The Medical Directors would like to thank Susan Fuchs, MD, Associate Director of Emergency Medicine, Children's Memorial Hospital and Associate Professor of Pediatrics at Northwestern University School of Medicine for developing the foundation of these protocols.

Thanks to Mary Clyde Pierce MD, Robert Hickey MD, Ray Pitetti MD, David LaCovey EMT-P, and Neil Jones EMT-P from the Children's Hospital of Pittsburgh for their expertise in reviewing and revising these protocols.

This set of protocols includes several revisions from the previous set:

• The addition of nebulized epinephrine for specific airway problems
• The addition of a Pain Management Protocol
• Revision of the Shock Protocols and the addition of septic shock
• Revision of Trauma Protocols

The Medical Direction committee has put great effort into developing these protocols such that they will enable you as a Pittsburgh Paramedic to provide the absolute highest level of patient care possible. Our intent was to make them the foundation of a system that will support your patient care efforts as best as possible.

We certainly appreciate the opportunity to serve you and hope that you find these protocols beneficial to your mission.
 
 

I. THE PITTSBURGH EMS PROTOCOL SYSTEM

II. CONTINUOUS QUALITY IMPROVEMENT (CQI)

III. SYSTEM DESIGN

IV. INTRODUCTION

V. DRUG DOSES RECOMMENDED IN CHILDREN

VI. PROTOCOL 701 - RESPIRATORY DISORDERS 

•     Protocol 701A - AIRWAY OBSTRUCTION
•     Protocol 701B - RESPIRATORY DISTRESS
•     Protocol 701C - RESPIRATORY FAILURE
•     Protocol 701D - ANAPHYLAXIS

•     Protocol 702A - CARDIOPULMONARY RESUSCITATION
•     Protocol 702B - ASYSTOLE/PULSELESS ELECTRICAL ACTIVITY (PEA)
•     Protocol 702C - VENTRICULAR FIBRILLATION

•     Protocol 703A - BRADYARRHYTHMIAS
•     Protocol 703B - SUPRAVENTRICULAR TACHYCARDIA
•     Protocol 703C - VENTRICULAR TACHYCARDIA

X. PROTOCOL 705 - ALTERED LEVEL OF CONSCIOUSNESS

XI. PROTOCOL 706 - SEIZURE

XII.  PROTOCOLXII 707 - SYNCOPE

XIII. PROTOCOL 708 - TRAUMA - GENERAL

•     Protocol 708A - MAJOR OR MULTI-SYSTEM TRAUMA
•     Protocol 708B - HIGH RISK
•     Protocol 708C - EXTRICATION

XV. PROTOCOL 710 - SPINAL CORD INJURY

XVI. PROTOCOL 711 - CHEST TRAUMA

•     Protocol 711A - FLAIL CHEST
•     Protocol 711B - SUCKING CHEST WOUND
•     Protocol 711C - IMPALED OBJECT
•     Protocol 711D - CARDIAC TAMPONADE (SUSPECTED)
•     Protocol 711E - TENSION PNEUMOTHORAX

•     Protocol 712A - FRACTURES  /  DISLOCATIONS
•     Protocol 712B - AMPUTATIONS

•     Protocol 713A - THERMAL BURNS
•     Protocol 713B - ELECTRICAL BURNS

XX. PROTOCOL 715 - SUSPECTED CHILD ABUSE AND NEGLECT (SCAN)

XXI. PROTOCOL 716 - PAIN MANAGEMENT

This ALS protocol system is designed to meet the requirements of and be in conformity with Act 45 (the EMS Act of the State of Pennsylvania and its Rules and Regulations). The system is based on several important principles:

1. Prehospital care is the practice of medicine outside the hospital.

2. All medical care rendered within the system is done so through the authority and privileges of the Medical Directors' license to practice medicine.

3. All medical care is under the supervision of the Medical Directors and their designates.
 

PROTOCOLS prescribe the standard of care which has been adopted by the Medical Director; they represent the usual and customary treatment which is expected to occur in the system.

1. Protocols serve as guidelines for both field medics and command physicians. Note, however, that command physicians do have the authority to deviate from protocol for appropriate medical reasons.

2. The appropriate protocol MUST be implemented for every patient who meets criteria for a particular protocol. Thus, paramedics are given STANDING ORDERS to implement a protocol up to the DOTTED LINE prior to contacting Medical Command. Paramedics are encouraged to contact the Command Physician as early as possible, but this should not delay initial care to the patient.

3. Paramedics are encouraged to call for EMS Physician response as soon as possible after discovering any of the following:

• difficult airway (meet en route if trauma)
• shock
• serious cardiac arrhythmias
• severe respiratory distress
• cardiac arrest or other life-threatening situation.

4. Paramedics are expected to understand and evaluate the appropriateness of orders received from the Command Physician. Should an order seem inappropriate (e.g., non-standard dose of medication) or reason for protocol deviation unclear, do not hesitate to express your concern to the Command Physician. You may also request review by the faculty back-up physician or Medical Director on Call. Such activities in no way create ill-will; to the contrary, they are expected and necessary to ensure the highest quality patient care and are part of your responsibility as a medic.

• INABILITY TO CONTACT COMMAND: In the unlikely event that the field team is unable to contact Medical Command PRIOR to hospital arrival due to equipment failure, non-availability of a Command Physician, or other extraordinary circumstance, paramedics are granted STANDING ORDERS to proceed below the dotted line if, in the paramedic's judgment, further delay would lead to serious deterioration or death of the patient. Whenever you are unable to contact Command, YOU MUST:

B. Complete Pittsburgh EMS "Quality Improvement" report explaining reasons for failure to contact command.

C. Complete EMSI "Use of Standing Orders" report (only if proceeded below dotted line).

The Medical Directors of Pittsburgh EMS are dedicated to the goal of assuring that this system is providing the highest quality of prehospital medical care that is achievable.

To this end, components of the system undergo frequent review by representatives of members and customers of the system. These reviews are then used to improve that particular components of the system.

Your participation in CQI is essential for achieving steady progress on the quality highway. We strongly encourage your input in this process and have established a user-friendly mechanism for you. Any time you think of a way to improve the system, simply complete a "Quality Management Report Form" and submit it to the Patient Care Coordinator. You should report any deficiencies which you find in the system as well so we can keep track of their occurrence and work together on ways to fix them.

Be assured that the Medical Directors will review all reports and suggestions and provide feedback in a timely fashion.
 

