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PATIENT CARE PROTOCOLS AND
STANDING ORDERS
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
EMT
Intermediate
Paramedic
Medical Control
Table of Contents
GENERAL PROTOCOLS
Page
9
Universal Patient Care Protocol------------------------------------------------------- 10
Airway, ADULT---------------------------------------------------------------------------- 11
Airway, ADULT FAILED----------------------------------------------------------------- 12
Airway, PEDIATRIC---------------------------------------------------------------------- 13
Back Pain------------------------------------------------------------------------------------ 14
Behavioral----------------------------------------------------------------------------------- 15
Fever ---------------------------------------------------------------------------------------- 16
IV Access------------------------------------------------------------------------------------ 17
Pain Control--------------------------------------------------------------------------------- 18
MEDICAL PROTOCOLS
Page 19
Abdominal Pain---------------------------------------------------------------------------- 20
Allergic Reaction--------------------------------------------------------------------------- 21
Altered Mental Status (AMS) ----------------------------------------------------------- 22
Asystole-------------------------------------------------------------------------------------- 23
Bradycardia, ADULT--------------------------------------------------------------------- 24
Cardiac Arrest------------------------------------------------------------------------------ 25
Chest Pain / Suspected Cardiac Event---------------------------------------------- 26
Dental Problems--------------------------------------------------------------------------- 27
Epistaxis------------------------------------------------------------------------------------- 28
Hypertension ----------------------------------------------------------------------------- 29
Hypotension Shock (Non-Trauma), ADULT---------------------------------------- 30
Overdose / Toxic Ingestion ------------------------------------------------------------- 31
Post Resuscitation------------------------------------------------------------------------ 32
Pulmonary Edema------------------------------------------------------------------------ 33
Pulseless Electrical Activity (PEA) ---------------------------------------------------- 34
Revised: 07/11/2011
M. Stover, MD
2
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
EMT
Intermediate
Paramedic
Medical Control
MEDICAL PROTOCOLS, Continued
Respiratory Distress, ADULT------------------------------------------------------------ 35
Seizures, ADULT
---------------------------------------------------------------------- 36
Atrial Fibrillation / Atrial Flutter ------------------------------------------------------ 37
Supraventricular Tachycardia (SVT), ADULT
Suspected Stroke
Syncope
---------------------------------- 38
---------------------------------------------------------------------- 39
------------------------------------------------------------------------------- 40
Ventricular Fibrillation (VF) / Pulseless Ventricular Tachycardia ------------ 41
Ventricular Tachycardia (VT)
Vomiting and Diarrhea
------------------------------------------------------ 42
--------------------------------------------------------------- 43
PEDIATRIC & OBSTETRIC (OB) PROTOCOLS
Childbirth / Labor
Page 44
---------------------------------------------------------------------- 45
Newly Born ------------------------------------------------------------------------------- 46
Obstetrical (OB) Emergency
Bradycardia, PEDIATRIC
------------------------------------------------------- 47
--------------------------------------------------------- 48
Head Trauma, PEDIATRIC
-------------------------------------------------------- 49
Hypotension Shock (Non-Trauma), PEDIATRIC ------------------------------- 50
Multiple Trauma, PEDIATRIC
---------------------------------------------------- 51
Pulseless Arrest, PEDIATRIC
---------------------------------------------------- 52
Respiratory Distress, PEDIATRIC ---------------------------------------------------- 53
Seizures, PEDIATRIC
------------------------------------------------------------- 54
Supraventricular Tachycardia (SVT), PEDIATRIC
TRAUMA PROTOCOLS
Bites & Envenomations
------------------------- 55
Page 56
------------------------------------------------------------- 57
Aquatic Life ------------------------------------------------------------------------------- 58
Burns ---------------------------------------------------------------------------------------- 69
Drowning / Near Drowning ------------------------------------------------------------- 60
Revised: 07/11/2011
M. Stover, MD
3
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
EMT
Intermediate
Paramedic
Medical Control
TRAUMA PROTOCOLS, Continued
Electrical Injuries
---------------------------------------------------------------------- 61
Extremity Trauma
---------------------------------------------------------------------- 62
Head Trauma, ADULT
------------------------------------------------------------- 63
Hyperthermia
---------------------------------------------------------------------- 64
Hypothermia
---------------------------------------------------------------------- 65
Multiple Trauma, ADULT ------------------------------------------------------------- 66
Spinal Immobilization
--------------------------------------------------------------- 67
WMD-Nerve Agent Protocol
---------------------------------------------------- 68
EMS TREATMENT & PATIENT CARE POLICIES------------------------Page 70
Air Transport -------------------------------------------------------------------------------- 71
Child Abuse Recognition & Reporting
-------------------------------------------- 75
Criteria for Death / Withholding Resuscitation
----------------------------------- 76
Deceased Subjects ----------------------------------------------------------------------- 77
Discontinuation or Prehospital Resuscitation
----------------------------------- 78
Disposition / Patient Discharge Instructions (Refusal) -------------------------- 79
South Carolina DO NOT RESUSCITATE Form ----------------------------------- 80
Documentation of the Patient Care Report
Documentation of Vital Signs
----------------------------------- 81
----------------------------------------------------- 82
Domestic Violence (Partner and/or Elder Abuse) Recognition & Reporting- 83-84
Infant Abandonment
------------------------------------------------------------------- 85
Patient Without a Protocol -------------------------------------------------------------- 86
Physician on Scene ----------------------------------------------------------------------- 87
Poison Control Center ------------------------------------------------------------------ 88
Safe Transport of Children -------------------------------------------------------------- 89
Transport
-------------------------------------------------------------------------------- 90
Revised: 07/11/2011
M. Stover, MD
4
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
EMT
Intermediate
Paramedic
Medical Control
PATIENT CARE PROCEDURES----------------------------------------------Page 91
Acute Myocardial Infarct / STEMI Patient-------------------------------------------- 92
12 Lead ECG ------------------------------------------------------------------------------- 93
Airway- Combitube ---------------------------------------------------------------------- 94
Airway- King LTD -------------------------------------------------------------------------- 95
Airway- LMA --------------------------------------------------------------------------------- 96
Airway- Intubation Confirmation, End Tidal CO2 Detector -------------------- 97
Airway- Nasotracheal Intubation -------------------------- ---------------------------- 98
Airway- Nebulizer Inhalation Therapy ------------------------------------------------ 99
Airway- Orotracheal Intubation ------------------------------------------------------- 100
Airway- Respirator Operation ---------------------------------------------------------- 101
Airway- Suctioning, Advanced --------------------------------------------------------- 102
Airway- Suctioning, Basic ---------- ---------------------------------------------------- 103
Airway- Ventilator PEEP/CPAP
------------------------------------------------ 104-105
Arterial Line Maintenance ------------------------------------------------------------
106
Assessment, Adult ----------------------------------------------------------------------
107
Assessment, Pediatric ------------------------------------------------------------------ 108
Blood Glucose Analysis ----------------------------------------------------------------- 109
Capnography ------------------------------------------------------------------------------ 110
Cardioversion ----------------------------------------------------------------------------- 111
Chest Decompression ------------------------------------------------------------------ 112
Childbirth ------------------------------------------------------------------------------------ 113
CNS Catheter- Epidural Maintenance ----------------------------------------------- 114
CNS Catheter- Ventricular Catheter Maintenance ------------------------------- 115
Cardiopulmonary Resuscitation (CPR) ---------------------------------------------- 116
Decontamination ------------------------------------------------------------------------- 117
Defibrillation- Manual ------------------------------------------- ------------------------
118
Defibrillation- Automated --------------------------------------------------------------- 119
External Cardiac Pacing ----------------------------------------------------------------- 120
Injections- Subcutaneous (SQ), Intramuscular (IM) ------------------------------ 121
Revised: 07/11/2011
M. Stover, MD
5
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
EMT
Intermediate
Paramedic
Medical Control
PATIENT CARE PROCEDURES, Continued
Military Anti-Shock Trouser (M.A.S.T.) --------------------------------------------
122
Pain Assessment and Documentation ---------------------------------------------
123
Pulse Oximetry --------------------------------------------------------------------------- 124
Venous Access- Blood Draw ---------------------------------------------------------- 125
Venous Access- Central Line Maintenance --------------------------------------- 126
Venous Access- External Jugular Access ----------------------------------------- 127
Venous Access- Extremity ------------------------------------------------------------- 128
Venous Access EZ-IO -------------------------------------------------------------- 129-136
Venous Access- Intraosseous (IO), Pediatric
---------------------------------
137
Wound Care -------------------------------------------------------------------------------- 138
Restraints
-------------------------------------------------------------------------------- 139
Spinal Immobilization
Splinting
-------------------------------------------------------------- 140
-------------------------------------------------------------------------- 141-142
Stroke Screening – L.A. Prehospital Stroke Scale
Thrombolytic Screening
-------------------------- 143
-------------------------------------------------------------- 144
APPENDICES----------------------------------------------------------------Page
145
APGAR Score ---------------------------------------------------------------------------- 146
Rule of Nines Burn Chart ------------------------------------------------------------- 147
Restraint Checklist Form
------------------------------------------------------------- 148
Los Angeles (L.A.) Prehospital Stroke Screening Form -----------------------
149
Wong Baker Pain Scale------------------------------------------------------------------- 150
Pediatric Reference Chart --------------------------------------------------------- -151-152
Revised Trauma Score ------------------------------------------------------------------- 153
Glasgow Coma Score -------------------------------------------------------------------- 154
MEDICATION LIST ----------------------------------------------------------------Page 155
Adenosine (Adenocard)
Revised: 07/11/2011
-------------------------------------------------------------- 156
M. Stover, MD
6
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
Albuterol
EMT
Intermediate
Paramedic
Medical Control
----------------------------------------------------------------------------------- 157
Amiodarone -------------------------------------------------------------------------- 158-159
Aspirin (ASA) ------------------------------------------------------------------------------ 160
Atropine
----------------------------------------------------------------------------- -161-162
Atrovent -------------------------------------------------------------------------------- -------163
Calcium Glucanate
---------------------------------------------------------------- ------164
D5W ----------------------------------------------------------------------------------------- 165
D50 ------------------------------------------------------------------------------------------ 166
Diazepam (Valium) ----------------------------------------------------------------- 167-168
Diltiazem (Cardizem) --------------------------------------------------------------------- 169
Diphenhydramine (Benadryl) ----------------------------------------------------------- 170
Dopamine ---------------------------------------------------------------------------------- 171
Epinephrine 1:1,000 ----------------------------------------------------------------- 172-173
Flumazenil (Romazicon) ------------------------------------------------------------ 174-175
Furosemide (Lasix) ---------------------------------------------------------------------- 176
Glucagon ------------------------------------------------------------------------------------ 177
Labetalol ------------------------------------------------------------------------------- 178-179
Lidocaine ------------------------------------------------------------------------------ 180-181
Magnesium Sulfate ----------------------------------------------------------------------- 182
Midazolam (Versed)
Morphine Sulfate
------------------------------------------------------------- 183-184
------------------------------------------------------------------ 185-186
Naloxone (Narcan) ---------------------------------------------------------------------- 187
Nitroglycerine ---------------------------------------------------------------------------- 188
Procainamide
---------------------------------------------------------------------- 189
Sodium Bicarbonate
----------------------------------------------------------190-192
Sodium Chloride (Normal Saline) ---------------------------------------------------- 193
Solumedrol (Methylprednisolone) ---------------------------------------------------- 193
Revised: 07/11/2011
M. Stover, MD
7
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
EMT
Intermediate
Paramedic
Medical Control
Solumedrol --------------------------------------------------------------------------------- 194
Thiamine ----------------------------------------------------------------------------------- 195
Zofran ---------------------------------------------------------------------------------------
190
STANDARDS OF PRACTICE--------------------------------------------------Page 196
First Responder
------------------------------------------------------- 197
Emergency Medical Technician (EMT)
------------------------------------------- 198
Emergency Medical Technician- Intermediate (EMT-I) ----------------------- 199
Emergency Medical Technician- Paramedic (EMT-P) --------------------- 200-201
Revised: 07/11/2011
M. Stover, MD
8
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
EMT
Intermediate
Paramedic
Medical Control
General Protocols
Revised: 07/11/2011
M. Stover, MD
9
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
EMT
Intermediate
Paramedic
Medical Control
Universal Patient Care Protocol
Scene Safety
Primary Survey
Ad. Vs. Ped. assessment
(Broselow-Luten tape in pediatrics)
Cardiac Arrest
Airway Protocol
Ad. / Ped.
Cardiac Arrest
Protocol
Vital Signs w/ pulse oximetry
(Temp if appropriate)
P
Refer to appropriate
protocol
Consider Cardiac
Monitor w/ 12 lead
M
P
B
Blood Glucose
B
If patient does not fit
into a protocol
M
CONTACT MEDICAL CONTROL
Pearls:
 Any patient contact, which does not result in an EMS transport, must have a completed
refusal form.
 Exam: Minimal exam if not noted on the specific protocol is vital signs, mental status,
and location of injury or complaint.
 Required vital signs on every patient, per complaint, include blood pressure, pulse,
respirations, pain / severity.
 Pulse oximetry and temperature documentation is dependant on the specific complaint.
 A pediatric patient is defined by the Broselow-Luten tape. If the patient does not fit on
the tape, they are considered adult.
 Timing of transport should be based on patient’s clinical condition and the transport
policy.
Revised: 07/11/2011
M. Stover, MD
10
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
EMT
Intermediate
Paramedic
Medical Control
Airway - ADULT
Access ABC’s,
Respiratory rate, Effort,
Gag Reflex and SPO2
Adequate
F
R
Pulse Oximetry
F
R
Supplemental Oxygen
indicated
F
R
Basic Manual
Maneuvers including
O2
F
R
F
R
P
M
Nasotracheal
Intubation
P







