR Order, EMS personnel shall provide care for the patient as
required by protocol. This does not mean EMS must begin resuscitation if deemed futile per the
Withholding Protocol.
6. Disputes related to OOH DNR Orders. In case a dispute arises regarding an OOH DNR Order,
EMS personnel shall contact On -Line Medical Control (OLMC) for direction and assistance.
7. Pregnant Persons and OOH DNR Orders. EMS personnel may not withhold cardiopulmonary
resuscitation or certain other life -sustaining treatment from a person known to be pregnant unless
futility criteria are met as per the Withholding Protocol.
8. Other presented paperwork or request for termination. Contact OLMC dpresented with other
request to withhold resuscitation efforts such as a verifiable Medical Power of Attorney (mPOA), Medical Orders
on Scope of Treatment (MOST), Physician's Orders for Life -Sustaining Treatment (POLST) or any request by
family members on -scene.
Figure: 25 TAC §157.25 (h)(2) OUT -OF -HOSPITAL DO -NOT -RESUSCITATE (OOH-DNR) ORDER
_&0 TEXAS DEPARTMENT OF STATE HEALTH SERVICES I Print Fonn
1162012) DO NOT This document becomes effective immediately on the date of execution for health care professionals acting in out -of -hospital settings. It remains in effect until
RESUSCITATE the person is pronounced dead by authorized medical or legal authority or the document is revoked. Comfort care will be given as needed.
Male
Person's full legal name Date of birth El Female
A. Declaration of the adult person: I am competent and at least 18 years of age. I direct that none of the following resuscitation measures be initiated or continued for me:
cardiopulmonary resuscitation (CPR), transcutaneous cardiac pacing, defibrillation, advanced airway management, artificial ventilation.
Person's signature Date Printed name
B. Declaration by legal guardian, agent or proxy on behalf of the adult person who is incompetent or otherwise incapable of communication:
I am the: ❑ legal guardian; ❑ agent in a Medical Power of Attorney; OR Elproxy in a directive to physicians of the above -noted person who is incompetent or otherwise
mentally or physically incapable of communication.
Based upon the known desires of the person, or a determination of the best interest of the person, I direct that none of the following resuscitation measures be initiated or continued for the
person: cardiopulmonary resuscitation (CPR), transcutaneous cardiac pacing, defibrillation, advanced airway management, artificial ventilation.
Signature Date Printed name
C. Declaration by a qualified relative of the adult person who is incompetent or otherwise incapable of communication: I am the above -noted person's:
spouse, adult child, r parent, OR r nearest living relative, and I am qualified to make this treatment decision under Health and Safety Code §166.088.
To my knowledge the adult person is incompetent or otherwise mentally or physically incapable of communication and is without a legal guardian, agent or proxy. Based upon the known desires of
the person or a determination of the best interests of the person, I direct that none of the following resuscitation measures be initiated or continued for the person: cardiopulmonary
resuscitation (CPR), transcutaneous cardiac pacing, defibrillation, advanced airway management, artificial ventilation.
Signature Date Printed name
D. Declaration by physician based on directive to physicians by a person now incompetent or nonwritten communication to the physician by a competent person: I am the above -noted
person's attending physician and have:
r seen evidence of his/her previously issued directive to physicians by the adult, now incompetent; OR r observed his/her issuance before two witnesses of an OOH-DNR in a nonwritten manner.
I direct that none of the following resuscitation measures be initiated or continued for the person: cardiopulmonary resuscitation (CPR), transcutaneous cardiac pacing, defibrillation,
advanced airway management, artificial ventilation.
Attending physician's Printed Lic
signature Date name #
E. Declaration on behalf of the minor person: I am the minor's: ❑ parent; ❑ legal guardian; OR ❑ managing conservator.
A physician has diagnosed the minor as suffering from a terminal or irreversible condition. I direct that none of the following resuscitation measures be initiated or continued for the person:
cardiopulmonary resuscitation (CPR), transcutaneous cardiac pacing, defibrillation, advanced airway management, artificial ventilation.
Signature Date
Printed name
TWO WITNESSES: (See qualifications on backside.) We have witnessed the above -noted competent adult person or authorized declarant making his/her signature above and, if applicable, the
above -noted adult person making an OOH-DNR by nonwritten communication to the attending physician.
Witness 1 signature Date Printed name
Witness 2 signature Date Printed name
Notary in the State of Texas and County of . The above noted person personally appeared before me and signed the above noted declaration on this date:
Signature & seal: Notary's printed name: Notary Seal
[ Note: Notary cannot acknowledge the witnessing of the person making an OOH-DNR order in a nonwritten manner ]
PHYSICIAN'S STATEMENT: I am the attending physician of the above -noted person and have noted the existence of this order in the person's medical records. I direct health care professionals
acting in out -of -hospital settings, including a hospital emergency department, not to initiate or continue for the person: cardiopulmonary resuscitation (CPR), transcutaneous cardiac
pacing, defibrillation, advanced airway management, artificial ventilation.
Physician's signature Date
Printed name License #
F. Directive by two physicians on behalf of the adult, who is incompetent or unable to communicate and without guardian, agent, proxy or relative: The person's specific wishes are unknown, but resuscitation measures
are, in reasonable medical judgment, considered ineffective or are otherwise not in the best interests of the person. I direct health care professionals acting in out -of -hospital settings, including a hospital emergency
department, not to initiate or continue for the person: cardiopulmonary resuscitation (CPR), transcutaneous cardiac pacing, defibrillation, advanced airway management, artificial ventilation.
Attending physician's Date Printed Lic# signature name
Signature ofsecond physician Date Printed Lic#
name
Physician's electronic or digital signature must meet criteria listed in Health and Safety Code §166.082(c).
All persons who have signed above must sign below, acknowledging that this document has been properly completed.
Person's signature Guardian/Agent/Proxy/Relative signature
Attending physician's Second physician's signature
signature
Witness 1 Witness Notary's.
signature signature signature
This document or a copy thereofmust accompany the person during his/her medical transport.
Emergency 911 Calls from within a hospital
1. Purpose. This policy addresses when a patient calls for an ambulance within a hospital. This policy does
not apply when a person or patient is calling from other types of care facilities.
2. Scope. This policy applies when a person contacts the Fort Worth Fire Alarm Office (FAO) from within a
hospital requesting an ambulance for care. This policy describes the procedure to follow when providing
care to this patient.
Appropriate action to follow. If a person within a hospital contacts the FAO requesting an ambulance,
the following procedure will be followed:
3.1. Properly EMD the call: The call will be screened utilizing current procedures and then confirm
that the patient is calling from within the hospital.
3.2. Provide instructions: If the person is calling from within the hospital, they should be
instructed to immediately report to the Triage Nurse or Charge Nurse and inform them that
they have contacted 911 requesting an ambulance.
3.2. 1. Explain to the person that an ambulance may not be dispatched by their request and that
it must be requested by the hospital personnel.
3.3. Contact the Hospital: The Communications Specialist should immediately contact the charge
nurse of that ED or hospital by phone and advise them of the situation.
3.4. If the person is outside of the hospital: If the patient requesting the ambulance is outside of
the hospital, or there is any confusion, the Communications Specialist should follow regular
911 call procedures. If the patient is on hospital grounds, transport should be to that hospital's
emergency department.
4. If the hospital then requests an ambulance: If the hospital requests an ambulance for the patient, the
Communications Specialist should follow the process for inter -facility transfer.
Emergency Care Attendants
1. Purpose. The purpose of this policy is to establish care guidelines for First Responders trained
at the Emergency Care Attendant (ECA; Texas Department of State Health Services) /
Emergency Medical Responder (EMR; National Registry of EMTs)
2. Scope. This policy applies to all Fort Worth Regional EMS System (System) providers credentialed at the
ECA / EMR Level.
3. Protocol variations. ECA / EMR providers will generally operate under the "Basic" level in the System
protocols, with the following modifications. ECA / EMR:
3.1. May provide general first aid as per Basic level protocols.
3.2. May administer oxygen as per protocol at the Basic level.
3.3. Are required to have available epinephrine auto -injectors and be trained in their use; they may not
administer IM injections otherwise.
3.4. May administer naloxone (Narcan) as per the Basic level protocol for suspected opioid intoxication;
they may not administer intra-nasal medications otherwise.
3.5. Are permitted to assist with patient self -administration of nitroglycerin (already prescribed and
available on -scene) if the systolic blood pressure is greater than 100, as per the Acute Coronary
Syndrome/STEMI protocol.
3.6. May administer aspirin as per the Acute Coronary Syndrome/STEMI protocol.
3.7. May administer oral glucose as per the Altered Mental Status and Diabetic Emergencies protocols.
3.8. May administer Isopropyl Alcohol as per the Adult and Pediatric Nausea and Vomiting protocol.
3.9. May not administer CPAP.
3.10. May not administer nebulized medications.
3.11. May not perform spinal motion restriction; patients who may have suffered spinal trauma should
have manual cervical spine stabilization performed until higher -level providers arrive.
4. Required medications/equipment for ECA / EMR First Responders:
4.1. Oxygen, with BVM, nasal cannula, and non-rebreather devices in both adult and child sizes
4.2. Emergency childbirth kit
4.3. Epinephrine auto -injector in both pediatric and adult doses
4.4. Aspirin
4.5. Oral glucose
4.6. Naloxone
4.7. Isopropyl Alcohol pads
4.8. Basic bandaging / splinting materials
4.9. Blood pressure cuff with stethoscope
4.10. Glucometer
4.11. Manual suction device
Equipment Failure
1. Purpose. This policy describes the process of reporting equipment failures
2. 2. Scope. This procedure applies to all Fort Worth Regional EMS System (System) providers who
experience an equipment failure while providing patient care.