2. Appropriate units dispatched

3. Patient accessed/chief complaint or problem identified
    (e.g. altered level of consciousness)

4. Appropriate protocol selected and initiated
    (e.g. "altered level of consciousness protocol")

5. MEDIC COMMAND contacted/patient and protocol reported
    (e.g. "Medic Command, Medic One with a 2 y.o. male on the altered level of consciousness protocol)

6. MEDIC COMMAND assigns Med Channel and notes time
    (e.g. "Medic One, go to Med 6 for Physician.")

7. MEDIC COMMAND notifies primary and faculty back-up physician:
    (e.g. "MD-24 and MD-2, go to Med 6 for Medic One for altered level of consciousness protocol")

8. Field unit provides report on patient. Physician  gives orders and monitors channel for updates.

9. Field unit reports and Medic Command records time of all interventions.
    (e.g. "MEDIC COMMAND, IV started")

10. Field unit reports to MD results of therapy, suggests additional management, etc.

11. When possible, Medic Command notifies receiving hospital.

Seeing children ill, injured, or in pain is difficult for everyone. It involves a balance between performing duties in a professional and efficient manner and trying not to identify with the particular situation. It is the approach to the pediatric patient and the family that represents one of the greatest challenges to the emergency care provider.

We must be aware that "children are not just small adults" with respect to the type of injuries and illness suffered, as well as differences in anatomy, physiology, and developmental level. These considerations result in some differences in history-taking, physical assessment, therapeutic intervention, triage, packaging, and transport.

The following set of protocols, designed specifically for the care of the ill and injured children, recognizes and takes into account these differences.

On the other hand, there are certain problems affecting both children and adults where there is overlap in etiology, goals, rationale for treatment, and intervention techniques. When such overlap exists, you will be directed to the adult protocol pertaining to that protocol.

Susan M. Fuchs, M.D.

September 1996
 

PROTOCOL 701A - AIRWAY OBSTRUCTION

NOTE:
Any patient in cardiac or respiratory arrest in a restaurant or where food is being served, or with a history of foreign body ingestion (i.e., recently playing with toys, marbles, or food), should be presumed to have a foreign body upper airway obstruction. The Heimlich maneuver must be performed or the upper airway visualized with direct laryngoscopy as soon as possible.

INDICATIONS

1. All patients who CAN NOT PHONATE, or are cyanotic, and are suspected of foreign body upper airway obstruction.
2. All patients in cardiac arrest that occurred in a restaurant or during a meal.

PROTOCOL

Determine responsiveness and whether or not the child can cough or speak:
 

PATIENT CONSCIOUS
 

1. Encourage coughing. If ineffective and the CHILD > 1 YEAR, perform the Heimlich maneuver (subdiaphragmatic abdominal thrusts) in a series of 5 thrusts and repeat until effective or until the patient becomes unconscious.

2. In INFANTS or CHILDREN < 1 YEAR, straddle the infant over the rescuer's arms in a prone position with the head lower than the trunk and support the head.

A. Deliver 5 back blows with the heel of the hand between the infant's shoulder blades.

B. Turn the infant onto the supine position, keep the head lower than the trunk and give 5 chest thrusts (same location as CPR). Repeat until effective or patient becomes unconscious.

PATIENT UNCONSCIOUS

1. Perform Heimlich maneuver (5 thrusts) in CHILDREN > 1 YEAR, or 5 back blows/5 chest thrusts in CHILDREN < 1 YEAR.

2. If the object is not expelled and a laryngoscope is available, visualize the upper airway with a laryngoscope and remove the foreign body with Magill forceps. DO NOT USE BLIND FINGER SWEEPS!

3. Open airway and re-attempt to ventilate. If unable to ventilate, repeat steps 1 and 2 until successful.
 

• Contact Medical Command and request EMS Physician response as soon as airway obstruction is recognized or suspected.
• At any point, if the patient becomes unconscious or respiratory failure occurs, go to Respiratory Failure Protocol (701C).

• elevated respiratory rate -elevated heart rate
• retractions -nasal flaring
• cyanosis (late sign)
• toxicity (looks ill)
• anxious or listless

• Localizing signs include:

EXCLUSIONS:

• History of foreign body - Go to Protocol 701A (Airway Obstruction).
• Urticaria or wheezing with hypotension. - Go to Protocol 701D (Anaphylaxis).

• Assure airway patency. Administer oxygen 10-15L/min (mask, tubing, blow-by).
• Assist ventilation if indicated. Attempt to maintain pulse ox >94%.
• Assess breath sounds:

3. Monitor, keep warm and transport parent and child; allow the child to assume a position of comfort;
    DO NOT USE RESTRAINTS;  DO NOT START IV.
 
4. Initiate transport and contact Medical Command.

5. Further possible orders:

• EPINEPHRINE (1:1000) 0.01mg/kg; (0.01cc/kg) SQ; MAX 0.35 ml/dose
• Additional ALBUTEROL
• NEBULIZED EPINEPHRINE 5mg (5 ml epinephrine 1:1,000) via inhalation

 
 

INDICATIONS FOR ENDOTRACHEAL INTUBATION:

• inability to ventilate the unconscious patient
• cardiac or respiratory arrest
• inability of the patient to protect his/her airway
• respiratory failure
• cyanosis
• obtundation with hypoventilation or respiratory distress

• Cardiac arrest - Go to Protocol 702 (CPR)
• History of foreign body - Go to Protocol 701A (Respiratory Obstruction)

• Over-zealous bagging can cause air entry into stomach and pneumothorax. Consider cricoid pressure (Sellick maneuver) in non-intubated patients.
•  For respiratory failure 2 epiglottitis, use ADULT bag and peds mask.
• Contact Medical Command and request EMS Physician response as soon as respiratory failure suspected.

1. AIRWAY: Assure airway patency. If required, use manual maneuvers (jaw thrust) with bag/mask breathing position and suction as indicated.

2. Patent airway?

        A. Yes - 100% oxygen and ventilate as necessary. Maintain pulse ox >94%.

        B. No- Go to Protocol 701A (Respiratory Obstruction)

3. Ventilation adequate?

        A. Yes - Transport if able to maintain airway or INTUBATE

        B. No - INTUBATE immediately.

4.  Have suction ready

5. Monitor heart rate - if during intubation attempt HR drops to <80 (infant), <60 (child), terminate intubation and ventilate (BVM).
 

6. Monitor, transport and establish IV access en route.
 
 

INDICATIONS:
 

•  Patients with systemic signs/symptoms of allergic reaction: hives, generalized itching or flushing, upper airway irritation or blockage, wheezing, hypotension, urticaria, angioedema or other signs of allergic reaction.

•  Patients with local reaction (itching, redness, swelling) to known allergan.