Obstructed
Airway per AHA
Guidelines
F
R
Orotracheal
Intubation
F
R
P
P
F
R
P
Digital
Intubation
P
B
BIAD
B
P
Contact Medical
M
Control
Consider Failed
Airway Protocol
M
Pearls:


F
R
Apnea or Absent
Gag Reflex
Positive Respirations
or positive gag reflex
F Nasopharyngeal Airway /
R
BVM Ventilations
Obstructed
Inadequate
Contact Medical
Control
Direct
P
Laryngoscopy
If capnography
available, ventilate
patient to maintain
CO2 level between
35 and 45.
M
For this protocol, adult is defined as 12 years old or greater.
Capnography is mandatory with all methods of intubation if available. Other secondary conformation devices
will be used in the absence of capnograhy ie. End Tidal CO2 detector. Document results.
Maintain C-spine immobilization for patients with suspected spinal injury.
Do not assume hyperventilation is psychogenic – use oxygen, not a paper bag.
Sellick’s maneuver should be used to assist with difficult intubations.
Providers should consider using a BIAD (Blind Insertion Airway Device) when they are unable to intubate a patient.
Hyperventilation in head trauma should only be used to maintain a pC02 of 30 – 35.
Continuous pulse oximetry should be utilized in all patients with an inadequate respiratory function.
Place all intubated patients in full spinal immobilization. (Inform the receiving RN and Physician as to the nature
of the c-collar application- For TRAUMA or AIRWAY CONTROL ONLY; Assist with removal if requested by the
receiving physician).
Revised: 07/11/2011
M. Stover, MD
11
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
EMT
Intermediate
Paramedic
Medical Control
Airway - Failed ADULT
2 Failed Intubation
Attempts by most
proficient technician
on scene
No more than 3
attempts
F
R
SPO2 >90% with
BVM
No
Yes
If SPO2 <90% or if patient
becomes difficult to ventilate
F
F
Nasal / Oral Airway R
R
Facial Trauma or Swelling
Yes
F
R
Continue BVM
P
F
R
M


F
R
Continue BVM
F
R
No
B
Pearls:

F
R
Digital
Intubation
BIAD
Contact Medical Control
P
B
If capnography
available, ventilate
patient to maintain
CO2 level between 35
and 45.
M
If first intubation attempt fails, make an adjustment and then try again: (consider)
* Different laryngoscope blade
* Different ETT size
* Change cricoid pressure
* Apply BURP maneuver (Push trachea Back [posterior], up, and to patient’s right)
* Change head positioning
Continuous pulse oximetry or capnography should be utilized in all patients with an inadequate respiratory
function.
Notify Medical Control as EARLY AS POSSIBLE about the patient’s difficult / failed airway.
Revised: 07/11/2011
M. Stover, MD
12
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
EMT
Intermediate
Paramedic
Medical Control
Airway - PEDIATRIC
Access ABC’s,
Respiratory rate, Effort,
Gag Reflex and Pulse
Oximetry
Adequate
Obstructed
Inadequate
F Supplemental Oxygen
R
indicated
F
R
F
R
Basic Maneuvers
including O2
Positive Respirations or
positive gag reflex
F
R
F F
R
F
R
F
R
Apnea or Absent Gag
Reflex
Oxygenate, Ventilate, F
Position, Reassess
R
Consider Early
Rapid Transport
F
R
P
F
R
M
Orotracheal
Intubation
P
Direct
Laryngoscopy
F
R
P
P
F
R
Continue BVM
Contact
MCP
Obstructed Airway per
AHA Guidelines
If capnography
available, ventilate
patient to maintain
CO2 level between 35
and 45.
M
Pearls:

For this protocol, pediatric is defined as less than 12 years.

Capnography is mandatory with all methods of intubation if available. Other secondary conformation
devices will be used in the absence of capnograhy ie, ETCO2 detector. Document results.







Limit intubation attempts to 3 per patient.
Back Pain
If unable to intubate, continue BVM ventilations, transport rapidly, and notify receiving hospital early.
Maintain C-spine immobilization for patients with suspected spinal injury.
Do not assume hyperventilation is psychogenic – use oxygen, not a paper bag.
Sellick’s maneuver should be used to assist with difficult intubations.
Continuous pulse oximetry should be utilized in all patients with an inadequate respiratory function.
All intubated patients will be placed in full spinal protocol. (Inform the receiving RN and
Physician as to the nature of the c-collar application- For TRAUMA or AIRWAY CONTROL ONLY;
Assist with removal if requested by the receiving physician).
Revised: 07/11/2011
M. Stover, MD
13
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
EMT
Intermediate
Paramedic
Medical Control
Back Pain
History:

Age

Past Medical History

Past Surgical History

Medications

Onset of pain/ injury

Previous back injury

Traumatic mechanism

Location of pain

Fever

Improvement or worsening
with activity
Signs and Symptoms
Differential






Pain
Swelling
Pain with range of motion
Extremity Weakness
Extremity numbness
Shooting pain into an extremity

Bowel/ bladder dysfunction








Muscle spasm/ sprain
Herniated disc with
nerve compression
Sciatica
Spine fracture
Kidney stone
Kidney infection
Aneurysm
Pneumonia
Universal Patient
Care Protocol
Injury or traumatic mechanism
Yes
No
Spinal
F
Immobilization
R
Protocol
F
R
BP<90 regardless of
postural position
YES
Signs of Shock
I
IV Protocol
I
No
I
Normal Saline
Bolus
I
P
Pain Control
Protocol
P
M
Pearls:






No
Contact Medical
M
Control
Exam: Mental Status, HEENT, Neck, Chest, Lungs, Abdomen, Back, Extremities, Neuro
Abdominal aneurysms are a concern in patients over the age of 50
Kidney stones typically present with an acute onset of flank pain which radiates around to the groin area.
Patients with midline pain over the spinous processes should be placed in spinal immobilization.
Any bowel or bladder incontinence is a significant finding, which requires immediate medical evaluation.
If Spinal Immobilization is indicated and the patient refuses care, a Patient Refusal Form will be completed
regardless of transport.
Revised: 07/11/2011
M. Stover, MD
14
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
EMT
Intermediate
Paramedic
Medical Control
Behavioral
History:

Situational crisis

Psychiatric illness/
medications

Injury to self or threats to
others

Medic alert tag

Substance abuse/
overdose

Diabetes
Signs and symptoms:

Anxiety, agitation,
confusion

Affect change,
hallucinations

Delusional thoughts, bizarre
behavior

Combative/ Violent

Expression of suicidal/
homicidal thoughts
Differential:

Altered LOC differential

ETOH

Toxin/ Substance abuse

Medication effect/
overdose

Withdrawal symptoms

Depression

Bipolar

Schizophrenia

Anxiety Disorders
Scene Safety
Universal Patient
Care Protocol
Treat Suspected Medical
or Trauma Problems
Altered Mental Status,
Overdose, Trauma
Remove patient from stressful environment
Verbal Techniques
(reassurance, calm, establish rapport)
B
Restraint
Procedure
B
M
Contact Medical Control
P
Consider
Valium 2-5mg
M
P
Pearls:






Exam: Mental Status, Skin, Heart, Lungs, Neuro
Your Safety First!!!!!!
Exam: Mental Status, Skin, Heart, Lungs, Neuro
Be sure to consider all possible medical / trauma causes for behavior (hypoglycemia, overdose, substance
abuse, hypoxia, head injury, etc.)
Do not irritate the patient with a prolonged exam.
Do not overlook the possibility of associated domestic violence or child abuse.
Revised: 07/11/2011
M. Stover, MD
15
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
EMT
Intermediate
Paramedic
Medical Control
Fever
History:

Age

Duration/Severity of fever

Past medical history

Medications

Immunocompromised

Environmental exposure

Last acetaminophen or ibuprofen
and dosage

Out of country travel within past
14 days
Signs and Symptoms:

Warm

Flushed

Sweaty

Chills/ Rigors
Associated Symptoms

Myalgias, Cough,
Chest pain, Headache,
Dysuria, Abdominal pain,
Mental status Changes
Differential:

Infections/
Sepsis

Cancer

Medication
or Drug reaction

Connective
tissue disease

Hyperthyroid

Heat Stroke
Universal Patient Care
Protocol
F BP <90 regardless of F
R
R postural position
YES
IV Protocol
NS Bolus
I
Encourage PO Intake
I
F
R
Temperature
>100
F Use methods in
R
PEARLS
NO
F
R
<100
F
R
Appropriate protocol
by complaint
M Contact Medical Control M




Exam: Mental Status, Skin, HEENT, Neck, Heart, Lungs, Abdomen, Back, Extremities, Neuro
Febrile seizures are more likely in children with a history of febrile seizures and with a rapid elevation in
temperature.
Temperature may be decreased by a combination of 4 methods:
1. Radiation:
Heat loss to air (unwrap or remove clothing)
2. Evaporation: Heat loss from the evaporation of sweat or liquid from the skin (tepid water
bath to skin)
3. Convection: Heat loss from movement of air currents over the skin (increase air
movement to skin)
4. Conduction: Heat loss from the contact with solid substances (with heat stroke use cool packs
per protocol)
Rehydration with fluids increases the patient’s ability to sweat and improves heat loss.
Revised: 07/11/2011
M. Stover, MD
16
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
EMT
Intermediate
Paramedic
Medical Control
IV Access
**Intraosseous infusion may be
used in pediatric and adult
patients deemed “critical” and
venous access is required for
fluid resuscitation or delivery of
medications for resuscitation.**
Universal Patient
Care Protocol
Access need for IV
Emergent or
potentially
emergent medical
or trauma
I
Peripheral IV
External Jugular > 12 years old
and life threatening
Successful
Reassess and
monitor bolus






M requires Medical
M
Control Order
Intraosseous
(ped or adult device) P
EZ-IO
P

EJ < 12 yrs old
I
Unsuccessful
M
Contact Medical
Control
M
Intraosseous with the appropriate device in life threatening events only where no obvious peripheral
site is noted. Pediatric patients with life threatening events, consider IO as first access attempt.
Any prehospital fluids or medications approved for IV administration may be given through an intraosseous IV.
All IV rates should be at KVO (minimal rate to keep vein open) unless administering fluid bolus.
External jugular and / or IO lines can be attempted initially in life threatening events where no obvious
peripheral site is noted.
Upper extremity IV sites are preferable to lower extremity sites.
Lower extremity IV sites are contraindicated in patients with vascular disease or diabetes.
In post-mastectomy patients, avoid IV, blood draw, injection, or blood pressure in arm on affected side.
Revised: 07/11/2011
M. Stover, MD
17
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
EMT
Intermediate
Paramedic
Medical Control
Pain Control
U n iv e rs a l P a tie n t
C a re P ro to c o l
P a tie n t C a re B a s e d
o n S p e c ific
C o m p la in t
P a in s e v e rity > 6 /1 0
No
P a tie n t C a re B a s e d
o n S p e c ific
C o m p la in t
Yes
I
IV P ro to c o l
I
C o n tra in d ic a tio n to
s e d a tio n o r
A b d o m in a l P a in ?
No
M
M
Yes
P a tie n t C a re B a s e d
o n S p e c ific
C o m p la in t
C o n ta c t M e d ic a l C o n tro l
M o rp h in e S u lfa te
A d u lt: 2 m g IV /IM q 3 -5 m in
P
a s n e e d e d fo r p a in
U p to 1 0 m g T o ta l
P
M
M
P
C o n s id e r Z o fra n a d u lt: 4 m g IV S lo w o v e r
2 m in u te s . P e d s: 0 .1 5 m g /k g IV P s lo w
M ax dose of 4m g
P
Pearls:

Exam: Mental Status, Area of Pain, Neuro

Pain severity (0-10) is a vital sign to be recorded pre and post IV / IM / or PO medication delivery and at
disposition.

Vital signs should be obtained pre, 15 minutes post, and at disposition with all pain medications.

Relative contraindications to Morphine use include hypotension, head injury, respiratory compromise or severe
COPD, or known allergy.

All patients should have drug allergies documented prior to administering pain medications.