3. Overview. If while rendering patient care, a provider experiences a failure of any piece of equipment, it
must be reported to FWOMD and as per the agency's policy. This may also include the manufacturer and
the proper State/Federal agencies.
4. The Process.
4.1. The provider experiencing the equipment failure should retain the specific item and all associated
components if possible.
4.2. Package the item in a biohazard bag if it is contaminated with human fluids.
4.3. Turn the item into their agency's designated individual as stated in their policies & procedures.
4.4. The Agency should then report the failure to the FWOMD and follow agency policy and procedures
for reporting requirements to the manufacturer and potentially State and/or Federal agencies.
Examination and Testing
1. Purpose. The FWOMD relies on periodic examinations, verifications, and competency
evaluations as tools to assess retention of required knowledge, protocol application, and
mastery of skill performance among credential EMS clinicians.
2. Scope. This policy applies to all Fort Worth Regional EMS System (System) providers
seeking initial credentialing or maintenance of current credentials.
3. Procedure.
3.1.1.1. All System providers are required to pass the following verification
exams/evaluations to be credentialed:
3.1.2. Clinical Knowledge Assessment,
3.1.2.1. A multiple-choice scenario exam evaluating protocol application and
understanding for protocols that do not have an associated PRM.
3.1.2.2. Exam pass score is 78976 with three (3) attempts
3.1.2.3. Clinicians may utilize the protocol app during testing
3.1.3. Successful completion of a skills verifications packet for credential level
3.1.3.1. Each skill associated with the scope of practice of the credentialed level will be
evaluated utilizing a standardized skill verification process
3.1.4. MegaCode evaluation for medical and trauma, along with adult, pediatric, and infant
resuscitation.
3.1.4.1. MegaCode evaluation is a standardized scenario -based protocol application
assessment required for credentialing at the Paramedic level and above
3.2. Clinical Credentialing Interview (CCI)
3.2.1. The CCI is the final step in the credentialing of an individual seeking to be credentialed
at any level below Paramedic
3.2.2. The CCI is a table -top case presentation conducted by FWOMD to assess individuals'
readiness to function independently in the System
3.3. Medical Director Interview (MDI)
3.3.1. Mock -Medical Director Interview
3.3.1.1.The Mock-MDI is a table -top case presentation conducted by FWOMD to assess
individuals' readiness for their credentialing MDI
3.3.2. MDI
3.3.2.1.The MDI is the final step in the credentialing of an individual seeking to be
credentialed at the Paramedic level or higher.
3.3.2.2.The MDI will be scheduled at the recommendation of FWOMD after a Mock
MDI has been conducted in assessment of readiness
3.3.2.3.The MDI is a table -top case presentation conducted by a Medical Director or
designated EMS Fellow to assess individuals readiness to function independently
in the EMS System
3.3.2.3.1.The MDI at the MHP and CCP credential level will be conducted by a
Medical Director
Examination and Testing
3.4. Exam / Evaluation Attempts
3.4.1. Clinical Knowledge Assessment Exam
3.4.1.1.Three (3) attempts are provided with mandatory review sessions between 2" d and
Yd attempt with FWOMD or Agency Training Officer.
3.4.2. Protocol Review Modules
3.4.2.1. Unlimited attempts are given at agency's discretion
3.4.2.2. Upon failing to meet the 80% or agency defined passing score, the individual
must rewatch the PRM to attempt the exam again
3.4.3. Skills verification
3.4.3.1. Unlimited attempts for each skill verification at agency's discretion
3.4.3.2. Remediation is to be provided between each failed attempt
3.4.3.3. Should it be determined the individual will not be successful, the individual will
be eligible to credential at a lower level at the agency's discretion.
3.4.4. Clinical application scenarios (MegaCodes)
3.4.4.1. Individual is given 3 attempts, at least 72 hours a part
3.4.4.2. If unsuccessful on the third attempt, the individual must successfully complete
the corresponding card course of the MegaCode scenario failed
3.4.4.2.1. Corresponding card course with MegaCode
3.4.4.2.1.1. AMLS = Medical
3.4.4.2.1.2. PHTLS = Trauma
3.4.4.2.1.3. ACLS = Adult Resuscitation
3.4.4.2.1.4. PALS = Pediatric / Infant
3.4.4.2.2. Upon presenting a valid course completion card, the individual will then be
expected to pass the specific MegaCode. Next steps, should the MedgaCode
again be failed, will be at the discretion of the System Medical Director and
agency.
3.4.4.3. If unsuccessful in passing the corresponding card course, the individual will be
eligible to credential at a lower level at the agency's discretion
3.4.5. Clinical Credentialing Interview
3.4.5.1. Individuals are given 3 attempts, at least 24 hours a part
3.4.5.2. If unsuccessful on the third attempt, the individual will be eligible to credential at
a lower level at the agency's discretion
3.4.6. Mock Medical Director Interview
3.4.6.1. Individuals are given 3 attempts, at least 24 hours a part
3.4.6.2. If unsuccessful on the third attempt, the individual will be eligible to credential at
a lower level at the agency's discretion
3.4.7. Medical Director Interview
3.4.7.1. Individuals are given 3 attempts, at least 24 hours a part
3.4.7.2. If unsuccessful on the third attempt, the individual will be eligible to credential at
a lower level at the agency's discretion
Examination and Testing
3.5. If an individual fails at any required component of credentialing, they may be offered a lower -
level credential if available at agency's discretion and System Medical Director agreement.
3.5.1. The individual's ability and timeframe to reenter the credentialing process is at the
agency's discretion
3.6. Maintaining Credentialing
3.6.1. All existing credentialed personnel within the System are required to follow all
requirements listed in the Continuing Education Policy and the Credentialing
Requirements Policy to maintain their FWOMD credential.
3.6.2. Individuals are responsible for gathering their own study materials. OMD will provide
an electronic copy of the approved protocols and any course material that may be required.
Field Training Officers
Purpose. The FWOMD is responsible for credentialing emergency medical services personnel. That
process depends on the integrity of the Field Training Officer (FTO) program within the Fort Worth
Regional EMS System (System). The objective of the FTO Selection Process is to assure that a
standardized method for selection of FTOs will be used in a consistent manner and to assure that the
System Medical Director or designee will participate in the selection process.
2. Scope. The FTO assignment procedure applies to System agencies.
While the System Medical Director or designee is a participant in the selection of FTOs, these personnel
are employees of that individual agency and must comply with their specific policies.
3. The Selection Process. Each agency is responsible for organizing the FTO selection process.
At minimum, the Agency shall implement a non -biased, non-discriminatory selection process that
allows candidates to compete based on their qualifications. The System Medical Director or designee
shall be a participant in the selection process.
4. Final Selection. The System Medical Director or designee will provide the agency with written
confirmation of recommended candidates. The System Medical Director, in cooperation with the agency,
shall have final approval of all FTO personnel.
5. Allowance for alternate training programs: If a First Responder agency does not use an FTO-based
process, the clinical training process for that agency will be reviewed and approved by the System Medical
Director.
6. Due to the diverse nature of FRO training, individual FRO agencies will work with OMD to develop
agency -specific FTO selection criteria and training.
Helicopter EMS
1. Purpose. The FWOMD is responsible for establishing guidelines for the role of helicopter utilization
in emergency care. The FWOMD recognizes the benefit of this specialized service but also realizes it
must be used appropriately and safely.
2. Scope. This policy applies to Fort Worth Regional EMS System (System) providers responsible for
initiating a helicopter response. All HEMS requests must be done through the Fort Worth Fire
Alarm Office (FAO).
Appropriate use of helicopter transport. There are circumstances that will require the
expeditious use of HEMS transport. These include, but are not limited to:
3.1. Patient inaccessible due to terrain or environmental conditions (i.e., high water, mud, rough
terrain).
3.2. Extended travel time of a critical patient (greater than 30 minutes) to an appropriate receiving
facility due to distance or traffic.
3.3. As an additional resource during a Mass Casualty Incident (MCI) with critically injured patients.
4. Requesting Emergency Helicopter Support.
4.1. Initiating a Standby/Launch Request. "Standby" status places the helicopter crew on alert for
possible scene response. A launch order or "alert go physically request the helicopter and flight crew
to lift-off and proceed to the requested location. Provide the height and weight of the patient (if
known) at the time of launch request. A standby/launch request through the FAO may be initiated
by any of the following:
4.1.1.Any first responding unit or ambulance.
4.1.2. Fire and Civil Defense personnel.
4.1.3. State and Local Law Enforcement personnel.
4.1.4.Industrial safety personnel.
4.2. Who May Cancel the Helicopter: Once launched the helicopter will only be cancelled by:
4.2. LThe initiating official/agency or Paramedic provider on -scene after patient contact
has been established, and:
4.2.1.1. Performance of a proper patient assessment, and
4.2.1.2. Notifying fire department incident commander of decision
4.2.1.3. If disagreement concerning cancellation exists between the incident commander and
credentialed provider, the ultimate decision will be made by the highest credentialed
provider on -scene.
5. Safety. The decision to launch is totally under the control of the helicopter pilot. Factors influencing flight
safety for the patient and HEMS personnel will always take precedence in this decision.
5.1. All personnel within the System shall complete a helicopter safety training program as part of their
orientation or continuing education program.
6. Documentation. A full patient care form must be completed for each patient transported by a helicopter.
7. QA/QI. HEMS utilization will be reviewed on an as needed basis.
Incident Command System
1. Purpose. The Fort Worth Office of the Medical Director (FWOMD) is tasked with setting standards
for patient care. Large or complex incidents require specialized policies to establish a unified command
structure, common terminology, and an incident action plan (IAP). The objective is to assure that
rescuers remain safe and that single resources are utilized effectively and efficiently as they treat and
transport patients in an organized fashion.
2. Scope. This policy applies to Fort Worth Regional EMS System (System) during a large-scale
incidents or a Mass Casualty Incident (MCI).