1. Assure airway patency, ventilation, and circulation.
 
2. OXYGEN
• Face mask at 15L/MIN;
• ASSIST VENTILATION
• INTUBATE as appropriate.
• Suction as needed.
• Maintain pulse ox >94%.
3. Monitor ECG.
 
4. EPINEPHRINE 1:1000 - 0.01 mg/kg (.01 ml/kg) SC (MAX .35ml)

5. IV Ringer's Lactate - 20 cc/kg rapid infusion if hypotensive.
 
6. Remove allergan if present (e.g., bee stinger)
 
7. Reassess airway patency, vital signs, and level of consciousness frequently.
 
8. Contact Medical Command

Command Physician may order:

• EPINEPHRINE 1:10,000 - 0.01mg/kg (0.1cc/kg) SLOW IV or additional epinephrine SC.
 
• DIPHENHYDRAMINE (Benadryl) - 1 mg/kg (0.02 cc/kg) IV (MAX dose 50mg)

• MAST inflation
 
• Additional IV FLUIDS
 
 

VII. PROTOCOL 702 - CARDIAC ARREST  

NOTE:

Most cardiac arrests in children are the result of respiratory arrests, and, therefore, the first priority of care should be the establishment of adequate ventilation.

INDICATIONS:
 

• Apnea, unresponsiveness and pulselessness.
• Use adult protocols for children > 50kg

1. BEGIN BLS - ventilation and compressions:

• VENTILATION - mouth-to-mouth, mouth-to-mask, or manual (BVM) ventilation.
• COMPRESSIONS - if ventilation does not result promptly in restoration of pulse above 60.

3. Quickly determine ECG rhythm. For specific arrhythmia management, see appropriate management protocols:

• Vfib (see Protocol 702C)
• Vtach (see Protocol 703C)
• Asystole/PEA (see Protocol 702B)

7. Monitor SCENE TIME.
 
 

NOTE:

• If rhythm is unclear and possible ventricular fibrillation, follow instructions for V Fib (702C).

 
• Begin all cardiac arrest series protocols with PROTOCOL 702A - CARDIOPULMONARY RESUSCITATION

1. BEGIN BLS:

• Maintain airway patency via positioning and suctioning as necessary.
• Hyperventilate with 100% oxygen.
• Chest compressions at rate of 100/min.

Repeat q3-5min. All dose 0.1mg/kg (0.1cc/kg) (1:1000) IV, IO, ET
 

4. If heart rate less than 60, ATROPINE 0.02 mg/kg (0.2cc/kg) MIN 0.1mg ET, IO, IV. Can repeat q5 min if rhythm persists, up to a TOTAL MAX of 1.0mg (child), 2.0mg (adolescent). (For ET use, double or triple IV dose).
 

5. Contact Medical Command
 
 
6. IV Ringer's Lactate regular drip with large bore at KVO rate (preferably at/above antecubital fossa or use external jugular).
 

7. Consider causes:

• hypovolemia
• cardiac tamponade
• tension pneumothorax
• hypoxemia
• acidosis
• pulmonary embolus

• BICARBONATE - 1 mEq/kg (1cc/kg of 8.4% soln)

• DEXTROSE 25% IV or IO

•  IV FLUIDS BOLUS 20cc/kg Ringer's Lactate or NSS

NOTE:

Begin all cardiac arrest series protocols with PROTOCOL 702A - CARDIOPULMONARY RESUSCITATION
 
 

PROTOCOL:
 

1. Defibrillate (2 joules/kg)
 
 
2. If VF persists or recurs, DEFIBRILLATE (4 joules) x 2.
 
 
3. Intubate and establish IV or IO access.
 
 
4. EPINEPHRINE 1:1,000 0.1mg/kg (0.1cc/kg) ET or; IV/IO Epinephrine 1:10,000 0.01mg/kg IV/IO via first route available.
 
 
5. DEFIBRILLATE (4 joules/kg)
 
 
6. Contact Medical Command and prepare for transport.
 

7. Further possible orders:
 

• LIDOCAINE 1 mg/kg (0.1cc/kg 1%) IV, ET or IO (for ET use, double or triple IV dose.)
• BICARBONATE (IV or IO) - 1 mEq/kg (1cc/kg of 8.4% soln) in children: (0.5 mEq/kg [0.5 cc/kg] in neonates, diluted 1:1 with NS or use 4.2% solution)
• GLUCOSE (IV or IO):

• BRETYLIUM 5 mg/kg (0.1 cc/kg) IV or IO rapidly. May repeat at double initial dose.
• Repeated DEFIBRILLATIONS.

NOTE:

The most common pediatric arrhythmias are asystole and bradyarrhythmias; however, pediatric rhythm disturbances can be divided into 3 types:
 
        1. rhythms producing a fast heart rate

        2. rhythms producing a slow heart rate

        3. absence of any organized electrical activity (asystole or ventricular fibrillation)
 

The first priority is correction of hypoxia. The first 2 types require urgent treatment only if the patient is symptomatic (hypotension or poorly perfused).
 
 
Otherwise, the management of arrhythmias in children closely follows adult protocols with the exception of the following drug doses and advisories.
 

ADVISORY #1: VERAPAMIL should not be used in the field for children

ADVISORY #2: For atrial tachycardias, cardioversion should not be performed unless the patient is in extremis and a long transport time is anticipated. Adenosine (0.01mg/kg then 0.2 mg/kg) should be considered for selected patients.
 
 

PROTOCOL:
 
 
 FOR ALL ARRHYTHMIAS (Series 703) THE FOLLOWING GENERAL PROTOCOL APPLIES:
 

1 . Assure airway patency, ventilation, and circulation.
 
2.  OXYGEN
• Face mask at 15L/MIN;
• ASSIST VENTILATION and INTUBATE as appropriate.
• Maintain pulse ox >94%.
• Suction as needed.
 