All patients who receive IM or IV medications must be observed 15 minutes for drug reaction.
Revised: 07/11/2011
M. Stover, MD
18
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
EMT
Intermediate
Paramedic
Medical Control
Medical Protocols
Revised: 07/11/2011
M. Stover, MD
19
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
EMT
Intermediate
Paramedic
Medical Control
Abdominal Pain
History:

Age

Past Medical/ Surgical
History

Medications

Onset

Palliation/ Provocation

Quality

Region/ Radiation/
Referred

Severity (1-10)

Time (Duration/
repetition)

Fever

Last meal eaten

Last bowel movement

Menstrual history
Signs and Symptoms:

Pain

Tenderness

Nausea

Vomiting

Diarrhea

Dysuria

Constipation

Vaginal bleeding/
Discharge

Pregnancy
Differential:

Pneumonia or PE

Liver

Peptic ulcer disease

Gallbladder

MI

Pancreatitis

Kidney stone

AAA

Appendicitis

Bladder/ Prostate
disorder

Pelvic

Spleen enlargement

Diverticulitis

Bowel Obstruction

Gastroenteritis
Universal Patient
Care Protocol
I
IV Protocol
NaCl Bolus if
Hypotensive
I
Nausea & Vomiting
Consider
Chest Pain Protocol
I
IV Protocol
P
Zofran
Adult: 4mg IVP slow
Peds: 0.15mg/kg IVP slow
To max dose of 4mg
I
Consider
Pain Control Protocol
M
Contact Medical
Control
P
M
Pearls:

Required Exam: Mental Status, Skin, HEENT, Neck, Heart, Lungs, Abdomen, Back, Extremities,
Neuro.

Document the mental status and vital signs prior to administration of Zofran.

Abdominal pain in women of childbearing age should be treated as an ectopic pregnancy until proven
otherwise.

The diagnosis of abdominal aneurysm should be considered with abdominal pain in patients over 50.

Appendicitis presents with vague, peri-umbilical pain which migrates to the RLQ over time.
Revised: 07/11/2011
M. Stover, MD
20
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
EMT
Intermediate
Paramedic
Medical Control
Allergic Reaction
History:








Onset and Location
Insect sting or bite
Food allergy/ exposure
Medication allergy/ exposure
New clothing, soap, detergent
Past history of reactions
Past medical history
Medication history
Signs and Symptoms:

Itching and hives

Coughing/ Wheezing or
respiratory distress

Chest or throat
constriction

Difficulty swallowing

Hypotension or shock

Edema
Differential:

Urticaria

Anaphylaxis

Shock

Angioedema

Aspiration/ Airway
obstruction

Vasovagal event

Asthma/ COPD

CHF
Universal Patient Care Protocol
Evidence of Impending
Respiratory distress or shock?
B
Auto Injector Epi-Pen
(Epi-Jr pen if < 12 y/o)
Hives/ Rash Only
No Respiratory
Component
B
Diphenhydramine
Adult: 25-50 mg IV/IM
P
Ped: 1 mg/kg IV/IM
(Max Ped dose = 50 mg)
Epinephrine 1:1,000
<50 y/o: 0.3-0.5mg SQ
>50 y/o:MCP only
Ped: 0.01 mg/kg SQ
Max Ped dose 0.3mg
P
P
P
Reassess Patient
Albuterol / if wheezing
Adult:2.5-5.0mg via neb
Ped: 2.5mg via neb
May repeat up to 3x
P
P
Diphenhydramine
Adult: 50 mg IV/IM
Ped: 1 mg/kg IV/IM
(Max Ped dose = 50 mg)
P
Respiratory distress with
evidence of increased work of
breathing and / or wheezing.
P
Shock defined by tachycardia
and or hypotension.
P
P
IV / Cardiac Monitor
If evidence of anaphylaxis
Epinephrine 1:10,000 0.3 mg IV
M






Contact Medical Control
M
Exam: Mental Status, Skin, Heart, Lungs.
Administering epinephrine in patients who are >50 years of age, or that have a history of cardiac
disease, or if the patient’s heart rate is >150 may precipitate cardiac ischemia. These patients should
receive a 12 lead ECG.
May repeat Albuterol up to 3 times if no cardiac Hx and HR <150 ( HR < 200 in Peds)
Any patient with respiratory symptoms or extensive reaction should receive IV or IM diphenhydramine.
The shorter the onset from symptoms to contact, the more severe the reaction.
EMT / I or EMT / B must receive medical control order prior to administration of epi pen unless
patient has a prescription for same.
Revised: 07/11/2011
M. Stover, MD
21
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
EMT
Intermediate
Paramedic
Medical Control
Altered Mental Status
History:

Known diabetic

Drugs

Report of drug
use

Past medical
history

Medications

Hx of trauma
Signs/ Symptoms:

Decreased mental
status

Change in
baseline mental
status

Bizarre behavior

Hypoglycemia

Hyperglycemia
Differential:

Head
trauma

Infection

CNS

Thyroid

Cardiac

Shock







Toxicologic
Diabetes
Acidosis/ Alkalosis
Environmental exposure
Pulmonary
Electrolyte abnormality
Psychiatric disorder
Universal Patient
Care Protocol
F
R
Spinal Immobilization Protocol,
If applicable
Glucose <70
B
Patient Conscious
with intact gag reflex
Oral Glucose
I
IV Protocol
B
Blood Glucose
12 Lead ECG
If available
P
P
I
P
Glucagon, if no IV
Adult: 1 mg IM
Ped > 3y/o 0.5mg IM
Glucose >250
signs of dehydration
P
I
Infant: 0.5g/kg of D25%
P
B
P
50% Dextrose (D50%)
Adult: 25 g IV
I
I
Glucose 70- 250
B
Consider Thiamine
100mg IM or slow IVP for
suspected ETOH abuse
F
R
Naloxone
Adult:1 - 2 mg IV or IM
for RR < 12
Ped: 0.1 mg/kg
IV or IO
Normal Saline
Bolus
P
P
NO
Consider other causes:
(Head Injury,
Overdose, Stroke,
Hypoxia)
Refer to Appropriate
Protocol
Return to baseline?
Yes






Revised:

M
Contact Medical Control
M
Exam: Mental Status, HEENT, Skin, Heart, Lungs, Abdomen, Back, Extremities, Neuro.
Be aware of Altered Mental Status (AMS) presenting as a sign of an environmental toxin or HazMat exposure and protect personal safety.
It is safer to assume hypoglycemia than hyperglycemia if doubt exists.
Do not let alcohol confuse the clinical picture. Alcoholics frequently develop hypoglycemia.
Low glucose (< 70), normal glucose (70 – 120), high glucose (>250)- These parameters are
relative to the patients- if possible, try to ascertain patients normal glucose levels.
Consider restraints for patient’s M.
and/or
personnel’s
07/11/2011
Stover,
MD protection per the restraint procedure.
If the patient is thought to have abused ETOH, administer Thiamine 100mg IM or slow IVP
22
I
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
EMT
Intermediate
Paramedic
Medical Control
Asystole
History:








Past medical history
Medications
Events leading to arrest
End stage renal disease
Estimated downtime
Suspected hypothermia
Suspected overdose
DNR or living will
Signs and Symptoms:

Pulseless

Apneic

No electrical activity
on ECG
Differential:

Device error

Medical or trauma

Hypoxia

Potassium (Hypo/ Hyper)

Drug overdose

Acidosis

Hypothermia

Death
Universal Patient
Care Protocol
YES
Criteria for Death?
NO
Withhold
Resuscitation
F
R
CPR 30:2
F
R
I
IV & Airway
Protocol
I
Epinephrine 1:10,000 IV/ET
Adult: 1 mg q 3-5 min
P
Ped: 0.01 mg/kg IV/IO
Max single dose 0.5 mg
P
Stop
Resuscitation
P
YES
P
Criteria for
discontinuation
P
P
NO
At any time
Consider
Sodium Bicarbonate
Adult: 50 mEq IV
Ped: 1mEq/kg IV or IO
May repeat with half dose
after 10 minutes
P
Return of spontaneous
circulation
M
Contact Medical Control
P
M
Go to Post Resuscitation
Protocol
Pearls:

Exam: Mental Status
 Always confirm asystole in more than one lead.
 Consider underlying causes.
 Once patient is intubated, continue compressions at a rate of 100/minute
Revised: 07/11/2011
M. Stover, MD
23
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
EMT
Intermediate
Paramedic
Medical Control
Bradycardia, ADULT
History:

Past Medical history

Medications
o Beta blockers
o Calcium channel
blockers
o Clonidine
o Digitalis

Pacemaker
Signs and Symptoms:

HR < 60BPM

Chest pain

Respiratory
distress

Hypotension/
Shock

Altered LOC

Syncope
Differential:

Acute MI

Hypoxia

Hypothermia

Sinus Bradycardia

Athletes

Head injury or CVA

Spinal cord lesion

Sick Sinus Syndrome

AV Blocks(1st , 2nd, 3rd
Degree)

Hypoglycemia
Universal Patient
Care Protocol
P
12 Lead ECG if
P
available
I
IV Protocol
I
Symptomatic?=
CP, RD,
Hypotension w/
Signs of shock
YES
NO
Monitor
P
M
P
Contact Medical Control
Versed 2mg IV
M
Consider
Sedation
Atropine
0.5-1.0mg IV
Repeat q 3-5 min
Total Max 3 mg
P
External
Pacing
P
P
M
Contact Medical Control
M
P
Dopamine
5-20 mcg/kg/min IV Drip
Titrate dosing to BP of
90mmHg
P
P
Pearls:

The use of Lidocaine in heart block can worsen bradycardia and lead to asystole and death.

Pharmacological treatment of bradycardia is based upon the presence or absence of significant
signs and symptoms (symptomatic vs. asymptomatic).

If hypotension
with signs of shock exists,
treat ASAP.
Revised:
07/11/2011
M. Stover,
MD

If blood pressure is adequate, monitor only.

Avoid Atropine in second degree type II or third degree AV block.

Sedation should take place as long as not contraindicated. For initial dose of versed
consider decreased dose if B/P is 80-100mm/hg
24
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
EMT
Intermediate
Paramedic
Medical Control
Cardiac Arrest
History:







Events leading to arrest
Estimated downtime
Past medical history
Medications
Existence of terminal illness
Signs of lividity, rigor mortis
DNR or Living will
Signs and Symptoms:

Unresponsive

Apneic

Pulselessness
Differential:

Medical vs. Trauma

V-Fib vs. V-Tach

Asystole

PEA
Universal Patient
Care Protocol
Criteria for Death?
YES
NO
Withhold
Resuscitation
F
R
CPR
F
R
F
R
AED
Procedure
F
R
P
Assess
Rhythm
P
At any time
Return of spontaneous
circulation
Go to
appropriate
Protocol
Go to Post Resuscitation
Protocol




Success is based on proper planning and execution. Procedures require space and
patient access. Make room to work.
Reassess airway frequently and with every patient move.
Maternal Arrest – Treat mother per appropriate protocol with immediate notification to
Medical Control and rapid transport.
Follow current AHA recommendations.
Revised: 07/11/2011
M. Stover, MD
25
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
EMT
Intermediate
Paramedic
Medical Control
Chest Pain/ Suspected Cardiac Event
History:











Age
Medications
Past medical history
Allergies
Recent physical exertion
Onset
Palliation/ Provocation
Quality
Region
Severity
Time
Signs and Symptoms:

CP (Pain, pressure,
aching, vice like tightness)

Location (Substernal,
epigastric, arm, jaw, neck,
shoulder)

Radiation of pain

Pale, diaphoresis

Shortness of breath

Nausea, vomiting,
dizziness
Differential:

Trauma vs. Medical

Angina vs. MI

Pericarditis

PE

Asthma/ COPD

Pneumothorax

Aortic dissection or
aneurysm

GE Reflux or Hiatial hernia

Esophogeal spasm

Chest wall injury

Pleural pain
Universal Patient
Care Protocol
P Aspirin 324mg
P
> 30 y/o
12 Lead ECG (if
P
available) transmit
to ED
I
P
P
IV Protocol
M


P
I
Nitroglycerine
Nitroglycerine
if
BP >110
> 100 Sys.
if BP
Sys.
spray or
or tab.SL
1 1spray
tab. SL
qq 55min
min.
Complete
Thrombolytic
Checklist
IF STEMI IS NOTED
FOLLOW STEMI PROTOCOL
UNDER PATIENT PROCEDURES
P
Morphine 2mg IV
q 3-5 min
up to 10mg total
MCP Only
P
Continue NTG and MS
Therapy until pain is
relieved as long as BP
remains > 100 systolic
P
Consider Zofran adult: 4mg
IV Slow over 2 minutes.
P Peds: 0.15 mg/kg IVP slow P
Max dose of 4mg
P
Contact Medical Control
M
Hypotension/
Dysrhythmias
Treat per protocol
Exam: Mental Status, Skin, Neck, Lung, Heart, Abdomen, Back, Extremities, Neuro.
Avoid Nitro in patients who have used impotency (Viagra, Levitra and Cialis) medication in the past 48 hrs due to
potential severe hypotension.
 If patient has taken nitroglycerin without relief, consider potency of the medication.
 If positive ECG changes, establish a second IV while en route to the hospital.
 Monitor for hypotension after administration of nitroglycerin and/or morphine.
Revised:
07/11/2011
M. Stover, MD
 Diabetics
and geriatric patients often have atypical pain, or only generalized complaints.
 Perform V4R if ST elevation noted in Lead II, III, and aVF.
26
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
EMT
Intermediate
Paramedic
Medical Control
Dental Problems
History:







Age
Past medical history
Medications
Onset of pain/ injury
Trauma
Location of tooth
Whole vs. partial injury
Signs and Symptoms:

Bleeding

Pain

Fever

Swelling

Tooth missing or fractured
Differential

Decay

Infection

Fracture

Avulsion

Abscess

Facial Cellulitis

Impacted tooth

TMJ Syndrome

MI
Universal Patient
Care Protocol
F Control Bleeding with
R
Pressure
F
R
Tooth
Avulsion
YES
Place tooth in milk
or Normal Saline
NO
Pain Control
Protocol
Reassess and
Monitor
M





Contact Medical Control
M
Significant soft tissue swelling to the face or oral cavity can represent a cellulites or abscess.
Scene and transport times should be minimized in complete tooth avulsions. Reimplantation is
possible within 4 hours if the tooth is properly cared for.
All tooth disorders typically need antibiotic coverage in addition to pain control.
Occasionally cardiac chest pain can radiate to the jaw.
All pain associated with teeth should be associated with a tooth which is tender to tapping or touch
(or sensitivity to cold or hot).
Revised: 07/11/2011
M. Stover, MD
27
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
EMT
Intermediate
Paramedic
Medical Control
Epistaxis
History:







Age
Past medical history
Medications
Previous episodes
Trauma
Duration of bleeding
Quantity of bleeding
Signs and Symptoms:

Bleeding from nasal
passage

Pain

Nausea

Vomiting
Differential:

Trauma

Infection

Allergic rhinitis

Lesions

Hypertension
Universal Patient
Care Protocol
F
R
Ice Packs
Compress Nostrils
Tilt Head Forward
F
R
I
IV Protocol
I
BP < 90mm/hg and lungs clear
No
Consider Hypertension
Protocol
Yes
I
Normal Saline
Bolus
M




I
Contact Medical Control
M
Exam: Mental Status, HEENT, Heart, Lungs, Neuro.
It is very difficult to quantify the amount of blood loss with epistaxis.
Bleeding may also be occurring posteriorly. Evaluate for posterior blood loss by examining the
posterior pharynx.
Anticoagulants include Aspirin, Coumadin, non-steroidal anti-inflammatory medications
(ibuprofen), and many over the counter headache relief powders.
Revised: 07/11/2011
M. Stover, MD
28
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
EMT
Intermediate
Paramedic
Medical Control
Hypertension
History:

Documented hypertension

Related diseases
(Diabetes, CVA, Renal
failure, cardiac)

Medications

Pregnancy
Signs and symptoms:
One of these:

Systolic BP >200

Diastolic BP >120
AND at least one of these:

Headache

Nosebleed

Blurred vision

Dizziness
Differential:

Hypertensive
encephalopathy

Primary CNS injury

MI

AAA

Pre-eclampsia/ Eclampsia
Universal Patient
Care Protocol
M
I
IV Protocol
I
P
12 Lead ECG
If Available
P
Contact Medical Control M
Symptomatic
Patient
P
Asymptomatic
Patient
Consider Labetolol 10-20 mg
IV slow (over 2 minutes)
MCP Only
P
Continue
Monitoring
Continue
Monitoring
Pearls:




Avoid Nitro in patients who have used impotency medication (Viagra, Levitra and Cialis) in the past 48 hrs due
to potential severe hypotension.
Never treat elevated BP based on one set of vital signs
Symptomatic hypertension is typically revealed through end organ damage to the cardiac, CNS or renal
systems.
All symptomatic patients with hypertension should be transported with their head elevated.
Revised: 07/11/2011
M. Stover, MD
29
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
EMT
Intermediate
Paramedic
Medical Control
Hypotension Shock (Nontrauma), ADULT
History:







Signs and Symptoms:

Restlessness/ Confusion

Weakness/ Dizziness

Weak rapid pulse

Pale, cool clammy skin

Delayed capillary refill

Hypotension

Coffee-ground emesis

Tarry stools
Blood loss
Fluid loss
Infection
Cardiac ischemia
Medications
Allergic reaction
Pregnancy
Differential:

Shock
Hypovolemic, Cardiogenic,
Septic, Neurogenic,,
Anaphylactic

Ectopic pregnancy

Dysrhythmias

PE

Tension pneumothorax

Medication effect

Vasovagal

Physiologic
Universal Patient
Care Protocol
I
Non Cardiac
Non Trauma
I
Normal Saline
Bolus
IV Protocol
I
Cardiac
Trauma
I
I
M
P
Treat per appropriate
cardiac protocol
Treat per appropriate
trauma protocol
Contact Medical
Control
Consider
Dopamine
5-20 mcg/kg/min
titrate to systolic
BP of 90 = mm/Hg
No rales present
I
consider fluid bolus
M
P
Pearls:
 Exam: Mental Status, Skin, Lung, Heart, Abdomen, Back, Extremities, Neuro
 Hypotension can be defined as a systolic blood pressure of less than 100.
 Consider all possible causes of shock and treat per appropriate protocol.
Revised: 07/11/2011
M. Stover, MD
30
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
EMT
Intermediate
Paramedic
Medical Control
Overdose/ Toxic Ingestion
History:

Ingestion or suspected ingestion
of a potentially toxic substance

Substance ingested, route,
quantity

Time of Ingestion

Reason (Suicidal, accidental,
criminal)

Available medications in home

Past medical history
B
Blood Glucose
I
IV Protocol
Narcotic
Overdose w/resp.
depression
Tricyclic
Overdose
P
P
Naloxone
Adult: 2mg IV/IM
Peds: 0.1 mg/kg
IV / IO
M
Contact
Medical Control
B
I
Organophosphates
Carbamates
Contact
Medical Control
M
P
P
Contact
M
M
Medical Control
Differential:

Tricyclic antidepressants

Acetaminophen

Depressants

Stimulants

Anticholinergic

Cardiac medications

Solvents, Alcohols, Cleaning agents

Insecticides
Universal Patient Care
Protocol
ALWAYS CONSIDER
CONTACTING POISON
CONTROL WHENEVER
NECESSARY
Sodium
Bicarbonate
P Adult: 50 mEq IV +
100mEq in 1,000ml
NaCl at 200 ml/hr
Signs and Symptoms:

Mental status changes

Hypotension/ Hypertension

Decreased respiratory rate

Tachycardia, dysrythmias

Seizures
Atropine
1-2 mg IV/IM
M
Other
Hypotension
Seizures
Dysrythmias
Altered LOC
M
P
M
Contact
Medical Control
M
Appropriate
Protocol
Pearls:












Exam: Mental Status, Skin, HEENT, Lung, Heart, Abdomen, Extremities, Neuro
Do not rely on patient history of ingestion, especially in suicide attempts.
Bring bottles, contents, emesis to ED.
Tricyclic: 4 major areas of toxicity: seizures, dysrhythmias, hypotension, decreased mental status or
coma; rapid progression from alert mental status to death. TCA examples: amitriptyline (Elavil),
,desipramine, imipramine, nortriptyline.
Acetaminophen: If not detected and treated, causes irreversible liver failure.
Depressants: decreased HR, decreased BP, decreased temp., decreased respirations, non-specific
pupils.
Stimulants: increased HR, increased BP, increased temperature, dilated pupils, seizures.
Anticholinergic: increased HR, increased temperature, dilated pupils, mental status changes.
Cardiac Meds: dysrhythmias and mental status changes.
Solvents: nausea, vomiting, and mental status changes.
Insecticides: increased or decreased HR, increased secretions, nausea, vomiting, diarrhea, pinpoint
pupils.
Consider restraints if necessary for patient’s and/or personnel’s protection per the Restraint procedure
Revised: 07/11/2011
M. Stover, MD
Poison Control 1-800-222-1222
31
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
EMT
Intermediate
Paramedic
Medical Control
Post Resuscitation
History:

Respiratory Arrest

Cardiac Arrest
Signs/ Symptoms:

Return of pulse
Differential:

Continue to address
specific differentials associated
with the original dysrhythmia
Repeat Primary
Assessment
F
R
Continue Ventilatory
Support with
100% Oxygen
I
P
F
R
I
Pulse
Oximetry
IV Protocol
F
R
I
12 lead ECG
Transmit to ED if Available
F
R
F
R
Vital Signs
P
Capnography
If Available
P
F
R
P
Hypotension?
Ventricular
Ectopy
Bradycardia
Consider
Fluid Bolus
Amiodarone
150mg IV over 10 min
IV Drip at 1 mg/min
P
P
Peds:5mg/kg over
20-60min
Repeat 5mg/kg Max 15mg/kg
Treat per
Bradycardia
Protocol
I
Consider
Dopamine
P 5-20 mcg/kg/min P
titrate to BP
of = 90 mmHg
If Arrest Recurs
Revert to
Appropriate
Protocol
M
Contact Medical Control
M
Pearls:
 Exam: Mental Status, Skin, Neck, Lungs, Heart, Abdomen, Extremities, Neuro
 Most patients immediately post resuscitation will require ventilatory assistance.
 The condition of post-resuscitation patients fluctuates rapidly and continuously, and they
Revised: 07/11/2011
M. Stover, MD
require close monitoring.
 Appropriate post-resuscitation management can best be planned in consultation with
medical control.
32
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
EMT
Intermediate
Paramedic
Medical Control
Pulmonary Edema
History:

Congestive heart
failure

Past medical history

Medications

Cardiac History
Signs/ Symptoms:







Respiratory distress, bilateral rales
Apprehension, orthopnea
Jugular vein distention
Pink frothy sputum
Peripheral edema, diaphoresis
Hypotension, shock
Chest Pain
Differential:

Myocardial Infarction

Congestive heart failure

Asthma and/or COPD

Anaphylaxis

Aspiration

Pleural effusion

Pneumonia

Pulmonary embolus

Pericardial tamponade
Universal Patient
Care Protocol
P CPAP Procedure
P
P
P
Nitroglycerine
if BP >100
I
IV Protocol
P
I
Furosemide 40mg / double
daily dose up to
80 mg IV Total
12 Lead ECG
If Available
P
Symptoms Resolved
P
P
Symptoms Persist
M
Contact Medical Control
Reassess and
Monitor
P
M
Pearls:








Contact Medical Control
M
Morphine
2 mg IV, then
2 mg IV q3-5 min
up to 10mg total
Consider Zofran
P
Exam: Mental Status, Skin, Neck, Lung, Heart, Abdomen, Back, Extremities, Neuro
Avoid Nitro in any patient who has used impotency medication in the past 48 hours due to possible severe hypotension.
If patient has taken nitroglycerin without relief, consider potency of the medication.
Concerns with Morphine include severe COPD and respiratory distress. Monitor the patient closely.
Consider myocardial infarction in all these patients.
Diabetics and geriatric patients often have atypical pain, or only generalized complaints.
Careful monitoring of level of consciousness, BP, and respiratory status with treatments is essential.
Allow the patient to be in their position of comfort to maximize their breathing effort.
Revised: 07/11/2011
M. Stover, MD
M
33
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
EMT
Intermediate
Paramedic
Medical Control
Pulseless Electrical Activity (PEA), ADULT
History:

Past medical history; Medications

Events leading to arrest

End stage renal disease

Estimated downtime

Suspected hypothermia; Overdose
Tricyclics, Digitalis, Beta blockers,
Calcium channel blockers

DNR/DNAR or Living will
AT ANY TIME
Return of spontaneous
circulation
Go to post resuscitation
protocol
Signs/ Symptoms:

Pulseless

Apneic

Electrical activity
on ECG
Differential:
 Hypovolemia
 Cardiac tamponade
 Hypothermia
Drug Overdose
 Massive MI
Hypoxia
 Tension pneumothorax
 Pulmonary embolus
 Acidosis
 Hyper/ hypokalemia
Universal Patient
Care Protocol
P
F
R
CPR
F
R
I
IV and Airway
Protocol
I
Epinephrine 1:10,000
1 mg q 3-5 min
CONSIDER CAUSES EARLY IN
ALL PEA PATIENTS
P
I
Consider Fluid Bolus
I
I
Consider 25 g of D50
If BG < 70
I
Thiamine 100mg prior to
D50
For Suspected ETOH
Abuse
P
P
Consider:
Calcium Glucanate: 5-20ml slow IVP
P
Sodium Bicabonate: 50 mEq
May repeat at half dose in 10 min
P
Dopamine: 5-20 mcg/kg/min
titrate to systolic BP of 90 mmHg
Chest Decompression
P
Criteria for
Discontinuation
NO
M
Pearls:





Contact Medical Control
P
YES
M
P
Stop
Resuscitation
Exam: Mental Status.
Consider each possible cause listed in the differential: Survival is based on identifying and correcting the
cause!!!!!
Discussion with Medical Control can be a valuable tool in developing a differential diagnosis.
Atropine may be of benefit in the presence of a brady or relative bradycardic rate.
For Dialysis patients consider Calcium Glucanate early.
Revised: 07/11/2011
M. Stover, MD
34
P
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
EMT
Intermediate
Paramedic
Respiratory Distress,
History:





Asthma/ COPD
CHF
Home treatment
Medications
Toxic exposure
Signs / Symptoms:

Shortness of breath

Pursed lip breathing

Decreased ability to
speak

Increased respiratory rate

Wheezing, rhonchi

Use of accessory
muscles

Fever, cough

Tachycardia
Medical Control
ADULT
Differential:

Asthma

Anaphylaxis

Aspiration

COPD

Pleural
effusion

Pulmonary
embolus

Inhaled toxin




Pneumonia
Pneumothorax
Cardiac
Pericardial
tamponade

Hyperventilation
Universal Patient
Care Protocol
I
IV Protocol
I
Rales/ Signs
of CHF
Wheezes
Pulmonary Edema
Protocol
P
Albuterol
2.5 mg +
Atrovent 0.02 % 500 mcg
P
M
Solu-Medrol
125 mg IV
Contact
Medical Control
P
P
M
Pearls:

Exam: Mental Status, HEENT, Skin, Neck, Lung, Heart, Abdomen, Extremities, Neuro.