Procedure Overview. All emergency events will be managed in accordance with the nationally
recognized Incident Command System (ICS) as established by the Federal Emergency Management
Administration. The Fire Department Incident Commander (IC) will direct the overall operation at
the scene. Emergency medical services will operate as a Branch within the ICS structure and will make
medical decisions in cooperation with the IC. Patient care must never be delayed due to a
jurisdictional dispute.
4. Training. Each agency within the System is responsible for assuring designated personnel receive the
appropriate ICS training published by the Federal Emergency Management Agency Emergency
Management Institute or an equivalent course. All medical personnel should be familiar with ICS and
mass casualty response plans.
Emergency Medical Services Operation. At any scene requiring a unified command structure, EMS
personnel will provide care according to medical protocols and within their scope of medical training
and qualifications.
5.1. The Fire Department Incident Commander is in command of the incident and the scene. In the
event that a FWFD ambulance paramedic is the first to arrive at a scene, that individual will act
as the IC until relieved by the Fire Department IC.
5.2. The first FWFD ambulance personnel on -scene will be responsible for patient treatment and
transport.
5.3. The FWFD Paramedic, along with a Firefighter, will be in charge of the Triage, Treatment,
and Transport areas (T-3).
5.3.1.The FWFD Basic provider, along with a Firefighter, will triage all patients to the designated
areas within the T-3 by utilizing the START system.
5.4. The Fire Department personnel on -scene will be responsible for:
5.4. 1. Initial triage of victims & Strike Teams to extricate victims to the casualty collection points.
5.5. Requests for additional resources shall be directed to the Incident Commander.
5.5.1. When emergency helicopter service is needed, the Incident Commander is responsible for
securing an appropriate landing site and for all safety procedures.
5.5.2.The Appropriate destination -facility decisions will be made with consultation between the
FWFD Paramedic and helicopter personnel, taking into consideration patient and/or family
wishes when appropriate.
6. Patient hand-offs
6.1. See Transition of Care policy
6.2. In the event of disagreement in patient care, On -Line Medical Control will be contacted
immediately for appropriate orders. All incidents of this nature will be forwarded to the System
Medical Director for review.
Incident Disposition and Cancelation
1. Purpose. This policy establishes criteria for various dispositions for First Responders
and FWFD ambulances, including cancelation.
2. Scope. This policy applies to all System agencies.
3. Disposition reasons for EMS -related calls for service.
3.1. First Responder disposition of calls.
3.1.1. Assist a Citizen: Upon completion of a clinical evaluation, the First Responder
determines that a person needs assistance unrelated to an acute or deteriorating
medical condition and there is no need for an ambulance. Appropriate
documentation should be completed by the First Responder.
3.1.2. No Patient Found: Upon arrival and after every reasonable effort to find the
patient and potential errors have been ruled out, and no patient found. This
includes calls to a false/non-existent location.
3.1.3. Dead on Scene: Upon arrival, First Responders have identified that a patient is
dead as described in the appropriate protocol. Appropriate documentation should
be completed by the First Responder.
3.1.4. Against Medical Advice (AMA): Anytime a patient or their parent/guardian
demonstrates capacity and communicates a refusal of treatment or transport, the First
Responder is to complete the appropriate documentation as required by FWOMD.
3.1.5. Refusal Without Demonstration of Capacity: Anytime a patient or their
parent/guardian communicates a refusal of treatment, or transport, and is unable to
demonstrate capacity, the First Responder is to complete the appropriate
documentation as required by FWOMD.
3.1.6. Release at Scene (RAS): Anytime an individual meets the definition within the RAS
protocol, The First Responder will complete the RAS documentation as required by
FWOMD.
3.1.7. Treat -in -place Alternative: Anytime a patient is treated without transport utilizing
any currently implemented treat -in -place alternative. (Telehealth or protocol)
3.1.8. Care transferred to FWFD personnel (or agencies responding for mutual aid).
3.2. FWFD Ambulance disposition of calls.
3.2.1. Assist a Citizen: Upon completion of a clinical evaluation, the FWFD personnel
determine that a person needs assistance unrelated to an acute or deteriorating medical
condition and there is no need for ambulance treatment and/or transport. Appropriate
documentation should be completed by the FWFD personnel.
3.2.2. No Patient Found: Upon arrival and after every reasonable effort to find the
patient and potential errors have been ruled out, no patient can be found. This
includes calls to a false/non-existent location.
3.2.3. Dead on Scene: Upon arrival, FWFD personnel have identified that a patient
is dead as described in the appropriate protocol. Appropriate documentation
should be completed by FWFD personnel.
3.2.4. Against Medical Advice (AMA): Anytime a patient or their parent/guardian
demonstrates capacity and communicates a refusal of treatment or transport, the First
Responder is to complete the appropriate documentation as required by FWOMD.
Incident Disposition and Cancelation
3.2.5. Refusal Without Demonstration of Capacity: Anytime a patient or their
parent/guardian communicates a refusal of treatment, or transport, and is unable to
demonstrate capacity, the First Responder is to complete the appropriate
documentation as required by FWOMD.
3.2.6. Release at Scene (RAS): Anytime an individual meets the definition within the RAS
protocol, FWFD personnel will complete the RAS documentation as required by
FWOMD.
3.2.7. Transfer of care: When care is transferred from one FWFD provider to another (for
example, due to an equipment failure and change to a new ambulance, multiple
patients on scene with additional transporting resources, care assumed by Mobile
Health Paramedic (MHP) provider or Critical Care Paramedic (CCP). The first on -
scene FWFD personnel will document their care, then transfer the chart
electronically to the next care provider.
3.2.8. Transport to ED: Identified patient is transported to the emergency department.
3.2.9. Telehealth — Treatment in Place: Identified patient has accepted telehealth visit and
agreed to treatment on -scene with referral to primary care physician, or a scheduled in -
home urgent care visit, or a scheduled in -home visit by crisis outreach team.
3.2.10. Telehealth — Alternate Destination Transport: Identified patient has accepted
telehealth visit and agreed to transport to MHMR clinic or Urgent Care.
3.2.11. MIH Call Complete: This disposition is to only be used by MHP and CCP providers
with patients enrolled in MIH programs. In conjunction with FWOMD,
FWFD will create more descriptive codes, as needed, to properly identify
specific programs.
Medical Professional On -Scene
1. Purpose. Medical professionals at the scene of an emergency may provide assistance to pre -hospital care
personnel and should be treated with professional courtesy.
Scope. This policy applies to FWOMD-credentialed providers
Physician On -Scene, Not Requested by EMS
3.1. Prior to arrival of FWOMD credentialed providers
3.1.1. An on -scene physician who is caring for a patient may retain responsibility for patient care,
provided that physician accepts full legal and medical responsibility.
3.1.2. The on -scene physician will be placed in contact with On -Line Medical Control (OLMC), who
may authorize that physician to issue orders to FWOMD credentialed providers. Once
authorized by OLMC, the on -scene physician must accompany the patient to the hospital.
3.2. After arrival of FWOMD credentialed providers
3.2.1. A physician arriving after care has been initiated by the prehospital team will be placed in
contact with OLMC before becoming involved in patient care.
3.2.2. OLMC, the prehospital care team, and the on -scene physician will work collaboratively if
granted permission by OLMC.
4. Physician On -Scene, Requested by EMS
4.1. When a Specialty Care Physician is requested to the scene (e.g., Amputation Team) or is part of an
approved specialty transport team (e.g., ECMO)
4.1.1. EMS clinicians are authorized to follow orders given by the on -scene physician within the scope
of their credential level.
4.1.1.1. Contact OLMC should the on -scene physician issue orders outside the scope of credential
level
4.1.1.1.1. Authorized exceptions that do not need OLMC contact:
• The administration of blood products, provided and ordered by the on -scene
physician
• Dosing of protocolized medications outside protocol parameters.
Responding to Physician's Offices:
5.1. The FWOMD credentialed providers will comply with medical treatment requests the physician
makes within his/her office as long as the orders are within the provider's scope of credentialing, and
FWOMD protocols. Any orders that are in conflict with above should be discussed with OLMC.
5.2. If the physician gives orders that are to be carried out during transport and are outside protocol, the
paramedic will discuss these orders with OLMC once in the ambulance to assure that OLMC agrees
with the orders and that the orders comply with the protocols of the System.
6. Poison Control
6.1. Poison Control Center Specialists are authorized to direct medical care related to the medical
toxicology and/or hazardous material exposure aspects of patient care if contacted for direction limited
by credentialed scope and protocols. Care may be limited by supply and medication available for
treatment.
Care established by other medical professionals
7.1. Orders by nurses, nurse practitioners, physician assistants, and other State -certified providers are not
applicable to System providers.
7.1.1.If on arrival of FWOMD credentialed personnel, the patient is under the direct care of another
medical professional, and if the patient and medical professional desire to continue as such,
provide care in parallel with the medical professional and within the treatment protocol; if care
Medical Professional On -Scene
beyond
the credentialed scope of practice is requested, contact OLMC (e.g., OB — FHT monitoring)
7.1.2.A medical professional arriving after care has been initiated by the prehospital team will be
placed in contact with OLMC before becoming involved in patient care.
8. Critical Care Ground and Air Medical Transport Teams
8.1. The patient will remain in the care of the transport team. FWOMD credentialed providers may assist
in patient care at the request of the transport team as long as the care is within the credentialed scope
and protocol.
9. Services and Equipment.
9.1. If approved by OLMC, the services, and equipment of the emergency vehicle will be made available to
the on -scene physician or medical professional.
Medical Treatment of an Employee
1. Purpose. This policy describes the clinical practice of treating ill or injured employees of the Fort Worth
Regional EMS System
2. Scope. This procedure applies to all credentialed providers who are rendering patient care to an ill or
injured employee of the EMS System.