3. Monitor ECG. - determine rhythm. For specific arrhythmia management, see appropriate management protocols.
 
4. RHYTHMS are documented with strip-chart printout.
 
5. CONTACT MEDIC COMMAND - dispatch EMS Physician.
 
6. CPR when no pulses are present or heart rate less than 60.
 
7. IV or IO ACCESS.
 
8. Monitor SCENE TIME. - Limit to 20 minutes

 
 

INDICATION:

For all arrhythmias (series 703) the begin with the following the general PROTOCOL 703 - CARDIAC ARRHYTHMIAS protocol
 

PROTOCOL:
 
1. OXYGEN 10-15 L/m face mask.

2. Assess for signs or symptoms of hypoperfusion:

• Capillary refill > 2 seconds
• Absent or weak peripheral pulses
• Cool, cold, cyanotic extremities
• Poor muscle tone
• Altered level of consciousness (lethargic or failure to recognize parents)
• Hypotension (see chart below)

4. Initiate transport.

5. EPINEPHRINE bolus (1:10,000) 0.01mg/kg (0.1cc/kg)

•     IV/IO or 0.1mg/kg (0.1cc/kg 1:1000)
•     repeat q 3-5 min 1:1000 ET
•     then EPINEPHRINE (1:1000) infusion (0.6mg/kg in 100mL D5W) start at 1.0mL/hr = 0.1 mcg/kg/min
•     and titrate to desired effect (0.1-1.0mcg/kg/min).

• MINIMUM dose is 0.1mg. (For ET use, double or triple IV dose.)
• May repeat dose if necessary once.

NOTE:

For all arrhythmias (series 703) the begin with the following the general PROTOCOL 703 - CARDIAC ARRHYTHMIAS protocol

PROTOCOL:
 
 

1. OXYGEN 10-15l/MIN FACE MASK
 
2. Assess for signs or symptoms of hypoperfusion:

• Capillary refill > 2 seconds
• Absent or weak peripheral pulses
• Cool, cold, cyanotic extremities
• Poor muscle tone
• Altered level of consciousness (lethargic or failure to recognize parents)
• Hypotension (see chart below)

3. Contact Medical Command.

4. Further possible orders for unstable patients:

        A. Synchronized cardioversion (0.5 joules/kg)

•  May pretreat with VALIUM 0.1 mg/kg (0.02 cc/kg) IV  (Anticipate respiratory depression with the use of Valium.)

•  Repeat synchronous cardioversion at 1 and 2 J/kg if rhythm persists.

•  Bag/mask must be immediately available for assisting ventilation.

NOTE:

• If no pulse present, treat as VF (Protocol 702C)
• For all arrhythmias (series 703) the begin with the following the general PROTOCOL 703 - CARDIAC ARRHYTHMIAS protocol

PROTOCOL:
 

1. OXYGEN 10-15l/MIN FACE MASK
2. Assess for signs or symptoms of hypoperfusion:

• Capillary refill > 2 seconds
• Absent or weak peripheral pulses
• Cool, cold, cyanotic extremities
• Poor muscle tone
• Altered level of consciousness (lethargic or failure to recognize parents)
• Hypotension (see chart below)

3. Contact Medical Command.

4. Further possible orders:
 
        A. If stable:

•  IV or IO access
•  LIDOCAINE 1mg/kg (0.1cc/kg-1%) IV, IO, ET (MAX 50mg) (For ET use, double or triple IV dose).
•  May repeat one-half initial dose Q8min to maximum 3 mg/kg.

•  Cardioversion (0.5 joules/kg)

• Bag/mask must be immediately available for assisting ventilation.
• Establish IV or IO access and intubate
• LIDOCAINE 1 mg/kg (0.1 cc/kg) IV, IO, ET (For ET use, double or triple IV dose.) May repeat one-half initial dose Q8min to maximum 3 mg/kg.
• BRETYLIUM 5 mg/kg (0.1 cc/kg) IV, IO. Administer rapidly if patient unconscious and airway protected, otherwise over 8-10 minutes

INDICATIONS:
 
Shock should be suspected if any of the following signs of poor perfusion are present:

• Altered level of consciousness
• Hypotonia ("limp baby")
• Weak central (proximal) pulses with absent peripheral pulses
• Capillary refill > 2 sec
• Active bleeding or a history of active bleeding from bowel, stomach or major vessel
• Sustained pulse: (see chart below)

• Hypotension: (see chart below) or an observed fall of systolic BP > 10 mm Hg

EXCLUSIONS:

Trauma - use Protocol 708.
 
 

PROTOCOL:
 
 
1. Assure airway patency, ventilation, and circulation with c-spine control (if indicated).
 
2.  OXYGEN

• Face mask at 15L/MIN;
• ASSIST VENTILATION and INTUBATE as appropriate.
• Maintain pulse ox >94%.
• Suction as needed.

6. Check Chemstrip and treat if indicated
 
7. IV or IO ACCESS.
 
8. Initiate transport as soon as possible. Keep patient warm. Assure adequate oxygenation and ventilation.
 
9. Reassess vitals, breath sounds, signs of perfusion.

10. IV FLUIDS Ringer's Lactate (or NORMAL SALINE) 20cc/kg bolus (IV or IO)
      - Only if lungs are clear and there are no signs of fluid overload (i.e., CHF)
 
11. Additional Orders may include

• Additional IV FLUIDS

 
• DOPAMINE drip 200 mg IN 250 cc D₅W (or 400 mg in 500cc) [this yields 800 mcg/cc] and run at rate per Command Physician.

 
• DOBUTAMINE drip 250 mg in 250 cc D₅W (or 500 mg in 500cc) [this yields 1000 mcg/cc] and run at rate per Command Physician.

 
• MAST inflation

 
 

The primary goal in a patient who has a serious alteration in consciousness is AIRWAY PROTECTION. Protective reflexes such as cough and gag are lost; aspiration is an ever-present danger in these patients and can be lethal.
 
The specific goals of protection may be stated as being:

1. To protect the patient from physical or environmental harm.

2. To protect the patient's brain from injury due to lack of oxygen or glucose.

3. To protect the patient from aspiration.

4. To reverse several underlying causes of coma that may be present, such as hypoglycemia or opiate depression.

5. To gather information for hospital personnel.
 

INDICATION:

Alteration in normal mental status, including confusion, unusual behavior, or unresponsiveness to verbal or painful stimulus.
 

EXCLUSIONS:

1. Head injury or other trauma.

2. Shock or serious cardiac arrhythmia.

3. Apnea, cyanosis, obtundation with hypoventilation or respiratory distress
    (If any of above present, go immediately to proper protocol).
 

POSSIBLE CAUSES:

1. hypoxia

2. hypoglycemia

3. meningitis or encephalitis

4. status epilepticus or postictal state

5. sepsis

6. Reye's syndrome

7. hypertensive encephalopathy

8. intoxication/poisoning

9. shock (nontraumatic)

10. arrhythmia.
 
 

PROTOCOL:
 

1. Assure AIRWAY PATENCY with c-spine control (if indicated).
 
2. BREATHING - oxygen (mask, nasal cannula, BVM), suction and assist ventilation as needed to maintain pulse ox >94%.
 
3. CIRCULATION - monitor pulse, blood pressure, respiratory rate.
 
4. Establish baseline data:

        a. pupil size and reactivity

        b. level of responsiveness to verbal, tactile, painful stimuli

        c. muscle tone
 

        e. history of diabetes?