Pulse oximetry should be monitored continuously if initial saturation is ≤96%, or there is a decline in patient’s
status despite normal pulse oximetry readings.

Status asthmaticus – severe prolonged asthma attack unresponsive to therapy – life threatening!!!

Albuterol may be repeated up to 3 times if no cardiac history and HR < 150 bpm..

A silent chest in respiratory distress is a pre-respiratory arrest sign.

Use capnography if available.
Revised: 07/11/2011
M. Stover, MD
35
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
EMT
Intermediate
Paramedic
Medical Control
Seizure, ADULT
History:

Reported/ witnessed
seizure activity

Previous seizure history

Medic Alert bracelet

Seizure medication

History of trauma

History of diabetes

History of pregnancy
Signs and symptoms:

Decreased mental status

Sleepiness

Incontinence

Observed seizure activity

Evidence of trauma
Differential:

CNS Trauma

Tumor

Metabolic problem

Hypoxia

Electrolyte abnormality

Drugs and/or Infection

ETOH Withdrawal

Eclampsia

Stroke

Hyperthermia
Universal Patient
Care Protocol
F
R
Spinal
Immobilization
Protocol
F
R
Status Epilepticus
Focused HX and
physical exam
Postictal
I
IV Protocol
I
Airway Protocol
B
I
IV Protocol
Blood Glucose
B
I
>70
P
Seizure Recurs?
Valium 5mg IV/IM/IO or PR
P
may repeat after 10 minutes
Valium 5mg IV/IM/IO or PR
may repeat after 10 minutes
P
(if sz persists contact
medical control)
M
Pearls:








< 70
Contact Medical Control
I
P
M
50% Dextrose
25 grams IV or Glucagon
1mg IM if no IV access
I
Thiamine 100mg prior to
P D50 for suspected ETOH
abuse
P
Exam: Mental Status, HEENT, Lungs, Heart, Extremities, Neuro.
Status epilepticus is defined as two or more successive seizures without a period of consciousness or recovery. This is a true
emergency requiring rapid airway control, treatment, and transport.
Grand mal seizures (generalized) are associated with loss of consciousness, incontinence, and tongue trauma.
Focal seizures (petit mal) effect only a part of the body and are not usually associated with a loss of consciousness.
Jacksonian seizures are seizures which start as a focal seizure and become generalized.
Be prepared for airway problems and continued seizures. Assess for occult trauma and/or substance abuse.
07/11/2011
Stover, MD
Be Revised:
prepared to assist
ventilations especially if Valium M.
is used.
For any seizure in a pregnant patient, follow the OB Emergencies Protocol.
36
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
EMT
Intermediate
Paramedic
Medical Control
Atrial Fibrillation / Atrial Flutter
Signs and Symptoms:
History:

Medications

Diet

Drugs

Past medical history

History of palpitations

Syncope





HR > 150
QRS < .12 Sec
Dizziness
Chest Pain
Resp. Distress
Differential:

Heart Disease

Sick sinus syndrome

Myocardial infarction

Exertion

Pain

Emotional Stress

Fever
Universal Patient
Care Protocol
Hx of WPW
M
Contact Medical
M
Control
I
12 Lead
ECG if available
I
Unstable/
Symptomatic
M
Contact Medical Control
M
P
Contact Medical Control
Sedate with
Versed 2 mg
P
P
M
IV Protocol
Stable/Symptomatic
Stable/Asymptomatic
P
Differential Cont:

Hypoxia

Hypovolemia

Drug overdose

Hyperthyroidism

Pulmonary embolus

Electrolyte imbalance
M
P
Cardizem 0.25 mg/kg
SLOW IV; may repeat with
0.35 mg/kg after 15 min.
MCP ONLY
After Rate Control
12 lead ECG if available
P
(MCP Orders Only)
P
P
P
P
M
Cardioversion
100 Joules
P
Repeat Cardioversion
200j, 300j, 360j
P
Contact Medical Control
M
Perform 12 Lead on all
suspected all A-Fib/A-Flutter
Patients
Pearls:

Adenosine may not be effective in identifiable atrial flutter/fibrillation, yet is not harmful.

Monitor for hypotension after administration of Cardizem

Monitor for respiratory depression and hypotension associated with Versed.

Continuous pulse oximetry is required for all Atrial Fibrillation/ Atrial Flutter Patients.

Document all rhythm changes with monitor strips and obtain monitor strips with each therapeutic intervention.
Revised: 07/11/2011
M. Stover, MD
37
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
EMT
Intermediate
Paramedic
Medical Control
Supraventricular Tachycardia (SVT), ADULT
History:

Medications

Diet

Drugs

Past medical history

History of palpitations

Syncope
Signs and Symptoms:

HR > 150

QRS < .12 Sec

Dizziness

Chest Pain

SOB
Differential:

Heart Disease

Sick sinus syndrome

Myocardial infarction

Exertion

Pain

Emotional Stress

Fever
Contact Medical
M
Control
I
IV Protocol
I
Stable
Unstable
P
12 Lead ECG
If available
P
P
Vagal
Maneuver
P
P
P
P
Cardioversion
100 Joules
P
P
Repeat Cardioversion
200j, 300j, 360j
P
P
P
M
Sedate with
Versed 2 mg
P
Adenosine
6mg Rapid IV Push,
12mg Rapid IV,
12mg Rapid IV
P
Hypoxia
Hypovolemia
Drug overdose
Hyperthyroidism
Pulmonary embolus
Electrolyte imbalance
Universal Patient
Care Protocol
Hx of WPW
M






Contact Medical Control
M
Cardizem 0.25 mg/kg
SLOW IV; may repeat with
0.35 mg/kg after 15 min.
P
M
P
Adenosine
6mg Rapid IV Push,
12mg Rapid IV,12mg Rapid
IV
P
Contact Medical Control
M
Cardizem 0.25 mg/kg
SLOW IV; may repeat with
0.35 mg/kg after 15 min.
P
Pearls:







Exam: Mental Status, Skin, Neck, Lung, Heart, Abdomen, Back, Extremities, Neuro
Adenosine may not be effective in identifiable atrial flutter/fibrillation, yet is not harmful.
Monitor for respiratory depression and hypotension associated with Versed.
Continuous pulse oximetry is required for all SVT patients.
Document all rhythm changes with monitor strips and obtain monitor strips with each therapeutic
intervention.
Approved vagal maneuvers include coughing, straining as if attempting a bowel movement. Carotid
sinus massage is not approved
Unstable patients may require immediate Cardioversion without IV or sedation
Revised: 07/11/2011
M. Stover, MD
38
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
EMT
Intermediate
Paramedic
Medical Control
Suspected Stroke
History:

Previous CVA or
TIA’s

Previous cardiac or
vascular surgery

Associated diseases
(HTN, DM, CAD)

Atrial fibrillation

Medications

History of trauma
Signs and Symptoms:

Altered mental status

Weakness/ Paralysis

Blindness or other
sensory loss

Aphasia/ Dysarthria

Syncope

Vertigo

Vomiting

Headache

Seizures

Respiratory pattern
change

Hypertension/
hypotension
Differential:

See Altered LOC

TIA

Seizure

Hypoglycemia

Stroke
o Thrombotic
o Embolic
o Hemorrhagic

Tumor

Trauma
Universal Patient
Care Protocol
I
IV Protocol
I
B
Blood Glucose
B
<70
50% Dextrose
I
12-25 grams IV
Glucagon
P
1mg IM if no IV
P
>70
I
P
Thiamine 100mg IV
prior to D50 if
suspected ETOH
P
P
M
LA Prehospital
Stroke Scale
P
Contact Medical Control
M
Consider Causes
Altered LOC
Hypertension
Seizure
Pearls:
 Exam: Mental Status, HEENT, Lung, Heart, Abdomen, Extremities, Neuro.
 Thrombolytic Screening Checklist should be completed for any suspected stroke patient. With
duration of symptoms of less than 3 hours, scene times and transport times should be minimized.
 Onset of symptoms is the last witnessed time the patient was symptom free (i.e. awakening with
stroke symptoms would be defined as an onset time of the previous night when patient was symptom
free).
 The differential listed on the Altered Mental Status Protocol should also be considered.
 Elevated blood pressure is commonly present with stroke. Consider treatment if diastolic is >
120mmhg.
 Be alert for airway problems (swallowing difficulty, vomiting).
 Hypoglycemia can present as a localized neurologic deficit, especially in the elderly.
Revised: 07/11/2011
M. Stover, MD
39
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
EMT
Intermediate
Paramedic
Medical Control
Syncope
History:

Cardiac history, stroke,
seizure

Occult blood loss (GI,
eptopic)

Females: LMP, vaginal
bleeding

Fluid loss: nausea,
vomiting, diarrhea

Past Medical History

Medications
Signs and Symptoms:

Loss of consciousness with
recovery

Lightheadedness, dizziness

Palpitations, slow or rapid
pulse

Pulse irregularity

Decreased blood pressure
Differential:

Vasovagal

Orthostatic hypotension

Cardiac syncope

Micturation/defecation
syncope

Psychiatric

Stroke or Seizure

Hypoglycemia

Shock (see Shock Protocol)

Toxicologic (Alcohol)

Medication effect (HTN)
Universal Patient
Care Protocol
Suspected
Trauma
YES
F
R
NO
P
Cardiac
Monitor
Spinal
Immobilization
Protocol
F
R
AT ANY TIME
P
If relevant signs /
symptoms are found go to
appropriate protocol.
I
IV Protocol
I
B
Blood
Glucose
B
Dysrhythmia
Hypotension
Altered Mental Status
<70
>70
P
P
M
Pearls:




Revised:


12 Lead
ECG
I
50% Dextrose
25 grams
I
P
If no IV access,
Glucagon
1 mg IM
P
Thiamine 100mg IV prior to
D50 if suspected ETOH
abuse
P
P
Contact Medical Control
M
Exam: Mental Status, Skin, HEENT, Lungs, Heart, Abdomen, Back, Extremities, Neuro.
Assess for signs and symptoms of trauma if associated or questionable fall with syncope.
Consider dysrhythmias, GI bleed, ectopic pregnancy, & seizure as possible cause of syncope.
These patients should be transported.
07/11/2011
Stover,
MD based.
More
than 25% of geriatric syncope is M.
cardiac
dysrhythmia
If patient is suspected of ETOH abuse always administer Thiamine IVP before D50
40
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
EMT
Intermediate
Paramedic
Medical Control
Ventricular Fibrillation/ Pulseless V-Tach
History:






Signs and Symptoms:

Unresponsive, apneic,
pulseless

Ventricular fibrillation or
ventricular tachycardia on
ECG
Estimated down time
Past medical history
Medications
Events leading to arrest
Renal failure / dialysis
DNR or living will
Cardiac Arrest Protocol
For defibrillation purposes, all
energy settings are set for
Biphasic waveform patterns. If
Monophasic monitor is present
start with energy setting at 360 J.
Defibrillate
At 200 J Biphasic
P
I
P
P
IV / Airway
Protocol
P
Defibrillate
At 360 J Biphasic
Criteria to Discontinue
NO
P
P
P
If rhythm converts
P
start Amiodarone Drip
P
P
YES
P
Discontinue
P
P
Consider Lidocaine
1.5mg/kg
P
P
May repeat twice at
.75mg/kg
M
I
Defibrillate
At 300 J Biphasic
Amiodarone 150mg
P
P
x1
Defibrillate
Reminder:
Continuous High
Quality CPR
Amiodarone 300mg Rapid
P
IVP
P
P
P
Epinephrine 1:10,000
1mg q 5 Min
P
At any time
Return of spontaneous
circulation
Go to Post
Resuscitation Protocol
Differential:
 Asystole
 Artifact / Device failure
 Cardiac
 Endocrine / Metabolic
 Drugs
 Pulmonary
Contact Medical Control
P
If Torsades is suspected
Consider Mag Sulfate 1-2g IV
P
M

Pattern should be CPR drug-shock, CPR, drug-shock, etc..(repeat drugs as per drug list).

Reassess and document endotracheal tube placement and ET CO2 frequently, after every move, and at discharge.

If defibrillation is successful and patient re-arrests, return to previously successful energy level.

Calcium if hyperkalemia is suspected (renal failure, dialysis).