Overview. If an agency's employee is either ill or injured, that person should be treated as a "patient" and
all the FWOMD protocols, procedures, and policies apply to care for that individual. An employee
requiring medical care must have a patient care record completed whether or not they are transported to a
hospital or if they are released by other means (AMA, RAS, etc.). A credentialed provider may not
administer any type of medical treatment to another employee without properly following FWOMD
protocols, procedures, and policies.
4. Process.
4.1. If an agency's employee is ill or injured, proper medical attention should be activated and initiated.
The 911 system should be activated if necessary.
4.2. If the agency's employee refuses transport, then the proper AMA protocol should be followed. An
incident must be created, and the proper patient care record documented fully.
4.3. Any deviation from this process is prohibited by the System Medical Director and may lead to
disciplinary action by the agency, state, and federal oversight authorities.
4.4. Personnel should refer to agency -specific standard operating procedures for any agency -specific
requirements of notification or referral.
Medication Storage
Purpose. The Drug Enforcement Administration, and the Texas Department of State Health Services
(DSHS) require the System Medical Director to assure that all medications purchased under his/her license
are stored and secured according to laws and regulations.
Scope. This policy applies to medications required on ambulances, first responder vehicles,
special teams, and other response -capable Fort Worth Regional EMS System (System) vehicles.
3. Procedure
3.1. Storage of Medications in the Field.
3.1.1.Schedule II - IV Medications will be secured by field personnel while on duty either:
3.1.1.1. on the person of the Paramedic that accepted receipt of the medications and is assigned
to the apparatus, or
3.1.1.2. in a locked container on the apparatus, where the only person with the key or
combination is the Paramedic that accepted receipt of the medications and is assigned
to the apparatus, or
3.1.1.3. during EMS standby services, in a locked container in a designated first aid room
where the only person with the key or combination is the Paramedic assigned to the
room.
3.1.2. When the crew is not physically inside the unit, all other medications and equipment will be
secured on the apparatus by locking all exterior doors or compartments.
3.1.3.The Paramedic that accepted receipt of the medications on Special Teams, such as the Bike
Team, Mounted EMS Team, other Ad Hoc teams, or other response capable System vehicles,
will secure all Scheduled medications on their person.
3.2. Securing of ALS medications on a BLS resource
3.2.1. Agencies will have a policy/procedure addressing the securing of ALS medications on a unit when
being utilized as a BLS resource.
4. Reconciliation.
4.1. All System agencies that carry controlled substances must have a reconciliation policy and procedure
in place. FWOMD may conduct reconciliation record audits to assure compliance with this policy.
Drug Adulteration.
5.1. All medicines stored in the field must be stored according to current DSHS rules and regulations. This
includes all manufacturer temperature recommendations. Proper temperature monitoring and storage
techniques should be maintained by each System agency.
Patient Destination
1. Purpose. The purpose of this policy is to establish patient destination guidelines.
2. Scope. This policy includes all patient transports within the jurisdiction of the Fort Worth Regional EMS
System (System).
Selection of a Destination Facility. The selection of a destination facility must balance the goal of
delivering the highest quality patient care with respecting the individual patient's rights and desires to
make an informed choice. To accomplish this, patients will be transported to the closest, most appropriate
facility using the following criteria in the order listed.
3.1. Once it has been determined that a patient has decisional capacity, and if medically appropriate, they
shall be transported to the hospital of their request.
3.2. If the patient is unable to communicate, the patient is to be taken to the hospital of immediate family
request, as medically appropriate
3.3. If the family's facility preference is not known, the patient is to be taken to the closest, most
appropriate facility.
3.4. Special patient needs may dictate transport to a hospital that may not be the closest but is the most
appropriate facility for that patient's medical care needs (i.e., burns, major trauma, stroke, STEMI).
See Designated Specialty Receiving Facilities (below).
3.5. If a patient calls for EMS while within 250 yards of a full -service hospital's campus, the patient shall
be transported to that hospital's Emergency Department unless dictated as in 3.4.
3.6. If a patient has been seen and discharged from an Emergency Department of a full -service hospital
within 24-hours, the patient shall be transported back to that Emergency Department unless an
exception exists as outlined in 3.4.
3.7. Cardiopulmonary Arrest patients, if transported, should be transported to the closest full -service
hospital.
3.8. Credentialed providers shall not encourage patients to utilize one facility over another.
4. Resolving Conflicts. The following guidelines are to be used if the decision to transport the patient to the
closest appropriate or other facility results in a conflict with the patient or family of the patient.
4.1. In all cases, the patient or family are to be assisted to make an informed decision. As long as patients
have decisional capacity, their informed decision will be honored. The patient's present medical
condition and the reasons for transport to the closest appropriate medical facility should be discussed
with the patient or family if the patient lacks capacity. If the patient or patient's family, as allowed
in 3.1 or 3.2 above, insists on transport to another facility (other than a recommended facility based
on patient condition or clinical need), their informed decision will be honored as described in this
policy.
Patient Destination
5. Age -Specific Transport Guidelines. Any unresponsive patient with secondary sex characteristics shall be
treated as an adult patient and transported to an adult -care facility. The following table establishes the
age -related guidelines for selecting adult or pediatric destination facilities while recognizing the rules set
forth in sections 3 and 4 (above).
Adult Care Facility
Cook Children's
Medical/Trauma
? 15 Years
< 15 Years
Emergencies
Psychiatric Emergencies
13 Years
< 13 Years
Under certain circumstances, individual patients who are 15-years old or older and who have
established relationships with pediatric specialists may be transported to a pediatric care facility.
If in doubt, consult with OLMC.
Patients who are exhibiting both an acute medical and psychiatric emergency (e.g., overdose
with AMS) should be transported using the Medical/Trauma Emergency criteria
6. Emancipated Minors. Current laws dictate who may be declared an emancipated minor.
7. Police Custody. A patient who is under the custody of a police officer and who is being transported to a
hospital for assessment/treatment, including those under an application for detention, may be transported
to any hospital that is selected by the police officer as long as medically appropriate and as meets the age
requirements in this policy.
8. Correctional Facility Patients. Patients being transported from correctional facilities are to be transported
as follows:
8.1. Most federal correctional facilities have agreements with local hospitals. Patients should be transported
to facilities in accordance with such agreements. FWFD paramedics should ask an appropriate official
who is responsible for the patient to select the destination facility.
8.2. Other jails or detention facilities — patients are transported to facilities selected by the police officer
responsible for the patient.
9. Designated Specialty Receiving Facilities. A list of approved Specialty Receiving Facilities is available
on each tablet, on the intranet, and in the protocol app.
9.1. Trauma - Patients who meet American College of Surgeons trauma activation criteria should be
transported to an FWOMD-approved trauma facility.
9.2. Burn- Patients with significant 2nd or 3`d-degree burns, as detailed within the Burn protocol, should
be transported to an FWOMD-approved Burn center.
9.3. Cardiac - Patients experiencing ST-elevation myocardial infarction should be transported to an
FWOMD-approved PCI-capable facility.
9.4. Stroke - Patients experiencing acute stroke symptoms should be transported to an FWOMD-
approved stroke facility. A decision tool for transport to Primary vs. Comprehensive Stroke Center is
defined in the Stroke Protocol.
9.5. Obstetrics — gravid patients > 20-weeks' gestation should be transported to an FWOMD-approved
facility with OB capabilities.
9.6. Sexual Assault — patients with suspected or verbalized complaints of sexual assault should be
transported to an FWOMD-approved facility with SANE capabilities.
9.7. Designation of Specialty Receiving Facilities will occur based on the below criteria:
Patient Destination
9.7.1.Trauma — facilities that are approved by the Texas Department of State Health Services as a
Level I, 11, III, or IV trauma facility; or are in pursuit of such designation
9.7.2.Burn — facilities that are verified by the American Burn Association; or are in pursuit of such
designation
9.7.3.Cardiac — facilities that perform 24/7 percutaneous coronary intervention (PCI) for STEMI-
patients and are accredited, or in pursuit of accreditation, by the Joint Commission, American
Heart Association, or the American College of Cardiology
9.7.4.Stroke — facilities that are designated by the Texas Department of State Health Services as a
Primary or Comprehensive Stroke Center
9.7.5.Obstetrics — facilities that have a 24/7 Labor & Delivery unit
9.7.6.Sexual Assault — facilities that have formalized Sexual Assault Nurse Examiners (SANE), and
necessary equipment, available 24/7
10. Registries and Collaborative Data Sharing. The Medical Control Advisory Board (MCAB) has further
approved that all hospitals that wish to participate as Designated Specialty Receiving Facilities will
participate in the appropriate registries (e.g., trauma, stroke) and will share outcome information with the
FWOMD so as to determine the appropriateness of care.
11. Non-traditional Emergency Care Facilities. A non-traditional emergency care facility is a facility that is
structurally separate from a hospital (that may be affiliated or unaffiliated with a Hospital network) and
which receives an individual and provides emergency care. These facilities are not considered full -service
hospitals. Currently approved Non-traditional Emergency Care Facilities are available on the Specialty
Receiving Facilities List
12. Definitions of Hospital Divert Status
12.1. Full Divert — A hospital is CLOSED to ALL patients, including walk-in and EMS traffic.
12.1.1. Ambulance -only divert (where the facility remains open to walk-in traffic) is NOT
permitted
12.1.2. When a facility formally declares an Internal Disaster and has closed to any new patients
(EMS or walk-ins), they will be placed on Full Divert.
12.1.3. Examples of causes of Internal Disasters include, but are not limited to:
12.1.3.1. Structural damage to the facility, e.g., fire, explosion, flood, etc.
12.1.3.2. HazMat incidents
12.1.3.3. Hostage/Bomb Threat/Active Shooter situations
12.2. Specialty Divert - When a specific resource (e.g., all radiology, cardiac catheterization lab, etc.) is
temporarily unavailable, leading to an inability to care for a specialized patient population
12.2.1. Trauma Divert
12.2.1.1. Trauma Divert may occur when a designated trauma facility no longer meets the
requirements of a trauma center, e.g., no available OR/ICU bed, surgeon unavailable, etc.