5. Establish IV or IO access

6. Check Chemstrip:

 A. Glucose > 60:
 
•   NARCAN 0.1mg/kg (0.25 cc/kg) IV, ET, IO, IM (>5 yrs MIN 2mg)
•   If no response - Intubate and ventilate as needed.
•   Monitor vital signs and neurological status (pupils, response, tone).

•  Age < 12 yrs: D25 2cc/kg *(Dilute D50 1:1 with sterile water if necessary.)
•  Age > 12 yrs: D50 1cc/kg
•  If no IV access, Give GLUCAGON IM 0.025-0.1mg/kg (0.025 - 0.1cc/kg) Max 1.0mg

8.  Contact Medical Command

9.  Transport in right or left lateral position (unless immobilized or intubated).

INDICATIONS:
 

• Ongoing or recent seizure.
• Alteration in consciousness associated with eye deviation, loss of bowel/bladder control, non-purposeful rhythmic or tonic body movements.

• If glucose < 60, administer DEXTROSE:
• Age < 12 years: D25 2cc/kg *(Dilute D50 1:1 with sterile water if necessary.)
• Age > 12 years: D50 1cc/kg
• If no IV access, administer GLUCAGON 0.1 mg/kg (up to 1 mg) IM.

9. Search for etiology:
 

• head injury
• fever
• non-compliance with medication
• CNS infection
• hypoxia, arrhythmias

• VALIUM 0.1mg/kg slow IV push or 0.5mg/kg per rectum (up to 5 mg if age < 12 and 10 mg age > 12)
• Additional VALIUM as ordered by the command physician

NOTES:

1. The common denominator of syncope is INADEQUATE BRAIN PERFUSION. This may be due to several reasons:
 

• Vasovagal Attack
• Hypoxia
• Cardiac Arrhythmias
• Hypoglycemia
• Hypovolemia
• Hyperventilation
• Cerebral Ischemia or Infarction

INDICATION:

Patients with any transient loss of or alteration in normal consciousness or mentation.
 
 

EXCLUSIONS:
 

• Persistent alteration of consciousness - use Protocol 705.
• Signs of shock - use Protocol 704.

• 10-15L/min by mask, nasal cannula, blow-by.
• Maintain pulse ox >94%.

• Age < 12 years: D25 2cc/kg D25 2cc/kg *(Dilute D50 1:1 with sterile water if necessary.)
• > 12 years: D50 1cc/kg
• If no IV access, administer GLUCAGON 0.1 mg/kg (up to 1 mg) IM.

GENERAL GUIDELINES FOR ALL 708 SERIES PROTOCOLS:
 

1. MAXIMUM allowable time-on-scene for all trauma protocols is 10 MINUTES. Scene times over 10 minutes MUST have documentation on trip sheet explaining circumstances (e.g., extrication or access problem).
 

2. Patients who meet regional trauma triage guidelines as listed below MUST be transported to the appropriate Pediatric Trauma Facility, considering patient preference, transport time, and specific specialty services.
 

3. TRAUMA CENTER NOTIFICATION - It is the responsibility of the field team to ensure trauma centers are given ample warning of the impending arrival of these patients. Trauma Teams require some minutes to assemble, prepare equipment, ensure blood is immediately available, etc. Neglect of the important function of notification may jeopardize the patient's welfare and lead to major complications.
 
 

INDICATION:
 

Injury to several organ systems or anatomic areas or severe injury to one system. The term implies severity as well, with instability of vital signs and grave risk to life and limb.
 

TIME:
 
 
10 minutes on-scene time maximum unless extrication or other extenuating circumstances.
 
 

PROTOCOL:
 
 
1. Ensure SAFETY of personnel at the scene.
 
2. PRIMARY TRAUMA SURVEY -Treat critical conditions:

        A. AIRWAY: Control AIRWAY with cervical spine precautions. If required, use manual maneuvers (jaw thrust) with bag/mask breathing
 
        B. BREATHING: Administer supplemental OXYGEN at 10-15L/min by face mask. ASSIST VENTILATION and INTUBATE as appropriate.
 

            If appropriate, INTUBATE patient:

•  endotracheal with IN-LINE CERVICAL IMMOBILIZATION.
• Digital (>13 yrs) or lighted stylet method (ET Tube > 6.0) may be used.

• IMMOBILIZE the patient and protect the cervical spine with a rigid collar and backboard/CID or backboard with towels and tape.

 
NOTE: In cases of blunt trauma, place MAST on longboard prior to patient and finish applying while en route.

• The MAST suit should not be used in cases of penetrating chest trauma.
• CAUTION: The abdominal portion of the MAST trousers should NOT be inflated in children <4 years due to the incidence of respiratory compromise. EXCEPTIONS ARE: Pelvic fractures, known intra abdominal bleeding or when patient is intubated. Command physician discretion will determine use for penetrating trauma to the abdomen.

• unrelieved airway obstruction
• major chest injury or respiratory distress
• shock
• decreased level of consciousness
• cardiac or respiratory arrest

6. SECONDARY SURVEY (Perform en route if "load & go" situation present.)
 
    A. Begin large bore intravenous lines or intraosseous line.

• Run wide open under pressure Lactated Ringers (at least 20cc/kg) if tachycardic or signs of poor perfusion,
• Reassess.
• Pressure infuse if patient is hypotensive.
• If no signs of poor perfusion, no tachycardia and no hypotension, give 20cc/kg bolus then run IV at KV

    C. REEVALUATE every 3-5 minutes en route.

7. If analgesia appropriate and not contraindicated, use NITROUS OXIDE/OXYGEN mixture.

• NOTE: This requires approval of the EMS Physician.

GOALS:

The application of the "HIGH RISK" protocol is based upon the fact that some patients who are seriously ill or injured may present initially with little to indicate an underlying major problem. This is a "preventive protocol", one which anticipates deterioration of the patient despite the apparent lack of indications for an aggressive approach to therapy.

The protocol is based on the concept of INJURY POTENTIAL.
 

INDICATIONS:

All patients, despite normal or near-normal vital signs, who present with or sustain the following, are to be included in this protocol:

• Penetrating wounds
• Vehicular accidents with extensive interior or exterior damage to the vehicle
• Motorcycle accidents
• Motor vehicle-pedestrian accidents
• Entrapment/Impalement
• Falls greater than patient's height
• Evident or likely blood loss - external or internal (e.g., GI bleeding)

2. PRIMARY TRAUMA SURVEY-Treat critical conditions:

2. PRIMARY TRAUMA SURVEY -Treat critical conditions:

        A. AIRWAY: Control AIRWAY with cervical spine precautions. If required, use manual maneuvers (jaw thrust) with bag/mask breathing
 
        B. BREATHING: Administer supplemental OXYGEN at 10-15L/min by face mask. ASSIST VENTILATION and INTUBATE as appropriate.
 

            If appropriate, INTUBATE patient:

•  endotracheal with IN-LINE CERVICAL IMMOBILIZATION.
• Digital (>13 yrs) or lighted stylet method (ET Tube > 6.0) may be used.

• IMMOBILIZE the patient and protect the cervical spine with a rigid collar and backboard/CID or backboard with towels and tape.

 
NOTE: In cases of blunt trauma, place MAST on longboard prior to patient and finish applying while en route.

• The MAST suit should not be used in cases of penetrating chest trauma.

CAUTION: The abdominal portion of the MAST trousers should NOT be inflated in children <4 years due to the incidence of respiratory compromise. EXCEPTIONS ARE: Pelvic fractures, known intra abdominal bleeding or when patient is intubated. Command physician discretion will determine use for penetrating trauma to the abdomen.

• unrelieved airway obstruction
• major chest injury or respiratory distress
• shock
• decreased level of consciousness
• cardiac or respiratory arrest

6. SECONDARY SURVEY (Perform en route if "load & go" situation present.)
 
    A. Begin large bore intravenous lines or intraosseous line.

• Run wide open under pressure Lactated Ringers (at least 20cc/kg) if tachycardic or signs of poor perfusion,
• Reassess.
• Pressure infuse if patient is hypotensive.
• If no signs of poor perfusion, no tachycardia and no hypotension, give 20cc/kg bolus then run IV at KV

    C. REEVALUATE every 3-5 minutes en route.

7. If analgesia appropriate and not contraindicated, use NITROUS OXIDE/OXYGEN mixture.

• NOTE: This requires approval of the EMS Physician.

NOTE:

• Initial efforts must be directed toward the environmental safety of both patient and rescuers, and then to the examination and management of the patient.

• The goal is to maintain vital functions prior to and during extrication and to institute life support procedures as much as possible.

INDICATIONS:

All patients who are trapped, impaled, or who are at risk of the crush syndrome.
 
 

PROTOCOL:
 
 
1. Ensure SAFETY of personnel at the scene, request physician response.

2. PRIMARY TRAUMA SURVEY -Treat critical conditions:

        A. AIRWAY: Control AIRWAY with cervical spine precautions. If required, use manual maneuvers (jaw thrust) with bag/mask breathing
 
        B. BREATHING: Administer supplemental OXYGEN at 10-15L/min by face mask. ASSIST VENTILATION and INTUBATE as  appropriate.
   Assist ventilation if respiratory rates are:  

AGE	RESPIRATORY RATE
INFANT	< 20 breaths/min
PRE-SCHOOL (1-4 years)	< 15 breaths/min
CHILDREN (> 4 years)	< 10 breaths/min

 
 

            If appropriate, INTUBATE patient:
 

•  endotracheal with IN-LINE CERVICAL IMMOBILIZATION.
• Digital (>13 yrs) or lighted stylet method (ET Tube > 6.0) may be used.
 
 
        C. CIRCULATION: CONTROL SEVERE EXTERNAL BLEEDING with constant direct pressure.
 

4. Ensure protection of patient against from weather, rescue operations and other hazards as possible.

5. Initiate IV Ringer's Lactate large bore with regular drip tubing - begin at 20cc/kg over 20 minutes.

6 CONTACT MEDICAL COMMAND - Command MD will advise regarding:

• airway management
• IV FLUID administration
• MAST inflation
• use of ANALGESIA when appropriate. (This will usually be Nitrous Oxide)
• SODIUM BICARBONATE for large crush injuries (prior to release)

8. During extrication, monitor vitals, level of consciousness, respiratory and cardiovascular status and ECG as possible.

9. If cardiovascular collapse occurs following release of crushed area, give SODIUM BICARBONATE 1mEq IV/kg push.

10. Upon extrication, IMMOBILIZE on longboard (have MAST on long board but DO NOT inflate unless used to splint a leg fracture).

11. Expedite transport to Pediatric Trauma Center and provide update on patient status while en route:

• Keep patient warm.
• Pain control - NITROUS OXIDE:OXYGEN mixture. (Useful for children >6 years who are able to hold mask and follow commands).

• To maintain the airway and circulatory status of the head injured patient and to protect the spine.
• To record an initial examination and GCS.
• To institute measures that may reduce intracranial pressure.
• To expeditiously present to the hospital team the patient who may require neurosurgical intervention.

• Have a Glasgow Coma Score (CGS) < 8 or are comatose.
• Deteriorate more than 2 points on the GCS at the scene or en route.
• Exhibit unilateral or bilateral flexor or extensor response to pain.
• On serial examination, develop unequal pupils and who are unresponsive to verbal stimuli.

This protocol applies only to those who have a blood pressure appropriate for their age and in whom occult bleeding is unlikely.
 
 
PROTOCOL:
 
1. Assure AIRWAY patency, then IMMOBILIZE and protect the cervical spine with a rigid collar and backboard/CID or backboard with towels and tape.
 
2. CONTROL THE AIRWAY as appropriate:

• give 100% OXYGEN using C-spine precautions if necessary.
• maintain pulse ox >94%.

• maintain in-line cervical immobilization (NOT TRACTION).
• give LIDOCAINE 1.0 mg/kg IV or IO 60-90 seconds prior to intubation (if IV access readily available).

GOALS:

• Protection of the patient against further injury.
• Maintenance of vital functions in patients with suspected or actual spinal cord injury.
• Maintenance of perfusion to the damaged spinal cord to reduce changes of edema and further insult.
• Data recording for serial evaluation of the patient.
• Psychological support in the early management of the patient with spinal cord injury.
• Facilitation of entry of the patient into a trauma system designed to care for these patients.

• Patients with blunt or penetrating trauma near or in area of spinal column.
• Patients with numbness, weakness or other neurologic deficits after trauma.
• Mechanism suggestive of potential spine injury such as, MVA, bicycle accident, blunt facial trauma, fall, GSW near the midline.

1. SUPPORT AND REASSURE patient. Explain all procedures. Make no definitive comments regarding prognosis, extent of injury, etc.

2. CONTROL THE AIRWAY as appropriate:

• give OXYGEN at 8-10L/min using C-spine precautions.
• maintain pulse ox >94%.