12.2.1.2. Trauma divert may only be initiated with the agreement of the facility's on -duty
Emergency Physician and Trauma Surgeon
12.2.1.3. Before a Level 1 or 2 Trauma facility will be placed on Trauma Divert, the Emergency
Physician or Trauma Surgeon must first get approval from the other Level 1 or 2 trauma
facility who will be responsible for receiving incoming trauma patients. The facility
requesting divert must contact the Fort Worth Fire Alarm Office (FAO), who will then
independently verify with the open facility before placing the requesting hospital on divert.
12.2.1.4. If all designated Trauma Centers simultaneously require Trauma Divert status,
Trauma Divert status shall be removed system -wide. During such times, the FAO will aid
with the appropriate distribution of trauma patients.
12.2.2. Cardiac Divert
12.2.2.1. Cardiac Divert may occur when a designated Cardiac facility no longer meets the
Patient Destination
requirements of a PCI center, e.g., no available cath lab, Interventional Cardiologist
unavailable, etc.
12.2.3. Stroke Divert
12.2.3.1. Stroke Divert may occur when a designated Stroke facility no longer meets the
requirements of a Primary or Comprehensive Stroke center, e.g., no available CT scanner,
etc.
13. Outpatient Hemodialysis Facilities - During a Presidential and/or Texas Governor declared disaster,
individuals receiving dialysis for the management of their End Stage Renal Disease (ESRD) may be taken
to outpatient hemodialysis treatment facilities, if appropriate. Patients will be evaluated for any significant
exacerbation of their ESRD symptoms and for any other acute medical conditions to ensure an appropriate
destination for treatment. Patients requesting transport for dialysis, AND who are asymptomatic or have
mild complaints consistent with their typical pre -dialysis symptoms (e.g., weight gain, edema, shortness of
breath, fatigue, nausea/vomiting), may be transported to an outpatient dialysis facility.
14. Divert Process — The following process shall be followed for all changes to Divert status (Full or Specialty):
14.1. The Administrator on Call (AOC) for the facility requesting divert will notify the FAOof the type
and expected duration of diverting and the names and direct phone numbers of the facility's on -duty
Emergency Physician and AOC.
14.2. For Specialty Divert, FAO will notify the System Medical Director, Shift Commander, and Field
Crews of facility divert status and timeframe.
14.3. For Full Divert, the below steps will be followed:
14.3.1. The Communications Center will dispatch an EMS Supervisor to the facility to meet with and
offer assistance to the facility AOC and on -duty Emergency Physician.
14.3.2. After this meeting, the EMS Supervisor shall initiate a conference call with the AOC, Shift
Commander, and the System Medical Director
14.3.2.1. The ultimate responsibility of approving a divert status lies with the System Medical
Director.
14.3.2.2. Once the conference call has been completed, the Shift Commander will notify the
FAO to page on -duty field providers and EMS Supervisors regarding the hospital facility's
divert status.
14.3.3. The facility must also update and notify local (e.g., EMResources/NCTTRAC, Emergency
Operations Center) and state authorities (e.g., DSHS).
14.3.4. The facility's status shall be verified with the facility's AOC at least every 2-hours by an EMS
Supervisor.
14.3.5. The Shift Commander, System Medical Director, and Facility AOC shall confer by conference
call and review hospital divert status every six hours.
15. After -Action Review
15.1. Following any Full Divert activation, an after -action review will be held within 72-hours to include
the following stakeholders:
15.1.1. Hospital CEO, CMO, or COO
15.1.2. Fire Chief or designee
15.1.3. System Medical Director
16. System -wide Disasters and Patient Overload
16.1. In rare circumstances, such as prolonged public health emergencies, multiple System hospitals
may be overwhelmed by large patient volumes in their Emergency Departments.
16.2. In these instances, a distributed patient allocation process may benefit the hospitals and
patients of the System,
Patient Destination
16.3. The decision to activate a distributed patient allocation process will be made by discussion
amongst the service area full -service hospital administrators
16.3.1. .
16.3.2. Decisions regarding this process will be communicated to the facilities Medical Control
Advisory Board representatives
Protocol Maintenance
Purpose. The protocols, procedures and policies (PP&P) of the Fort Worth Office of the Medical Director
(FWOMD) are based on current scientific data, evidence -based best -practices, and standards of care, where
these are available. All PP&P are reviewed and approved by the Medical Control Advisory Board (MCAB),
which may include board -certified physicians representing a variety of specialties — e.g., emergency medicine,
cardiology, pulmonology, public health, trauma surgery, psychiatry and critical care. This policy provides
guidance on how these documents will be reviewed and revised to incorporate current best -practice
and scientific advances in clinical care
2. Scope. This policy applies to FWOMD.
3. Procedure.
3.1. Periodic Review:
3.1.1. Current protocols related to all aspects of patient care, including specialty programs, will be
reviewed by FWOMD at a minimum every 3-years.
3.1.2. Revisions may be made in whole or in part and will be submitted to MCAB for review and
approval.
3.2. Approval of revisions, notification to affected personnel and necessary training:
3.2.1.Once MCAB approves any revisions to current PP&P, FWOMD will replace the existing
electronic file with the revised document.
3.2.2. Members of the Fort Worth Regional EMS System (System) will be notified of any changes and
will be provided electronic copies of the revised document.
3.2.3.Any required training for approved changes will be developed by FWOMD in collaboration EMS
System agencies.
3.3. Immediate Revision:
3.3.1. Revisions to PP&P may be implemented by the System Medical Director prior to the next
regularly scheduled MCAB meeting and submitted to MCAB at the next regularly scheduled
meeting.
3.4. Biennial Protocol Competency:
3.4.1. To ensure maintenance of clinical competency, System credentialed providers may be tested in
part or in whole, biennially with any protocol update or revision.
3.5. Eligibility to Request Review:
3.5.1. Members of the EMS System, receiving hospital, or other facility may request a review of PP&P by
FWOMD.
Safe Haven — Baby Moses
1. Purpose. As a Fort Worth Regional EMS System first responder agency that is recognized by the Texas
Department of State Health Services under Chapter 773 of the Health and Safety Code as a First Responder
Organization, in-service fire apparatus, or any FWFD ambulance, or fire station may be considered a "Safe
Haven" for voluntary drop-off of children who appear to be 60-days old or younger in accordance with Texas
Family Code, this policy defines the procedure for the care of an infant left at a recognized location.
Scope. This policy applies to all EMS System providers.
3. Procedure.
3.1. Assessment and Care
3.1.1. Perform initial assessment:
3.1.1.1. Complete physical exam
3.1.1.2. Gather complete family medical history
3.1.1.3. Gather complete patient medical history
3.1.1.4. Provide care:
3.2. Provide care as indicated in accordance with FWOMD protocol
3.3. Transport
3.3.1.The newborn is to be transported to the closest full -service pediatric facility for further evaluation
and treatment.
3.4. Notification
3A.1.Notification is to be made to the Texas Department of Family and Protective Services regarding
the surrendered newborn and destination of transport.
Supplies and Equipment
1. Purpose. TAC Rule 15 7. 11 requires the Medical Director to set standards for patient care. Standards are
to include vehicles and onboard equipment. This policy establishes the standards for Medication,
Equipment, Devices, and Supplies (M.E.D.S.)
2. Scope. This policy applies to Fort Worth Regional EMS System (System) ambulances,
first responder vehicles, and special teams.
Procedure. All vehicles will be equipped per the approved inventory list. Proposed changes in the
inventory are to be submitted to the FWOMD for approval.
3.1. Brand Specific Items: In certain cases the OMD may specify a particular brand of
M.E.D.S. The decision to specify a particular brand will be based on the evaluation of
available products and through the participation of representatives from agencies that
will use the item.
3.2. Approved Inventory: Each ambulance and FRO primary apparatus utilized in first response and
transport shall carry at minimum the equipment and drug inventory listed on the applicable minimum
inventory equipment and drug list signed by the System Medical Director.
3.3. Evaluation of New M.E.D.S. This procedure is to assure that all new M.E.D.S is introduced into the
EMS System with the System Medical Director's approval.
3.3.1.The EMS System agency may research and suggest new M.E.D.S.
3.3.2.The EMS System agency and the System Medical Director agree to perform a field trial (if
necessary) on the specific M.E.D.S.
3.3.3.The recommendation is brought to the System Medical Director for approval.
3.3.4.The System Medical Director accepts or rejects the proposal.
3.3.5.If the trial proposal is accepted, the System agency's designated personnel will perform a clinical
field trial.
3.3.6.If the trial proposal is rejected the item will be dropped from consideration but may be reviewed
again later by the System Medical Director if deemed necessary.
3.3.7.Once a clinical field trial is completed a representative of the EMS System agency will present all
available data to the System Medical Director for review.
3.3.8.The System Medical Director will approve or reject the implementation of the new item based on
the following in collaboration with agency leadership:
3.3.8.1. Logistics, training requirements, implementation constraints,
4. Implementation of New Equipment
4.1. If approved by System Medical Director and System agency or FRO's municipality:
4.1.1.The new equipment will be ordered by the agency in a timely fashion.
4.1.2.The agency in collaboration with FWOMD may perform all the necessary training of field
personnel.
4.1.3.The FWOMD will compose the applicable protocol and/or procedure for the new M.E.D.S.
4.1.4.After the FWOMD has deemed that the proper training has been completed, the
new equipment will be implemented and added to the minimum inventory list.
4.2. If rejected by the System Medical Director the item will be dropped from consideration; however,
may be reviewed again at a later time if deemed necessary.