GOALS:

• To ensure for the patient with a chest injury a patent airway and adequate ventilatory mechanics.
• To ensure or restore the integrity of ventilation.
• To ensure or restore the circulatory status of the patient.
• To treat conditions specific to the chest injury.
• To ensure prompt access to a system of trauma care capable of addressing the patient's problem.

PROTOCOL 711A - FLAIL CHEST
 

INDICATIONS:   Patients following chest trauma who:

• Have tachypnea, dyspnea, or both.
• Display paradoxical motion of the chest wall, with a "floating segment."

• high flow (10-15 L/min) by mask, or positive pressure ventilation (BVM), if necessary.
• Use c-spine precautions if required.
• Maintain pulse ox >94%.

3. Place patient on injured side, if tolerated.
 

4. IV ACCESS (large bore) - Ringer's Lactate, KVO rate..
 

5. INTUBATION if necessary.
 

6. Initiate rapid TRANSPORT to nearest Pediatric Trauma Center.
 

7. Contact Medical Command
 

8. Monitor for tension pneumothorax:  Decreasing blood pressure associated with

• worsening dyspnea,
• unilateral decreased breath sounds,
• increasing resistance to ventilation.
• Treat tension pneumothorax -perform NEEDLE DECOMPRESSION of chest (per procedure protocol).

PROTOCOL 711B - SUCKING CHEST WOUND
 
 
INDICATIONS:

All patients who present with chest wounds that are open and leaking.
 
 
PROTOCOL:

1. OXYGEN - high flow (10-15L/min) by mask or positive pressure ventilation (BVM) when required.
 
2. SEAL wound with Vaseline gauze, plastic wrap, adhesive tape, preferably at end-expiration if child can cooperate.
 

3. Monitor for tension pneumothorax:  Decreasing blood pressure associated with

• worsening dyspnea,
• unilateral decreased breath sounds,
• increasing resistance to ventilation.

7. Initiate rapid TRANSPORT to Pediatric Trauma Center.
 
 

INDICATIONS:

Any patient with a foreign object impaled in chest or abdomen.
 

NOTE:

The following exceptions apply to the general rule of stabilizing an impaled object in place:

• If the patient is in cardiac arrest, remove any object impaled in the chest prior to beginning compressions.
• Impaled objects obstructing the airway or impeding ventilation should be removed.
• Objects impaled in the abdomen should be removed if the patient is in extreme shock and the object would interfere with the application of the abdominal chamber of the MAST.

1. OXYGEN - high flow (10-15 L/min) by mask or positive pressure ventilation (BVM).
 
2. STABILIZE OBJECT - in place.
 
3. INITIATE TRANSPORT.
 
 4. IV ACCESS - Ringer's Lactate (KVO)
 
 
 

INDICATIONS:

Patients with a systolic blood pressure less than expected for age, who are dyspneic and/or tachypneic with:

• Diminished or absent heart sounds.
• Obvious distended neck veins.
• Clearly-auscultated bilateral breath sounds.

1. OXYGEN - high flow (10-15 L/min) by mask or positive pressure ventilation (BVM) as appropriate.
 

2. INTUBATION/AIRWAY control as appropriate.
 

3. Immediate TRANSPORT - consult EMS physician. DO NOT DELAY TRANSPORT TO AWAIT ARRIVAL OF PHYSICIAN.
 

4. ECG Monitor.
 

5. En route - Begin large bore intravenous lines or intraosseous line.

• Run wide open under pressure Lactated Ringers (at least 20cc/kg) if tachycardic or signs of poor perfusion, then reassess.
• Pressure infuse if patient is hypotensive.
• If no signs of poor perfusion, no tachycardia and no hypotension, run IV at KVO.

Patients with chief complaint of progressively worsening dyspnea or tachypnea following chest trauma and who have both:

• Absent breath sounds on one side
• Falling B/P (inappropriate for age)

2. Immobilize C-spine if indicated and expedite TRANSPORT.
 
3. Consult Command Physician immediately.

4. Perform needle decompression of chest per procedure protocol.
 
5. Reassess vitals, lung sounds; apply ECG monitor

6. Initiate IV Ringer's Lactate at KVO rate.
 
7. Observe patient carefully for recurrence of tension pneumothorax.
 
 

PROTOCOL 712A - FRACTURES/DISLOCATIONS

 
INDICATIONS:

All patients who have suspected dislocations or fractures, especially of the pelvis or femur.
 

PROTOCOL:
 

1. PERFORM PRIMARY AND SECONDARY SURVEY, including:

• neurological and vascular exam of extremity distal to injury.
• OXYGEN and airway control.

4. SPLINTING:

• Attempt to splint in position found, particularly if the fracture is open and there is gross deformity.
• If grossly deformed limb cannot be splinted in place, apply traction until sufficient reduction to permit splinting.
• TRACTION splint for isolated femur fracture
• MAST SUIT (inflated) for pelvis and/or femur fracture
• AIR SPLINT or VACUUM SPLINT

7. Possible orders for analgesia include:

• Nitrous oxide:oxygen 50:50 mixture self-administered
• Morphine sulfate 1-3 mg IV or IO incremental doses

PROTOCOL 712B - AMPUTATIONS
 
 

NOTE:

This protocol addresses the problem of amputation of body parts, and attempts to facilitate the preservation of tissue and the delivery of the patient to a trauma center with expertise in microsurgical techniques for replantation. Although great advances have been made in reconstructive techniques, field team members are reminded that only the surgical team is qualified to estimate the outcome of reconstruction. This often requires microscopic examination in the operating room. Therefore, EMS personnel must not make any comment to the patient concerning the possible outcome of the patient's injury.
 
 
INDICATION:

Amputation or large avulsion of any body part.
 

EXCLUSIONS:

Major trauma to other body systems - use other appropriate protocol and have other personnel retrieve amputated part.
 
 
PROTOCOL:
 
1. Assure patent airway; OXYGEN - 10-15L/min

• Maintain Pulse ox >94%.

• Direct pressure and elevation.
• Proximal pressure point.
• If profuse or if significant bleeding persists after 10 minutes of above measures, apply blood pressure cuff proximal to injury and inflate to 20 mmHg above systolic blood pressure

        b. Place this bag in iced saline or cold water.

        c. Transport the part with the patient.
 
NOTE:

• DO NOT immerse parts directly in ice, saline, water or preservative.
• DO NOT wash the part with antiseptic.
• DO NOT use dry ice for preservation.
• DO NOT place cold packs directly against the part.

5. MONITOR bleeding and vital signs en route.
 

6. Transport to a Pediatric Trauma Center.
 

7. Consult Command Physician.
 

8. Possible orders for analgesia include:

• Nitrous oxide:oxygen 50:50 mixture self-administered
• Morphine sulfate 1-3 mg IV or IO incremental doses

INDICATIONS:

1. Patients with suspected inhalation injuries.

2. Patients with partial thickness (2) thermal burns of more than 10% of body surface area.

3. Patients will full thickness burns of more than 2% body surface area.

4. Burns to the face, hands, feet, and perineum.
 
 

NOTE:

To calculate percent of body surface area (BSA) burned:

• The palm is equal to 1% BSA.
• Children use the "rule of 9":

PROTOCOL:
 
 
1. Ensure SAFETY at the scene.
 

2. Assure AIRWAY patency and assist ventilation if necessary.
 

3. OXYGEN 15L/min via face mask, blow-by, or BVM.
 
 
4. REMOVE ALL BURNING OR SMOLDERING CLOTHING OR ARTICLES, including jewelry.
 
 
5. ASSESS for other injuries. IMMOBILIZE if indicated and DETERMINE extent of burn.
 
 
6. TRANSPORT to appropriate Burn Care facility.
 

7. INITIATE IV Ringer's Lactate at KVO rate.
 

8. CONTACT COMMAND PHYSICIAN
 

9. PAIN CONTROL:

• Nitrous oxide:oxygen mixture 50:50 mixture self-administered.
• MORPHINE SULFATE, 1-3mg IV or IO incremental doses titrated as per physician.

11. May use sterile saline soaked 4 x 4 on burns for patient not in shock and total body surface area burn <5%
 

12. RECORD data accurately with attention to:

• time of burn
• type of environment
• time IV fluids begun
• amount of fluids given

PROTOCOL 713B - ELECTRICAL BURNS
 
 
NOTE:

• Electrical burns are often accompanied by cardiopulmonary arrest. Arrhythmias may also occur.
• Because of burning of deep tissues between entry and exit sites, electrical burns are usually much more severe than external wounds suggest.

10. Consider need for analgesia:

•  Nitrous oxide:oxygen, 50:50 mixture self-administered.
•  MORPHINE SULFATE, 1-3mg IV or IO incremental doses titrated as per physician.

INDICATION:

History suggestive of exposure to toxic substance.
 
 

PROTOCOL:
 

1. Assure scene SAFETY.

2. Terminate exposure.
 
3. Assure AIRWAY patency; assist VENTILATION as needed.
 
4.  DECONTAMINATE:

• Skin: Remove clothing; wash with NSS.
• Eye: Flush with NS. Direct flow from inner to outer corner of eye and away from non-exposed eye.

6. Monitor and TRANSPORT to appropriate facility.
 
7. Bring in materials and/or containers of products ingested or exposed.

8. For ingestions, consider ACTIVATED CHARCOAL (1gram/kg by mouth) or SYRUP OF IPECAC (30cc by mouth) if:

• able to protect own airway,
• no abnormal level of consciousness,
• no seizures,
• no caustic or hydrocarbon ingestion.

INDICATIONS (WHEN TO SUSPECT):
 

1. HISTORY - RED FLAGS!

• History of injury incompatible with type of degree of injury.
• History of vague, parent reluctant to give history or contradictory histories given by each parent.
• History impossible for childish level of development.
• Significant and inappropriate delay between time of injury and time you were called.
• You have been repeatedly called to this home for ingestions and/or injuries and may have been asked to take the child to a different hospital each time.
• You have been repeatedly called to this home about alarming chief complaints and find a well infant (this may be a "preabuse" situation).

• Parent doesn't show concern appropriate to the child's injury.
• Parent shows inappropriate expectation of the child.
• Parent makes inappropriate demands of the child.
• Parent demonstrates angry impulsive behavior toward the child.

Patterns of injury:

• bruises in unusual location (e.g. back, buttocks, face, ears, upper arms, thighs, hands, feet).
• surface marks suggesting a weapon (e.g. belt, looped cord, switch, rope or chain).
• burns (e.g. immersion scalds, large imprints of an iron, radiator, heater or cigarette).
• long bone (especially humerus or femur) and/or rib fractures in children under 2 yrs of age with no reasonable history.
• skull fractures or signs suggesting CNS injury (especially in an infant with no reasonable history).
• signs suggestive of significant abdominal, perineal or chest injury without a reasonable history.
• signs of failure to thrive (thin or wasted infant or toddler), often dirty and apathetic.

• Severe acute injury with loss of consciousness, seizures or cardiovascular collapse.
• Sudden decompensation in an infant with prior head or abdominal injury.
• Sudden decompensation in an infant with failure to thrive due to dehydration or sepsis.
• Severe symptoms due to an ingestion.

PROTOCOL:
 
 
1. STABILIZE

• apply appropriate protocol as indicated by the patient's condition.

• evidence of violence or disarray,
• frightened/bruised mother or siblings,
• aggressive or inappropriate behavior of parent or other household member

NOTE: DO NOT MENTION THAT YOU SUSPECT ABUSE, ACT IN A JUDGMENTAL MANNER
OR CONFRONT THE PARENTS IN ANY WAY. This will only inflame them and may subject the
field team members and the patient to significant physical risk.

4. TRANSPORT the patient to the hospital.
 

5. REPORT YOUR CONCERNS - in private - to the Emergency Department personnel at the receiving hospital.
 

6. DOCUMENT patents' observations and comments.
 
 

INDICATION:

Patients in significant pain due to isolated injury or medical condition.
 
 

EXCLUSIONS:

1. Major trauma to head, chest, abdomen or pelvis follow appropriate protocol.

2. Patients with chest pain who meet criteria for Adult Protocol 301 (Chest Pain).
 
 

PROTOCOL:
 

1. PERFORM THOROUGH ASSESSMENT to rule out major trauma or serious medical problems.

2. Continuously monitor vitals, pulse ox and mental status for early signs of shock.
 
3. Provide patient with NITROUS OXIDE:OXYGEN for self-administration per Procedural Protocol.
 
4. IV Lactated Ringers KVO. Command Physician may order IV FLUID boluses based on case specifics.
 
5. CONTACT MEDICAL COMMAND and request EMS Physician response if required.
 
6. APPLY ECG MONITOR and pulse ox for prolonged extrications or if IV analgesics are administered.
 
 

7. ANALGESIA options:
 
 
 
 

NOTE: When using narcotics and benzodiazepines, especially together:

• observe closely for hypotension and respiratory depression.
• have Narcan available.