5. Expiration of medications and supplies
5.1. Expiration dates should be checked monthly, and items replaced as they expire.
6. For the Fort Worth Regional EMS System, FWOMD will manage all the minimum inventory lists with
DSHS
System Quality Improvement
1. Purpose. This policy is established to implement a systematic approach for benchmarking and measuring
clinical quality using standardized measurement strategies that prioritize patient -centric care and focus on
achieving desired outcomes.
2. Scope. This policy applies to the Fort Worth Regional EMS System
3. Clinical Benchmarks
3.1. The clinical benchmarks for Whole System Quality will be based on the following sources:
• AHA Mission Lifeline
• AHA Telecommunicator CPR Performance Measures
• National EMS Quality Alliance
• CARES — Cardiac Arrest Registry to Enhance Survival
3.2. Benchmarks for clinical quality will align with national performance measures whenever they are available
or follow the goals set forth by the American Heart Association (AHA).
3.3. See Appendix A for measure definitions
4. Quality Improvement
4.1. When clinical performance falls below national benchmarks or AHA goals, the "Model for Improvement"
will be used as the primary methodology for quality improvement initiatives.
4.2. The quality improvement process will include the following key elements.
• Identification of performance gaps
• Formation of multidisciplinary teams
• Drafting of project charters for each improvement initiative
• Establishment of outcome, process, and balancing measures to assess the impact of changes
• Testing and implementation of change theories using the Plan -Do -Study -Act (PDSA) methodology.
5. Implementation of Quality Improvement Initiatives
5.1. Identification of Performance Gaps:
• Regularly monitor and analyze clinical performance data to identify areas where performance falls
below national benchmarks or AHA goals.
5.2. Formation of a Multidisciplinary Team:
5.2.1. Establish multidisciplinary teams consisting of healthcare professionals, administrators, and other
relevant stakeholders to lead improvement initiatives.
5.3. Drafting of Project Charters:
5.3.1. Develop project charters for each improvement initiative, outlining the objectives, scope,
resources, and timeline for the project.
5.4. Establishment of Measures:
5.4.1. Define outcome measures that represent the desired improvements in clinical quality.
5.4.2. Define process measures that track the changes made to achieve these improvements.
5.4.3. Define balancing measures that assess any unintended consequences of improvement efforts.
5.5. Testing and Implementation of Change Theories:
5.5.1. Utilize the PDSA methodology to systematically test and implement changes aimed at achieving
the desired outcomes.
System Quality Improvement
5.6. Monitoring and Sustaining Improvements:
5.6.1. Continuously monitor the impact of implemented changes and adjust as necessary to sustain
improvements.
6. Compliance and Accountability
6.1. All personnel within the organization are responsible for adhering to this policy and participating in
quality improvement initiatives.
6.2. The Fort Worth Office of the Medical Director will oversee and coordinate the implementation of this
policy, monitor progress, and report on quality improvement efforts to senior leadership.
7. Review and Revision
7.1. This policy will be periodically reviewed and revised as needed to ensure its effectiveness in promoting
clinical quality and achieving desired patient outcomes.
8. Communication
8.1. This policy will be communicated to all relevant staff members and stakeholders within the organization.
Training and educational resources will be provided as necessary to facilitate understanding and
compliance.
System Quality Improvement — Video Laryngoscopy
1. Purpose: The purpose of this policy is to establish guidelines for the review, retention, and deletion of
video laryngoscopy data obtained from a video laryngoscopy device in the Fort Worth Regional EMS
System, for quality assurance ("QA") and quality improvement ("QI") activities.
2. Scope: This policy applies to all Video Laryngoscopy video files that have been retained by the Office of the
Medical Director (FWOMD) for QA/QI purposes.
Upload Process: All video laryngoscopy intubations performed in the EMS System will have the
accompanying video file uploaded for a quality review prior to the end of shift as outlined below:
3.1. Video laryngoscopy files will be uploaded to the UEScope app on designated devices.
4. Review: Video Laryngoscopy videos will be reviewed and may be used for quality assurance purposes
outlined below. The video should not be used for any other purpose other than those outlined in this policy.
The use of these videos should be limited to:
4.1. Case Reviews: Video files may be used to review intubation performance during Quality Assurance
case reviews with providers. This confidential review will consist of FWOMD Quality staff and only
those providers that were present and involved with the intubation on the respective case. Full,
unedited intubation videos will not be shared with any providers that were not involved with direct
patient care, more specifically patient intubation.
4.2. Intubation Training: Video files may be retained for system training purposes but must be edited to
redact all protected health information (PHI) and/or crew member identity.
4.3. Quality Improvement Activities: Videos may be reviewed by FWOMD staff to identify system
training objectives, research initiatives, performance trends, or any other purposes deemed necessary
for quality improvement.
Retention: Video Laryngoscopy data will be retained for a 90-day period to allow for review and
identification of videos that may be retained for training purposes. Videos that are retained for training
purposes must be edited to redact all PHI and/or crew member identity.
6. Deletion: After 90 days all videos that are not retained for quality assurance purposes shall be destroyed.
Transition of Care
1. Purpose. To minimize the potential for medical error, to ensure continuity of care, and enhance safety
during transitions of care.
Scope. This policy applies to all FWOMD-credentialed providers.
3. Inclusion criteria
3.1. Patient handoffs in a health care facility from a health care practitioner (Ex. Physician, Physician
Assistant, Advanced Practice Registered Nurse - CRNA, NP, Certified Nurse Midwife).
3.2. Handoffs between EMS crews and FROs at same credential level.
4. Exclusion Criteria
4.1. Transitions from non -clinician level staff (RN, LPN, CNA, tech, doula, etc.), non -medical persons
(bystanders, family).
4.1.1. Note: EMS System clinicians should, however, politely, and attentively obtain relevant
information from these care givers and thank them for their assistance.
4.2. For physicians not in a healthcare setting with an established patient care relationship, follow Medical
Professionals on Scene.
5. Definitions:
5.1. Sending clinician: the clinician/team responsible for care before hand-off.
5.2. Receiving clinician: the clinician/team responsible for care after hand-off.
6. Transition of Care
6.1. Assume patient care and medical decision making will be directed by the sending clinician until they
verbally transfer care to the receiving clinician. Understandably, they may not always verbally
communicate transfer of care, assuming it is implied. To minimize the chances for misunderstanding,
confirm that the clinician is transferring care and understands that the receiving clinician is now in
charge of patient care and will be operating under their protocols.
6.1.1. If there is no on -scene sending clinician physically present in the room with the patient, make every
effort to contact them if they are on -location.
6.1.2. Promptly contact OLPG for assistance if there is any conflict between sending and receiving
clinicians.
6.2. Prior to handoff. receiving clinicians may assist, within their credentialed scope, with appropriate care
prior to formal transfer of care and at the direction/request of the sending clinician.
6.3. After formal transfer of care: sending clinicians may assist, within their credentialed scope, with
appropriate care after formal transfer of care and at the direction/request of the receiving clinician.
7. Document estimated time of transfer of care in the ePCR.
Upgrading Ambulance Response
1. Purpose. This policy establishes the circumstances under which Fort Worth Regional EMS System
first responder personnel may request a FWFD ambulance response upgrade, the process for
upgrading a response, and related QA activities.
2. Scope. This policy applies to First Responder personnel and affects response priority upgrades.
The call would be upgraded based on the EMD criteria.
Procedure. Certain conditions may become apparent during initial contact with a patient that may
not have been identifiable by an EMD, or that had a delayed onset, and that may warrant a response
upgrade by FWFD ambulance.
3.1. If a first responder arrives at the patient's side and identifies any of the following findings,
conditions, or situations, a response upgrade to Priority 1 is warranted:
3.2. Airway:
3.2.1.There is complete airway obstruction; or
3.2.2.The patient's airway cannot be maintained.
3.3. Breathing:
3.3.1.The patient has severe difficulty breathing;
3.3.2.The patient cannot be ventilated.
3.4. Circulation:
3.4.1.An unanticipated cardiac arrest occurs or has occurred;
3.4.2.Uncontrollable bleeding is present; or
3.4.3. Severe loss of blood has occurred.
3.4.4.Altered Level of Consciousness:
3.4.4.1. The patient becomes unresponsive; or
3.4.4.2. Status seizures.
3.4.5.An upgrade to a Priority 2 may be requested if the first responder finds the patient's clinical
condition to be urgent.
3.5. Requesting a Response Upgrade. The first responder shall request a response upgrade by
contacting their respective dispatch center and asking them to contact the Fort Worth Fire
Alarm Office (FAO) for the purpose of upgrading a response priority. The reason for the
upgrade is required when making such a request. The FAO will upgrade the response based
on current EMD criteria.
3.6. Audit of Upgrade Requests. FWFD and each First Responder agency that has requested a
response upgrade during the month shall conduct a 100916 QA review of upgrade requests. The QA
review shall meet the following requirements:
3.6.1. A cooperative review shall be conducted each month by FAO quality assurance personnel,
the First Responder designee, FWOMD representative, and other personnel who may be
needed;
3.6.2. Together, they shall Review the initial dispatch and the request for the upgrade;
3.6.3. Review of the first responder patient care report and the ambulance patient care
report;
3.6.4. A QA report shall be provided to the System Medical Director and shall include the total
number of upgrade requests, the number of appropriate requests, and a qualitative summary
of possible improvements to the process.
Walk -In Patients
1. Purpose. The purpose of this policy is to establish a uniform method of managing a person's
arrival at fire or EMS stations requesting (explicit or implied) medical assistance.
2. Scope. This policy applies to all Fort Worth Regional EMS System agencies and their
personnel.
3. Compliance with Safe Haven Law(s), see Safe Haven — Baby Moses
4. Procedure. When a person arrives at a fire or EMS station requesting medical assistance or who is in
obvious medical distress, personnel should:
4.1. Perform initial assessments and administer indicated care in accordance with FWOMD protocol;
4.2. Make indicated notifications as required by agency policy; and
4.3. Request a FWFD ambulance.
Appendix A
System Performance Committee Recommended Measures and Goals
Cardiac Arrest
CA 01: Percentage of OHCA Cases Correctly Identified by PSAP That Were Recognizable
Description: Telecommunicator recognized OHCA / total OHCA (confirmed by EMS impression)
Goal: 95176 (AHA)
CA 02: Median time between 9-1-1 call and OHCA recognition
Description: Median amount of time in seconds between 9-1-1 call connected and OHCA recognition.
Goal: < 90 seconds (AHA)
CA 03: Percentage of Telecommunicator-Recognized OHCAs Receiving T-CPR
Description: Number of telecommunicator-recognized OHCA cases receiving T-CPR / number of QI-reviewed EMS -
confirmed OHCA with recognition noted.
Goal: 75% (AHA)
CA 04: Median time between 9-1-1 Access to tCPR hands -on -chest time for OHCA cases
Description: Median amount of time in seconds between 9-1-1 call connected and first chest compression directed by
telecommunicator.
Goal: < 15 0 seconds (AHA)
CA 05: Utstein Survival %
Description: Patients experiencing non -traumatic, bystander -witnessed out -of -hospital cardiac arrest (OHCA)
presenting with a shockable rhythm that are discharged from the hospital alive.
Goal: >30.79 (National Average)
CA 06: Utstein Survival with Good Neurological Function
Description: Patients experiencing non -traumatic, bystander -witnessed out -of -hospital cardiac arrest (OHCA)
presenting with a shockable rhythm that are discharged from the hospital alive with good neurological function.
Goal: > 27.5 % (National Average)
Airway Management
Airway 01: First Pass Intubation Success without Hypotension or Hypoxia
Description: The percentage of non -cardiac arrest intubations with first pass success without hypotension (SBP >_90)
or hypoxia (>_90) during the peri-intubation period (+/- 5 minutes from procedure time).
Goal: > National Average (when available)
Airway 02: Adequate Oxygen Saturation Achieved Before Intubation Procedure
Description: The percentage of intubation procedures in which adequate patient oxygen levels were achieved and
maintained for 3 minutes prior to the intubation procedure.
Goal: > National Average (when available)
Airway 03: Waveform Capnography Airway Device Monitoring
Description: The percentage of advanced airway procedures in which waveform capnography is used for tube
placement confirmation and monitoring
Goal: >National Average (when available)
Airway 04: Airway Composite (Defect -Free Care)
Description: The percentage of responses during which adequate oxygen levels (>_94%) are achieved and maintained
for 3 minutes prior to intubation procedure, endotracheal intubation placement is successful on first attempt without
hypotension (SBP >_90) or hypoxia (<90176) during the peri-intubation period, and waveform capnography is used for
verification and monitoring.
Goal: >National Average (when available)
Airway 05: Unrecognized Failed Airway
Description: The percentage of patients for whom EtCO2 is NOT present at the end of the event AND for whom
adjudication did not reveal a plausible explanation (ex. gradual loss of EtCO2 in cardiac arrest)
Goal: >National Average (when available)
STEMI
STEMI 02: Aspirin Administration for STEMI
Description: The percentage of EMS patients aged 18 years and older transported from the scene with Aspirin
administration for suspected heart attack.
Goal: > 7 5 % (AHA)
STEMI 03: 12-lead ECG Performed Within 10 minutes for STEMI Patients
Description: The percentage of EMS patients aged 18 years and older transported from the scene with chest pain or a
suspected MI for whom a 12-Lead ECG was performed <_ 10 minutes of first medical contact.
Goal: > 7 5 % (AHA)
STEMI 04: STEMI Alert Within 10 Minutes in STEMI Patients
Description: The percentage of EMS patients aged 18 years and older transported from the scene with a STEMI
positive ECG for whom pre -arrival notification was activated <_ 10 minutes of positive ECG.
Goal: >75916 (AHA)
Stroke
Stroke 01: Evaluation of Blood Glucose for Patients with Suspected Stroke
Description: The percentage of EMS patients aged 18 years and older transported from the scene with suspected stroke
for whom blood glucose was evaluated during the EMS encounter.
Goal: 2!75% (AHA)
Stroke 02: Stroke Screen Performed and Documented
Description: The percentage of EMS patients aged 18 years and older transported from the scene with a suspected
stroke for whom a stroke screen was performed and documented during the EMS encounter.
Goal: >_ 7 5 % (AHA)
Stroke 03: Stroke Alert for Suspected Stroke
Description: The percentage of EMS patients aged 18 years and older transported from the scene with a primary or
secondary impression of stroke whom a pre -arrival alert for stroke was activated during the EMS encounter.
Goal: >75% (AHA)
Stroke 04: Documentation of Last Known Well for Patients with Suspected Stroke
Description: The percentage of EMS patients aged 18 years and older transported from the scene with suspected stroke
for whom Last Known Well was documented during the EMS encounter.
Goal: > 7 5 % (AHA)
NEMSQA
Asthma 01: Administration of a Beta Agonist for Asthma
Description: The percentage of EMS responses originating from a 911 request for patients with a diagnosis of asthma
who had an aerosolized beta agonist administered.
Goal: > 51 % (National Average)
Hypoglycemia 01: Treatment Administered for Hypoglycemia
Description: The percentage of EMS responses originating from a 911 request for patients with symptomatic
hypoglycemia who receive treatment to correct their hypoglycemia.
Goal: > 43 % (National Average)
Respiratory 01: Respiratory Assessment
Description: The percentage of EMS responses originating from a 911 request for patients with primary or secondary
impression of respiratory distress who had a respiratory assessment.
Goal: >92% (National Average)
Seizure 02: Patients with Status Epilepticus Receiving Intervention
Description: The percentage of EMS responses originating from a 911 request for patients with status epilepticus who
received benzodiazepine during the EMS response.
Goal: >2896 (National Average)
Trauma 01: Pain Assessment of Injured Patients
Description: The percentage of EMS responses originating from a 911 request for patients with injury who were
assessed for pain.
Goal: >69% (National Average)
Trauma 03: Effectiveness of Pain Management for Injured Patients
Description: The percentage of EMS transports originating from a 911 request for patients whose pain score was
lowered during the EMS encounter.
Goal: > 18176 (National Average)
Appell"('11.A
CPR WORKSHEET
PATIENT INFORMATION
NAME: HISTORY:
DOB:
ON SCENE TIME: CPR START TIME: MEDICATIONS:
BYSTANDER WITNESSED: Y / N
BYSTANDER CPR: Y / N BYSTANDER AED: Y / N ALLERGIES:
lislaaellis • or
TIME
PROCEDURE
SUCCESSFUL?
PERFORMED BY / NOTES
CPR -MANUAL
Y/N
ATTACH PADS IN A/L POSITION
Y/N
Al RQ-3
Y / N
DEFIBRILLATION
Y / N
MCD AFTER 15 MIN MANUAL CPR
Y/N
DUAL SEQUENTIAL EXTERNAL
DEFIBRILLATION (DSED)
Y / N
Y/N
Y/N
"• • •
TIME
PROCEDURE
SUCCESSFUL?
PERFORMED BY / NOTES
IV / 10 ACCESS
Y / N
EPI
Y / N
EPI INFUSION
Y / N
BICARB
Y / N
Y/N
Y/N
Y/N
111
Y/N
d ' ' •
• •
TIME
PROCEDURE '
SUCCESSFUL?
7 PERFORMED BY / NOTES
ESMOLOL
Y / N
NOREPI (LEVO)
Y / N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
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Clinical Opiate Withdrawal Scale (COWS)
Resting Pulse Rate:
GI upset:
(Measured afterpatient is sitting or lying far I min)
(Over last 30 min)
0 - No GI symptoms
0 - HR 80 or below
1 - Stomach cramps
1 - HR 81 to 100
2 - Nausea or loose stool
2-HR101to120
3 - Vomiting or diarrhea
4 - HR > 120
5 - Multiple episodes of diarrhea or vomiting
Sweating:
Tremor:
(Over last 30 min and not due to room/environment temp or patient activity)
(Observation of outstretched hands)
0 - No report of chills or flushing
0 - No tremor
1 - Subjective report of chills or flushing
1 -Tremor can be felt, but not observed
2 - Flushed or observable moistness on face
2 - Slight tremor observable
3 -Beads of sweat on brow or face
4 - Gross tremor or muscle twitching
4 -Sweat streaming off face
Restlessness:
Yawning:
(Observation during assessment)
(Observation during assessment)
0 - Able to sit still
0 - No yawning
1 - Reports difficulty sitting still, but is able to do so
1 - Yawning Ix or 2x during assessment
3 - Frequent shifting or extraneous movements of legs/anus
2 - Yawning 3 or more during assessment
5 - Unable to sit still for more than a few seconds
4 - Yawning several times/minute
Pupil size:
Anxiety or Irritability:
0 - Pupils pinned or normal size for room light
0 - None
1 - Pupils possibly larger than normal for room light
1 - Reports increasing irritability or anxiousness
2 - Pupils moderately dilated
2 - Obviously irritable or anxious
5 - Pupils so dilated that only the rim of the iris is visible
4 - So irritable or anxious that participation in the
assessment is difficult
Bone or Joint Aches:
(If pain previously, only score the additional component attributed to opiate
Gooseflesh Skin:
withdrawal)
0 - Not present
0 - Skin is smooth
1 - Mild diffuse discomfort
3 - Piloerection of skin can be felt or hairs standing up on
2 - Patient reports severe diffuse aching of joints/muscles
arms
4 - Patient is rubbing joints or muscles and is unable to sit
5 - Prominent piloerection
Runny Nose or Tearing:
(Not accounted for by cold symptoms or allergies)
Total score (sum of all 11 items):
5 to 12 = Mild
0 - Not present
13 to 24 = Moderate
1 - Nasal stuffiness or unusually moist eyes
25 to 36 = Moderately Severe
2 - Nose running or tearing
> 36 = Severe Withdrawal
4 - Nose constantly running or tears streaming down cheeks
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PATIENT7
PEEP
PERFORM
❑ Plan
❑ Kit Dump
❑ Push
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* Push paralytic
Backup BV , SGA
9 ETT
� 90 second
C C : Cric
9 'Syringes
countdown
• Designate nate Roles
Tamer
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*Traua: open
-cellar
• Backups
❑ Pre-
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• HFN @ max
ET N
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❑ Perform
• HOB B0 deg
❑ 1'Ielictiors
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• PEEP v B
PA N PA
e 1 etarnine giveni
Bail Out Criteria:
Ventilate PRN
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p02 :594%
El monitor❑
Goals
Post
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. E
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.
I ntu ba�tio n
•BPq 2 min
• BP 100
•Et 05
• Sp02 opposite
IF GOALS NOT MET
Auscultate
BP cuff
DO NOT DSI.
I• Sedation
tCO2
Consider RSA.
MECHANICAL COMPRESSION DEVICE CHECKLIST
PRE -APPLICATION TIMEOUT
SIZE - is the patient too big / small?
TURN ON - ensure the device powers on and battery charge is good
S-T-A-R-S • ABORT - when to stop application / resume manual CPR
ROLES - role assignments / providers in place
• STRAP - no neck strap = no application
2 PHASE APPLICATION
1. After full 2 minute CPR cycle, pause CPR for rhythm check, manage rhythm
2. **BEGIN 10 SECOND COUNTDOWN**
PHASE 1 3. Providers lift patient by shoulders / roll patient to the side
4. Place back plate under patient ensuring attachment points are visible
5. **RESUME MANUAL CPR**
IF UNABLE TO COMPLETE IN 10 SECONDS - ABORT APPLICATION
8 seconds prepare to ABORT and resume manual compressions for a full 2 minute cycle**
**At
1. After full 2 minute CPR cycle, pause CPR for rhythm check, manage rhythm
2. **BEGIN 10 SECOND COUNTDOWN**
3. Apply device arms to back place and lock in place
• LUCAS - swing arm over and clamp on both sides
PHASE 2 • DEFIBTECH - clamp on both sides and insert piston arm
4. Engage piston
• LUCAS - pull piston down
• DEFIBTECH - press button to lower piston
5. Press play on device
IF UNABLE TO COMPLETE IN 10 SECONDS - ABORTAPPLICATION
**At 8 seconds prepare to ABORT and resume manual compressions for a full 2 minute cycle**
POST APPLICATION
• Apply neck straps and arm straps
F-1
• Mark sharpie around piston / puck
• Keep hands and eyes on device watching for movement
STEP
3-4
- 1
f
e!
Richmond Agitation -Sedation Scale (RASS)
Score
Term Description
+4
Combative/Violent
Overtly combative or violent and an immediate and significant danger to self and clinician
+3
Very Agitated
Aggressive, non -combative
+2
Agitated
Frequent, non -purposeful movements that impair assessment/monitoring
+ 1
Restless
Anxious or apprehensive, movements not aggressive or vigorous
0
Alert & Calm
Spontaneously pays attention to clinician
-1
Drowsy
Not fully alert, sustained (>_ 10 sec) awakening with eye contact to voice
-2
Light Sedation
Awakens briefly (< 10 sec) with eye contact to voice
-3
Moderate Sedation
Movement or eye opening to voice (but no eye contact)
-4
Deep Sedation
No response to voice, but movement or eye opening to physical stimulation
-5
Unarousable
No response to voice or physical stimulation
202
V 1.0 09/03/24
UE Transfer iOS App to DeetWin Cloud Transfer Instructions
Walkthrough Video Link: https://youtu.be/ilInw7RsKhc
1. Select the UE Transfer iOS application.
2. Enter the universal uploader account credentials on
the UE Transfer app's home screen and tap sign in.
a. Username: VLupload
b. Password: 911grove
3. Find your device's asset ID # on the back of the UEScope device. If using an FRO
device, it will be identified by the unit number, although the serial number may be
used as a backup.
-MedStar Mobile Healthcare
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3933
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203
V 1.0 09/03/24
4. Device Selection
a. Tap device list in upper left corner
b. If the device list is not already populated, click the blue down arrow to
download the system's device list.
c. Type in the search bar your device's asset ID #. Tap on your device.
if your device is not listed in the system's device list, seepage 7-8 for troubleshooting steps
and how to manually add the device.
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0 Devices
5. Ensure the UEScope device is powered on.
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6. Click connect to begin connecting to the UEScope device.
V 1.0 09/03/24
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3of8
205
V 1.0 09/03/24
S. Once the device is connected, the Wi-Fi symbol will turn green. Files will automatically
start uploading to the UE Transfer iOS
application. Tap "Check Out Files" to track
upload progress to the app.
3933
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9. Wait for all video files to be completely downloaded to the UE Transfer App. This may
take a few minutes for longer or multiple videos. DO NOT minimize the app or multi -
task on the iPad while files are being uploaded. IMPORTANT: These videos are only
local copies on the iOS app and are deleted at the end of the session, you must
continue with the full upload process to the DeepVin Cloud for them to be retained.
-Li < a.KF Select Upload
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VI-0 09/03/24
10. Uploading
a. To upload all the videos listed - Tap "Upload"
b. To individually select videos for upload — Tap "Select", then select all files you
want to upload, and then tap "Upload".
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11. Type the Response Number that the intubation was performed during (DO
NOT LEAVE BLANK). Then tap the blue "Upload Files" to begin uploading.
File -
Enter a run number
Uplded 2FilesAL
5 of 8
207
V 1.0 09/03/24
12.The upload process to the DeepVin Video Cloud takes a few moments. As files that are
uploading will have a spinning loading icon over them and will disappear once
successfully uploaded. Be patient, this may take some time (-3-5 min for a 10 min
file) when using mobile Wi-Fi. You may navigate away from the app to perform other
tasks, but do not "force quit" the app. If you are uploading videos for multiple
responses, repeat steps 9-11 for each individual response.
6of8
208
V 1.0 09/03/24
Troubleshooting for Common Problems:
If unable to find your device or upload a video AFTER attempting the troubleshooting steps below:
MedStar Devices
• Turn the UEScope device into logistics
• Email SelfReport with response number, device asset ID #, and serial number (or a
photo of the back of the device)
FRO Devices
• Have FRO crew notify their supervisor (e.g., FWFD Medic 1)
• EMS crew should email SelfReport with response number, device asset ID #, and
serial number (or a photo of the back of the device)
1) Upload is timing out or never finishes
a. Most common cause is a loss of the iPad internet connection during the upload.
b. If possible, ensure you are near the Wi-Fi source and not changing locations. Re-establish
Wi-Fi connection and then click Upload again (enter response number if necessary) and
wait for the files to upload.
c. If still unable to successfully upload, wait until you return to deployment center or station
and make one final attempt to upload on a different Wi-Fi connection.
2) Device Unable to Connect
a. Ensure you are selecting the correct device ID
b. Verify the UEScope device is turned on and fully booted
c. Click connect again
i. Ensure you are selecting join and allow in the iOS prompts
d. Attempt manual connection with the device (see next page)
3) Device Not Found in the List
a. Click the blue down arrow to refresh the system's device list.
b. If device ID is not found:
If an EMS device, ensure you are using 4-digit asset ID # and NOT the eight digit
white RFID tag.
ii. Search via serial number (see next page for photos)
c. Attempt manual connection with the device (see next page)
7ofs
209
V 1.0 09/03/24
Manual Connection Steps
• Find the device's serial number on the back of the device or in the Wi-Fi tab of the
settings menu on the UEScope.
00000965
• Tap add device and enter the login credentials and profile details, and then click save
a. Login Credentials
i. UET- is prefilled, enter serial number (NOT the 4-digit MedStar Asset ID) listed on the
back of the device.
11. Password should be auto filled, and should always be: 12345678
b. Profile
1. Enter Serial # again
ii. Name Tag is the 4-digit Asset ID or Department & Apparatus Call Sign
0 O
0 Devices
Q Search devices
a device to connect, or add a new one.
• Email SelfReport that device was unlisted (include device ID & serial #).
sofs
210
FORT WORTH.
I
City Secretary's Office
Contract Routing & Transmittal Slip
Contractor's Name: City of Lake First Responder and Provider Agreement
Subject of the Agreement:
Obligates each jurisdiction to comply with the terms of their respective EMS Interlocal Agreement.
M&C Approved by the Council? * Yes ❑ No M
If so, the M&C must be attached to the contract.
Is this an Amendment to an Existing contract? Yes ❑ No 0
If so, provide the original contract number and the amendment number.
Is the Contract "Permanent"? *Yes 0 No ❑
If unsure, see backpage for permanent contract listing.
Is this entire contract Confidential? *Yes ❑ No 0 If only specific information is
Confidential, please list what information is Confidential and the page it is located.
Effective Date:
If different from the approval date.
Expiration Date:
If applicable.
Is a 1295 Form required? * Yes ❑ No 21
*If so, please ensure it is attached to the approving M&C or attached to the contract.
Project Number: If applicable.
*Did you include a Text field on the contract to add the City Secretary Contract (CSC)
number? Yes 0 No ❑
Contracts need to be routed for CSO processing in the followingorder:
rder:
1. Katherine Cenicola (Approver)
2. Jannette S. Goodall (Signer)
3. Allison Tidwell (Form Filler)
*Indicates the information is required and if the information is not provided, the contract will be
returned to the department.