Defibrillation takes precedence over all treatment once the defibrillator is available.
Revised:
07/11/2011
M. Stover, MD

If Defibrillation is underway by First Responders (FR), FR defibrillation should continue until 6 defibrillations are
accomplished or patient is resuscitated.
 Polymorphic V-Tach (Torsades de Pointes) may benefit from magnesium sulfate IV.
41
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
EMT
Intermediate
Paramedic
Medical Control
Ventricular Tachycardia w/ a Pulse
History:
 Past medical history /
medications, diet,
drugs.
 Syncope / near syncope
 Palpitations
 Pacemaker
 Allergies: lidocaine /
novacaine
Signs and Symptoms:
 Ventricular tachycardia
on ECG (Runs or
sustained)
 Conscious, rapid pulse
 Chest pain, shortness of
breath
 Dizziness
 Rate usually 150 – 180
bpm for sustained VTach
Differential:
 Artifact / Device failure
 Cardiac
 Endocrine / Metabolic
 Drugs
 Pulmonary
Universal Patient
Care Protocol
I
IV Protocol
I
P
12 Lead ECG
If available
P
Stable
P
Amiodarone 150mgIV over
10 min
Persistant VT Repeat x1 P
Start Drip @ 1mg/min if
conversion
P
Consider
Lidocaine, 1.5mg/kg
M
Contact Medical
Control
P
M
Unstable
Sedate with
Versed 2 mg IV
P
P
P
Cardioversion
100j, 200j, 300j, 360j
P
Amiodarone 150mg IV over
10 min
P Persistant VT Repeat x1 P
Start Drip @1mg/min if
conversion
P
M
Consider
P
Lidocaine, 1.5mg/kg
Contact Medical
Control
M
Pearls:

Exam: Mental Status, Skin, Neck, Lung, Heart, Abdomen, Back, Extremities, Neuro.

For witnessed / monitored ventricular tachycardia, try having patient cough.

Polymorphic V-Tach (Torsades de Pointes) may benefit from the administration of magnesium sulfate.
Stover, MDwithout an IV or sedation.
 Revised:
Unstable07/11/2011
patients may require immediateM.
Cardioversion
42
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
EMT
Intermediate
Paramedic
Medical Control
Vomiting and Diarrhea
History:
 Age
 Time of last meal
 Last bowel movement/emesis
 Improvement or worsening
with
food or activity
 Duration of problem
 Other sick contacts
 Past medical history
 Past surgical history
 Medications
 Menstrual history (pregnancy)
 Travel history
 Bloody emesis / diarrhea
Signs and Symptoms:
 Pain
 Character of pain
(constant, intermittent,
sharp, dull, etc.)
 Distention
 Constipation
 Diarrhea
 Anorexia
 Radiation
 Associated symptoms:
(helpful to localize source)
Fever, headache, blurred
vision, weakness, malaise,
myalgias, cough, dysuria,
mental status
changes,rash
Differential:
 CNS (increased pressure, headache,
stroke, CNS lesions, trauma or
hemorrhage, vestibular)
 Myocardial infarction
 Drugs (NSAID’s, antibiotics, narcotics,
chemotherapy)
 GI or Renal disorders
 Diabetic ketoacidosis
 Gynecologic disease (ovarian cyst, PID)
 Infections (pneumonia, influenza)
 Electrolyte abnormalities
 Food or toxin induced
 Medication or Substance abuse
 Pregnancy
 Psychological
Universal Patient
Care Protocol
Symptomatic
I
IV Protocol
w/ bolus
B
Blood
Glucose
B
F
R
BP< 90
F
R
Asymptomatic
I
Vomiting?
P
Zofran adult: 4mg IV Slow over 2
minutes. Peds: 0.15 mg/kg IVP slow
Max dose of 4mg
M
Contact Medical
Control
P
M
Pearls:
 Exam: Mental Status, Skin, HEENT, Neck, Lungs, Heart, Abdomen, Back,
Extremities, Neuro
 Document the mental status and vital signs prior to administration of Zofran.
Revised: 07/11/2011
M. Stover, MD
43
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
EMT
Intermediate
Paramedic
Medical Control
Pediatric
And OB
Protocols
Revised: 07/11/2011
M. Stover, MD
44
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
EMT
Intermediate
Paramedic
Medical Control
Childbirth/ Labor
History:
 Due date
 Time contractions started / how often.
 Rupture of membranes
 Time / amount of any vaginal bleeding
 Sensation of fetal activity
 Past medical and delivery history
 Medications
Signs and Symptoms:
 Spasmotic pain
 Vaginal discharge or
bleeding
 Crowning or urge to push
 Meconium
Differential:
 Abnormal presentation
 Buttock
 Foot
 Hand
 Prolapsed cord
 Placenta previa
 Abruptio placenta
Universal Patient
Care Protocol
Left Lateral
Position
Hypertension
Abnormal Vaginal Bleeding?
YES
NO
Obstetrical
Emergencies
Protocol
Inspect
Perineum
< 36 WEEKS GESTATION
CROWNING
ABNORMAL PRESENTATION
SEVERE VAGINAL BLEEDING
MULTIPLE GESTATIONS
RAPID TRANSPORT IS
INDICATED
No Crowning
Crowning
PRIORITY SYMPTOMS:
I
IV Protocol
I
Monitor
If prolapsed cord
Knee to chest position
Push up on head
Newly Born
Protocol
M
Contact Medical
M
Control
Pearls:





Exam: (Of Mother) Mental Status, Lungs, Heart, Abdomen, Neuro.
Document all times (delivery, contraction frequency, and length).
If maternal seizures occur, refer to the Obstetrical Emergencies Protocol.
After delivery, massaging the uterus (lower abdomen) will promote uterine contraction and help to
control post-partum bleeding.
Some perineal bleeding is normal with any childbirth. Large quantities of blood or free bleeding are
abnormal.
Revised: 07/11/2011
M. Stover, MD
45
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
EMT
Intermediate
Newly Born
History:
 Due date and gestational age
 Multiple gestation (twins etc.)
 Meconium
 Delivery difficulties
 Congenital disease
 Medications (maternal)
 Maternal risk factors: substance
abuse, smoking
Paramedic
Medical Control
(Broselow Tape)
Signs and Symptoms:
 Respiratory distress
 Peripheral cyanosis or
mottling (normal)
 Central cyanosis
(abnormal)
 Altered level of
responsiveness
 Bradycardia
Differential:
 Airway failure
 Secretions
 Respiratory drive
 Infection
 Maternal medication effect
 Hypovolemia
 Hypoglycemia
 Congenital heart disease
 Hypothermia
Universal Patient
Care Protocol
Meconium in
Amniotic Fluid
YES
NO
Airway Suction
Dry Warm
Bulb suction
mouth/nose
Stimulate Note
APGAR Score
Respirations
Present?
No
F
R
Yes
BVM 40- 60
per minute
F
R
Reassess
Frequently
Heart Rate
<60 bpm
60- 100 bpm
>100 bpm
Pediatric
Airway Protocol
Pediatric
Airway Protocol
Monitor and
Reassess
HR >100
F
R
CPR
F
R
I
IV Protocol
I
Reassess
Heart Rate
Continue
Oxygen
HR 80-100
I
I
Dextrose 10% IV/IO
Fluid Bolus


I
I
M
Pearls:



IV Protocol
Contact Medical
Control
M
Exam: Mental Status, Skin, HEENT, Neck, Chest, Heart, Abdomen, Extremities, Neuro.
Maternal sedation or narcotics will sedate infant (Naloxone effective).
Consider hypoglycemia in infant
Document 1 and 5 minute APGAR scores (see appendix).
Consider Narcan 0.1 mg/kg IV / IO if known or suspected substance abuse by mother.
Revised: 07/11/2011
M. Stover, MD
46
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
EMT
Intermediate
Paramedic
Medical Control
Obstetrical Emergency
History:

Past medical history

Hypertension meds

Prenatal care

Prior pregnancies / births

Gravida / Para
Signs and Symptoms:

Vaginal bleeding

Abdominal pain

Seizures

Hypertension

Severe headache

Visual changes

Edema of hands and face
Differential:
 Pre-eclampsia / Eclampsia
 Placenta previa
 Placenta abruptio
 Spontaneous abortion
Universal Patient
Care Protocol
I
IV Protocol
I
Vaginal Bleeding?
Abdominal Pain?
Yes
Hypertension
Left Lateral
Position
M
Known Pregnancy
Missed Period
Yes
F BP< 90 Regardless F
R
of Position
R
Contact Medical
M
Control
Yes
No
B
Blood
Glucose
B
I
Fluid Bolus
Seizure or seizure like
activity
Magnesium
Sulfate
2 gr over 2min IV
Infusion
P
P
Valium 5mg IVP
P
Quiet Rapid
Transport
Pearls:







Abdominal Pain
Protocol
I
Left Lateral Position if
3rd trimester
No
P
No
M
Contact Medical
M
Control
Exam: Mental Status, Lung, Heart, Abdomen, Neuro.
Severe headache, vision changes, or RUQ pain may indicate pre-eclampsia.
In the setting of pregnancy, hypertension (HTN) is defined as a BP greater than 140 systolic or greater than 90 diastolic, or a
relative increase of 30 systolic and 20 diastolic from the patient’s normal (pre-pregnancy) blood pressure.
Maintain patient in a left lateral position to minimize risk of supine hypotension syndrome.
Ask patient to quantify bleeding – number of pads used per hour.
Any pregnant patient involved in a MVA should be seen immediately by a physician for evaluation and fetal monitoring.
For any hypoglycemic patient suspected of abusing ETOH, always administer 100 mg Thiamine before D50W.
Revised: 07/11/2011
M. Stover, MD
47
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
EMT
Intermediate
Paramedic
Bradycardia, PEDIATRIC
History:
 Past Medical History
 Foreign body exposure
 Respiratory distress or
arrest
 Apnea
 Possible toxic or poison
exposure
 Congenital disease
 Medication (maternal or
infant)
Medical Control
(Broselow Tape)
Signs and Symptoms:
 Decreased heart rate
 Delayed capillary refill
or cyanosis
 Mottled, cool skin
 Hypotension or arrest
 Altered level of
consciousness
Differential:
 Respiratory effort
 Respiratory obstruction
 Foreign body / Secretions
 Croup / Epiglotitis
 Hypovolemia
 Hypothermia
 Infection / Sepsis
 Medication or Toxin
 Hypoglycemia
 Trauma
Universal Patient
Care Protocol
Pediatric Airway
Protocol
Poor Perfusion
No
Yes
I
IV Protocol
I
F
R
HR <60
CPR
F
R
Monitor
M
Contact Medical
Control
M
Epinephrine 1:10,000
0.01 mg/kg IV/IO
Max single dose 0.5mg
May repeat q 3-5 min
P
Atropine
0.02 mg/kg IV/IO
Min 0.1mg dosing
May repeat q 3-5 min
P
I
P
Pearls:




Revised:


Consider
Transcutaneous Pacing
P
M
Consider
Dextrose 10%
Narcan
NS Bolus
P
P
I
Contact Medical Control
M
Exam: Mental Status, HEENT, Skin, Lung, Heart, Abdomen, Back, Extremities, Neuro.
Infant = < 1 year of age.
Most maternal medications pass though breast milk to the infant.
The
majority of pediatric arrests are due
airway problems.
07/11/2011
M.to Stover,
MD
Hypoglycemia, severe dehydration and narcotic effects may produce bradycardia.
Pediatric patients requiring external transcutaneous pacing require the use of pads appropriate for pediatric
patients per the manufacturers guidelines.
48
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
EMT
Intermediate
Paramedic
Medical Control
Head Trauma, PEDIATRIC
History:






(Broselow Tape)
Signs and Symptoms:




Time of injury
Mechanism (blunt vs
penetrating)
Loss of
consciousness
Bleeding
Past medical history
Evidence for multitrauma
Differential:


Pain, swelling, bleeding
Altered mental status
Unconscious
Respiratory distress /
failure
Vomiting
Major traumatic
mechanism of injury
Seizure








Skull fracture
Brain injury (Concussion,
Contusion, Hemorrhage or
Laceration)
Epidural hematoma
Subdural hematoma
Subarachnoid hemorrhage
Spinal injury
Abuse
Universal Patient
Care Protocol
Isolated Head
Trauma
No
Yes
Multiple Trauma
Protocol
Spinal
F
Immobilization
R
Protocol
F
R
I
I
IV Protocol
Does patient opens eyes to
“What happened to you”?,
or other verbal commands
Yes
Response to pain?
Maintain SPO2
>90%
Yes
B
<60
I
P






Blood
Glucose
Seizure?
B
No
Pediatric Seizure
Protocol
D25 2ml/kg
P
Intubate
maintain CO2 30-35/O2
Sat >90% with
Capnography if available
P
Monitor and
Reassess
I
Glucagon If no IV
Consider Narcan
0.1mg/kg
No
P
M
Contact Medical
Control
M
Exam: Mental Status, HEENT, Skin, Lungs, Heart, Abdomen, Back, Extremities, Neuro
If GCS < 12 consider air/rapid transport and if GCS < 8 intubation should be anticipated.
Increased intracranial pressure (ICP) may cause hypertension and bradycardia (Cushing’s Response).
Hypotension usually indicates injury or shock unrelated to the head injury.
The most important item to monitor and document is a change in the level of consciousness.
Revised:are07/11/2011
M. with
Stover,
Concussions
periods of confusion or LOC associated
trauma,MD
which may have resolved by the time EMS arrives.
Any prolonged confusion or mental status abnormality, which does not return to normal within 15 minutes, or any
documented loss of consciousness, should be evaluated by a physician ASAP.
49
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
EMT
Intermediate
Paramedic
Medical Control
Hypotension Shock(Non-Trauma), PEDIATRIC
Broselow Tape
History:



Signs and Symptoms:

Blood Loss
Fluid Loss
 Vomiting
 Diarrhea
 Fever
Infection





Differential:
Restlessness/
Confusion
Dizziness
Increased HR
Decreased BP
Pale, cool, clammy skin
Delayed capillary refill





Trauma
Infection
Dehydration
Congenital heart
disease
Medication or Toxin
Universal Patient
Care Protocol
I
IV Protocol
I
Evidence or history
of trauma?
Yes
No
Pediatric Multiple
trauma protocol
B
Blood Glucose
B
< 70
I
Dextrose 10% IV
I
P
Glucagon 0.5mg IM
If no IV
P
> 70




I
NS Bolus
20 cc / kg
I
M
Contact Medical
Control
M
P
Consider
Dopamine
5-20 mcg/kg/min
titrate to systolic
BP of 90 mmHg
P
Exam: Mental status, Skin, HEENT, Heart, Lung, Abdomen, Extremities, Back, Neuro
Consider all possible causes of shock and treat per specific protocol
Decreasing heart rate is a sign of impending collapse
Most maternal medications pass through breast milk to the infant
Revised: 07/11/2011
M. Stover, MD
50
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
EMT
Intermediate
Paramedic
Medical Control
Multiple Trauma, PEDIATRIC
History:









Signs and symptoms:


Time and mechanism of injury
Damage to structure or
vehicle
Location in structure or
vehicle
Others injured or dead
Speed and details of MVC
Restraints / Protective
equipment: Car seat, Helmet,
Pads
Ejection
Past medical history
Medications
Differential (Life Threatening):

Pain, swelling
Deformity,
lesions, bleeding
Altered mental
status
Unconscious
Hypotension or
shock
Arrest




(Broselow Tape)







Chest : Tension pneumothorax
Flail Chest
Pericardial Tamponade
Open chest wound
Hemothorax
Intra-abdominal bleeding
Pelvis / Femur fracture
Spine fracture / Cord Injury
Head injury (see Head Trauma)
Extremity fracture / dislocation
HEENT (Airway obstruction)
Hypothermia
Universal Patient
Care Protocol
Spinal
Immobilization
Protocol
F
R
I
IV Protocol
F
R
I
Vital Signs/
Perfusion
Abnormal
Rapid Transport
Focused
Exam
I
NS Bolus 20cc/kg
Repeat as needed (max
60 cc/kg If lungs are clear)
I
P
Tension Pneumothorax?
Chest Decompression
P
M





Normal
Transport
Contact Medical
M
Control
Exam: Mental status, Skin, HEENT, Heart, Lung, Abdomen, Extremities, Back, Neuro
Mechanism is the most reliable indicator of serious injury. Examine all restraints / protective
equipment for damage.
If prolonged extrication times of serious trauma consider air transportation to improve time to a
trauma center and the ability to give blood products.
Do not overlook the possibility of child abuse.
Children should be removed from car seats to allow for complete examination.
Revised: 07/11/2011
M. Stover, MD
51
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
EMT
Intermediate
Paramedic
Medical Control
Pulseless Arrest, PEDIATRIC (Broselow Tape)
History:




Signs and Symptoms:
Time of arrest
Medical history
Medications
Possibility of
foreign body
Hypothermia



Differential:

Unresponsive
Cardiac arrest
Respiratory
failure
Foreign body
Secretions
Infection (Croup,
Epiglotitis)
Hypovolemia
(Dehydration)
Congenital Heart
Disorder







Trauma
Tension
pneumothorax
Hypothermia
Toxin or
medication
Hypoglycemia
Acidosis




Universal Patient
Care Protocol
F
R
CPR
F
R
P
Cardiac
Monitor
P
V- Fib
V- Tach
Defibrillate
2 j/kg, CPR 5 cycles,
defibrillate at 4 j/kg
P
P
Endotracheal
Intubation
I
IV Protocol
M
Revised:


P
Defibrillation
4 j/kg
P
Consider
Amiodarone
5 mg/kg IV/IO
Repeat x1
Contact Medical
Control
P
Endotracheal
Intubation
I
IV Protocol
P
P
I
P
Epinephrine
1:10,000
0.01 mg/kg IV/IO
Max dose 1mg
Repeat q 3-5 min
P



Asystole
PEA
P
I
P
P
P
M
P
I
Epinephrine
1:10,000
0.01 mg/kg IV/IO
Max dose 1mg
Repeat q 3-5 min
Dextrose 25% 2cc/kg
Narcan 0.1mg/kg IV/IO
(pearls)
P
I
P
Contact Medical Control
Determine Causes:
Hypoxia, Acidosis, Volume M
Depletion, Hypothermia,
Hypoglycemia
M
Exam: Mental Status
Monophasic and Biphasic waveform defibrillators should use the same energy levels noted above.
In order to be successful in pediatric arrests, a cause must be identified and corrected.
07/11/2011
M. This
Stover,
Airway is the most important intervention.
shouldMD
be accomplished immediately. Patient survival is often
dependent on airway management success.
Narcan for suspected or known substance abuse.
52
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
EMT
Intermediate
Paramedic
Medical Control
Respiratory Distress, PEDIATRIC(Broselow Tape)
History:







Signs and symptoms:
Time of onset
Possibility of foreign body
Medical history
Medications
Fever or respiratory
infection
Other sick siblings
History of trauma


Differential:




Wheezing or stridor
Respiratory
retractions
Increased heart rate
Altered level of
consciousness
Anxious appearance






Asthma
Aspiration
Foreign body
Infection, Pneumonia,
Croup, Epiglotitis
Congenital heart disease
Medication or Toxin
Trauma
Universal Patient
Care Protocol
Respiratory
Insufficiency?
Yes
No
Position patient
for comfort
Pediatric Airway
Protocol
P
Yes
Albuterol
2.5mg via HHN
May repeat x3
P
if HR < 200 bpm
SEE PEARLS
Wheezing?
No
I
M
IV Protocol
If SPO2 <90%
I
Contact Medical
Control
M
P Consider Epi 1:1,000 0.01 mg/kg SQ
P
Solumedrol 1mg/kg IV
P
P
Pearls:
 Exam: Mental Status, HEENT, Neck, Skin, Lungs, Heart, Abdomen, Back, Extremities, Neuro.
 Pulse oximetry should be monitored continuously if initial saturation is < 96%, or there is a decline in
patient status despite normal pulse oximetry readings.
 Do not force a child into a position. They will protect their airway by their body position.
 The most important component of respiratory distress is airway control.
 Epiglottitis typically affects children < 2 years of age. It is bacterial, with fever, rapid onset, possible
stridor, patient wants to sit up to keep airway open, drooling is common. Airway manipulation may
worsen the condition.
Revised: 07/11/2011
M. Stover, MD
53
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
EMT
Intermediate
Paramedic
Seizure, PEDIATRIC
History:






(Broselow Tape)
Signs and Symptoms:
Fever
Prior history of seizures
Seizure medications
Reported seizure activity
History of recent head
trauma
Congenital abnormality



Medical Control
Differential:
Observed seizure
activity
Altered mental
status
Hot, dry skin or
elevated body
temperature







Fever and/or Infection
Head Trauma
Medication or Toxin
Hypoxia or Respiratory Failure
Hypoglycemia
Metabolic abnormality / acidosis
Tumor
Universal Patient
Care Protocol
Position on side
to prevent aspiration
Yes
Cooling
Measures
Febrile?
No
I
Blood Glucose <70
Dextrose 25% 2cc//kg
I
P
Glucagon 0.5mg IM if no IV
P
Active Seizure
Repeat Seizure
I









IV Protocol
I
P
Valium 0.2 mg/kg IV/IO or
0.5 mg/kg Rectal
M
Contact Medical Control
P
M
Exam: Mental Status, HEENT, Lung, Heart, Extremities, Neuro.
Status Epilepticus is defined as two or more successive seizures without a period of consciousness or
recovery. This is a true emergency requiring rapid airway control, treatment, and transport.
Grand mal seizures are associated with loss of consciousness, incontinence, and tongue trauma.
Focal seizures (petit mal) effect only a part of the body and are not usually associated with a loss of
consciousness.
Jacksonian seizures are seizures that start as a focal seizure and become generalized.
Be prepared to assist ventilations especially if a benzodiazipine is used.
If evidence or suspicion of trauma, spine should be immobilized.
If febrile, remove clothing and sponge with room temperature water.
In an infant, a seizure may be the only evidence of a closed head injury.
Revised: 07/11/2011
M. Stover, MD
54
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
EMT
Intermediate
Paramedic
Medical Control
Supraventricular Tachycardia, PEDIATRIC
(Broselow Tape)
History:






Signs and Symptoms:

Past medical history
Medications or Toxic
Ingestion (Aminophylline,
Diet pills, Thyroid
supplements,
Decongestants, Digoxin)
Drugs (nicotine, cocaine)
Congenital Heart
Disease
Respiratory Distress
Syncope or near
syncope








Differential:
Heart Rate:
Child > 180/bpm
Infant > 220/bpm
Pale or Cyanotic
Diaphoresis
Tachypnea
Vomiting
Hypotension
Altered Level of
Consciousness
Pulmonary Congestion
Syncope












Heart disease (Congential)
Hypo / Hyperthermia
Hypovolemia or Anemia
Electrolyte Imbalance
Anxiety/Pain/Emotional stress
Fever / Infection / Sepsis
Hypoxia
Hypoglycemia
Medication / Toxin / Drugs
Pulmonary embolus
Trauma
Tension Pneumothorax
Universal Patient
Care Protocol
P
Stable
M
Contact Medical
Control
Cardiac
Monitor
P
Unstable
M
I
IV Protocol
P Valsalva Manv.
P
M
Adenosine
.1mg/kg then
.2 mg/kg
Contact Medical
Control
Pre- Arrest
I
P
I
IV Protocol
I
M
Contact Medical
Control
M
P
Cardioversion
0.5 joules/ kg.
P
P
Cardioversion
1-2 joules/ kg.
P
P
M
Pearls:






Exam: Mental Status, HEENT, Skin, Lung, Heart, Abdomen, Back, Extremities, Neuro.
Carefully evaluate the rhythm to distinguish Sinus Tachycardia, Supraventricular Tachycardia, and
Ventricular Tachycardia.
Separating the child from the caregiver may worsen the child’s clinical condition.
Pediatric paddles should be used in children < 10kg or Broselow-Luten color Purple.
Continuous pulse oximetry is required for all SVT patients if available.
Document all rhythm changes with ECG strips and obtain monitor strips with each intervention.
Revised: 07/11/2011
M. Stover, MD
55
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
EMT
Intermediate
Paramedic
Medical Control
Trauma
Protocols
Revised: 07/11/2011
M. Stover, MD
56
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
EMT
Intermediate
Paramedic
Medical Control
Bites and Envenomations
History:







Signs and Symptoms:
Type of bite or sting
Description or bring
creature / photo with
patient for identification
Time, location, size of
bite/sting
Previous reaction to bite /
sting
Domestic vs Wild
Tetanus and Rabies risk
Immunocompromised
patient







Differential:
Rash, skin break,
wound
Pain, soft tissue
swelling, redness
Blood oozing from bite
wound
Evidence of infection
Shortness of breath,
wheezing
Allergic reaction,
hives, itching
Hypotension or shock








Animal bite
Human bite
Snake bite (poisonous)
Spider bite (poisonous)
Insect sting / bite (bee,
wasp, ant, tick)
Infection risk
Rabies risk
Tetanus risk
Universal Patient
Care Protocol
No
Contact Animal
Control
(if required)
EMS
Transport?
Yes
Immobilize
Area and Limb
Allergic
Reaction?
Yes
Allergic Reaction
Protocol
M
Pearls:













No
Pain Control
Protocol
Contact Medical
M
Control
Exam: Mental Status, HEENT, Skin, Lung, Heart, Abdomen, Back, Extremities (location of injury), and Neuro exam if
systemic effects are noted.
Human bites are much worse than animal bites due to normal mouth bacteria.
Carnivore bites are much more likely to become infected and have risk of rabies exposure.
Cat bites may progress to infection rapidly due to a specific bacterium.
Poisonous snakes in our area are of the pit viper family: rattlesnake, copperhead, and water moccasin.
Coral snake bites are rare: Very little pain…but very toxic. “Red on yellow – Kill a fellow, red on black – venom they lack”.
Amount of envenomation is variable, generally worse with larger snakes and early spring.
If no pain or swelling, envenomation is unlikely.
Black widow spider bites tend to be minimally painful, but over a few hours, muscular pain and severe abdominal pain may
develop (spider is black with red hour glass on belly).
Brown Recluse spider bites are minimally painful to painless. Little reaction is noted initially but tissue necrosis at the site
of the bite may develop over the next few days (brown spider with fiddle shape on back).
Evidence of infection: swelling, redness, drainage, fever, red streaks proximal to wound.
Immuno-compromised patients have an increased risk for infection: diabetes, chemotherapy, transplants,…
Consider contacting the South Carolina Poison Control Center for guidance.
Revised: 07/11/2011
M. Stover, MD
57
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
EMT
Intermediate
Paramedic
Medical Control
Aquatic Life
Universal Patient
Care Protocol
Yes
Allergic Reaction
Allergic Reaction
Protocol
No
Attempt to Identify
Type of Aquatic
Life Involved
Jelly Fish
Sea Urchins/ Sea
Cucumbers/
Starfish
Stingrays
Rinse with
F
F
Seawater NOT
R
R
Freshwater
F
R
F
R
Apply copius
amounts of vinegar
F
R
F
R
Remove Tentacles
with Forceps
F
R
F Gently Shave Affected F
R
Area
R
Irrigate with
NaCl
F
R
Immerse area
F
in Warm water
R
110-115 degrees F
F Remove spines F
R with forceps R
F
R
F
Cover with
F
R Sterile Dressing R
P
Pain Control
Protocol
F
R
Immerse area
F
in Warm water
R
110-115 degrees F
P
Pain Control
Protocol
P
P
M Contact Medical Control M


Jelly Fish- Venom is deposited by organelles called nematocysts. DO NOT APPLY FRESH WATER!
Fresh water causes osmotic shock to organelles and will release any venom still in nematocysts. Vinegar
is 5% acetic acid, which inactivates nematocysts.
Stingrays- Whip like tail impales the foot. Can even penetrate shoes. Many spines on tail that contain
venom glands. Pieces may remain hidden in the wound. Toxin inactivated by heat.
Revised: 07/11/2011
M. Stover, MD
58
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
EMT
Intermediate
Paramedic
Medical Control
Burns
History:








Signs and Symptoms:
Type of Exposure
(heat, gas, chemical)
Inhalation injury
Time of injury
Past medical history
Medications
Other trauma
Loss of consciousness
Tetanus /
Immunization status







Differential:
Burns, pain, swelling
Dizziness
Loss of consciousness
Hypotension / shock
Airway compromise /
distress
Singed facial or nasal
hair
Hoarseness / wheezing







Superficial (1st degree)
red and painful
Partial thickness (2nd
degree) blistering
Full thickness (3rd
degree) painless and
charred or leathery skin
Chemical
Thermal
Electrical
Radiation
Universal Patient
Care Protocol
Remove
Jewelry
Thermal
Chemical
If <10% BSA
Cool down with
Normal Saline
Eye Involvement?
Continuous Saline
Flush
Cover with dry
sheet or dressing
Remove Clothing
Expose Area
Flush Area with
Normal Saline for
10- 15 minutes
I
IV Protocol
Bolus
I
P
Pain Control
Protocol
P
M







Contact Medical
Control
M
Exam: Mental Status, HEENT, Neck, Skin, Lung, Heart, Abdomen, Back, Extremities, Neuro.
Critical Burns: > 25% body surface area (BSA); 3’ burns > 10% BSA; 2’ and 3’ burns to face, eyes, hands or feet; electrical
burns; respiratory burns; deep chemical burns; burns with extremes of age or chronic disease; and burns with associated
major traumatic injury. Early intubation is required in significant inhalation injuries.
Potential CO exposure should be treated with 100% oxygen.
Circumferential burns to extremities can cause vascular compromise secondary to soft tissue swelling.
Burn patients are prone to hypothermia – Never apply ice or try to cool burns that involve >10% BSA.
Do not over look the possibility for child abuse with children and burn injuries or of multiple system trauma.
See appendix for rule of nines.
Revised: 07/11/2011
M. Stover, MD
59
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
EMT
Intermediate
Paramedic
Medical Control
Drowning/ Near Drowning
History:
 Submersion in water
regardless of depth
 Possible history of
trauma ie: diving board
 Duration of immersion
 Temperature of water
Signs and Symptoms:
 Unresponsive
 Mental status changes
 Decreased or absent
vital signs
 Vomiting
 Coughing
Differential:
 Trauma
 Pre-existing medical problem
 Pressure injury (diving)
Barotrauma
Decompression sickness
Universal Patient
Care Protocol
F
R
Spinal
Protocol
F
R
I
IV Protocol
I
Monitor and
Reassess
P
Resp. Distress?
Wheezing Albuterol & Atrovent
Pulmonary Edema CPAP
M
P
Contact Medical
M
Control
Pearls:

Exam: Trauma Survey, Head, Neck, Chest, Pelvis, Abdomen, Back, Extremities, Neuro

With cold water no time limit – resuscitate all with CPR and one round of drugs until patient is
warmed.

All victims should be transported for evaluation due to potential for worsening over the next several
hours.

Drowning is a leading cause of death among would-be rescuers.

Allow appropriately trained and certified rescuers to remove victims from areas of danger.

With pressure injuries (decompression / barotraumas), consider transport or availability of a hyperbaric
chamber.
Revised: 07/11/2011
M. Stover, MD
60
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
EMT
Intermediate
Paramedic
Medical Control
Electrical Injuries
History:
 Lightening or electrical l
exposure
 Single or multiple
victims
 Other trauma secondary
from a fall from
electrical highwire or
MVC into power pole
with lines down
 Voltage and current
(AC / DC)
Signs and Symptoms:

Burns

Pain

Entry and exit wounds

Hypotension or shock

Arrest
Differential:
 Cardiac Arrest
 Seizure
 Burns (see Burn Protocol)
 Multiple trauma
Universal Patient
Care Protocol
P
12 Lead
ECG if available
P
I
IV Protocol
Bolus
I
Focused History
and Exam
F
R







Dressings
P
Pain Control
Protocol
M
Contact Medical
Control
F
R
P
M
Exam: Mental Status, HEENT, Neck, Lung, Heart, Abdomen, Back, Extremities, Neuro
Ventricular fibrillation and asystole are the most common dysrhythmias.
Damage is often hidden; the most severe damage will occur in muscle, vessels and nerves.
In a mass casualty lightening incident, attend to victims in full arrest first. If the victim did not
arrest initially, it is likely they will survive.
Do not overlook other trauma (i.e. falls).
Lightening is a massive DC shock most often leading to asystole as a dysrhythmia.
In lightening injuries, most of the current will travel over the body surface producing flash burns.
Revised: 07/11/2011
M. Stover, MD
61
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
EMT
Intermediate
Paramedic
Medical Control
Extremity Trauma
History:
 Type of injury
 Mechanism: crush /
penetrating / amputation
 Time of injury
 Open vs. closed wound /
fracture
 Wound contamination
 Medical history
 Medications
Signs and Symptoms:
 Pain, swelling
 Deformity
 Altered sensation /
motor function
 Diminished pulse /
capillary refill
 Decreased extremity
temperature
Differential:
 Abrasion
 Contusion
 Laceration
 Sprain
 Dislocation
 Fracture
 Amputation
U n iv e rs a l P a tie n t
C a re P ro to c o l
F
R
C o n tro l B le e d in g
W o u n d C a re
F
R
L ife o r L im b
T h re a te n in g In ju ry
I
IV P ro to c o l
I
P a in C o n tro l
P ro to c o l
A m p u ta tio n
F
R
P la c e A m p u ta te d P a rt in P la s tic B a g
K e e p P a rt C o o l, B u t N o t in D ire c t C o n ta c t w ith Ic e
W ra p w ith m o is t s te rile d re s s in g
M
C o n ta c t M e d ic a l
C o n tro l
F
R
M
Pearls:
 Exam: Mental Status, Extremity, Neuro
 In amputations, time is critical. Transport and notify medical control immediately, so that
the appropriate destination can be determined.
 Hip dislocations and knee and elbow fractures / dislocations have a high incidence of
vascular compromise.
 Urgently transport any injury with vascular compromise.
 Blood loss may be concealed or not apparent with extremity injuries.
 Lacerations must be evaluated for repair within six hours from the time of injury.
Revised: 07/11/2011
M. Stover, MD
62
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
EMT
Intermediate
Paramedic
Medical Control
Head Trauma
History:
 Time of injury
 Mechanism: blunt /
penetrating
 Loss of consciousness
 Bleeding
 Medical history
 Medications
 Evidence of multi-trauma
 Helmet use or damage
to helmet
Signs and Symptoms:
 Pain, swelling, bleeding
 Altered mental status
 Unconscious
 Respiratory distress / failure
 Vomiting
 Significant mechanism of
injury
Differential:
 Skull fracture
 Brain injury (concussion,
contusion, hemorrhage, or
laceration)
 Epidural hematoma
 Subdural hematoma
 Subarachnoid hemorrhage
 Spinal injury
 Abuse
Universal Patient
Care Protocol
Isolated Head
Trauma
No
Yes
Multiple Trauma
Protocol
Spinal
F
Immobilization
R
Protocol
F
R
I
I
IV Protocol
Pt. Alert &
Responsive
No
Yes
Is pt protecting
airway?
Yes
Maintain SPO2
>90%
Yes
B
Blood
Glucose
No
P
Seizure?
Lidocaine 100 mg &
Valium 10mg
Consider Versed 5mg
IV bolus
P
B
No
Seizure Protocol
P
Monitor and
Reassess
M
Contact Medical
Control
Intubate / Ventilate
Maintain CO2 @ 30-35w/
capnography if available
P
M



Exam: Mental Status, HEENT, Lung, Heart, Abdomen, Back, Extremities, Neuro
If GCS < 12 consider Air/Rapid Transport and if GCS < 9 intubation should be anticipated.
Increased intracranial pressure (ICP) may cause hypertension, irregular respirations and bradycardia (Cushing’s
Response) is the hallmark of herniation syndrome.

Hypotension usually indicates injury or shock unrelated to the head injury and should be aggressively treated.

The most important item to monitor and document is a change in the level of consciousness.

Consider restraints if necessary for patient’s and/or personnel’s protection per the Restraint Protocol.

Limit IV fluids unless patient is hypotensive (systolic BP < 90).

Concussions are periods of confusion or LOC associated with trauma, which may have resolved by the time EMS
arrives. Any prolonged confusion or mental status abnormality that does not return to normal within 15 minutes or any
Revised:
07/11/2011
Stover,
documented
loss of consciousness should be M.
evaluated
by a MD
physician ASAP.
63
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
EMT
Intermediate
Paramedic
Medical Control
Hyperthermia
History:
 Age
 Exposure to increased
temperatures and/or
humidity
 Past medical history /
medications
 Extreme exertion
 Time and length of
exposure
 Poor PO intake
 Fatigue and/or muscle
cramping
Signs and Symptoms:
 Altered mental status or
unconsciousness
 Hot, dry or sweaty skin
 Hypotension or shock
 Seizures
 Nausea
Differential:
 Fever (infection)
 Dehydration
 Medications
 Hyperthyroidism (Storm)
 Delirium tremens (DT’s)
 Heat cramps
 Heat exhaustion
 Heat stroke
 CNS lesions or tumors
Universal Patient
Care Protocol
F
R
Document
Temperature
F
R
Remove Heat Source
Remove Clothing
Apply room temperature
water to skin and increase
air flow around patient
I
IV Protocol
I
Monitor and
Reassess
Appropriate
Protocol
M
Pearls:









Contact Medical
M
Control
Exam: Mental Status, HEENT, Skin, Lungs, Heart, Neuro.
Extremes of age are more prone to heat emergencies (i.e. young and old).
Predisposed by use of: tricyclic antidepressants, phenothiazines, anticholinergic medications, and alcohol.
Cocaine, Amphetamines, and Salicylates may elevate body temperatures.
Sweating generally disappears as body temperature rises above 104 F (40 C).
Intense shivering may occur as patient is cooled.
Heat Cramps consist of benign muscle cramping secondary to dehydration and is not associated with an elevated
temperature.
Heat Exhaustion consist of dehydration, salt depletion, dizziness, fever, mental status changes, headache, cramping,
nausea and vomiting. Vital signs usually consist of tachycardia, hypotension, and an elevated temperature.
Heat Stroke consists of dehydration, tachycardia, hypotension, temperature > 104 F (40 C), and an altered mental
status.
Revised: 07/11/2011
M. Stover, MD
64
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
EMT
Intermediate
Paramedic
Medical Control
Hypothermia
History:
 Past medical history
 Medications
 Exposure to environment
even in normal
temperatures
 Exposure to extreme cold
 Extremes of age
 Drug use: Alcohol,
barbiturates
 Infections / Sepsis
 Length of exposure /
wetness
Signs and Symptoms:
 Cold, clammy
 Shivering
 Mental status changes
 Extremity pain or sensory
abnormality
 Bradycardia
 Hypotension or shock
Differential:
 Sepsis
 Environmental
exposure
 Hypoglycemia
 CNS dysfunction
Stroke
Head injury
Spinal cord injury
U n iv e r s a l P a tie n t
C a r e P r o to c o l
R e m o v e w e t c lo th in g
T e m p e r a tu r e
< 9 5 F (< 3 5 C )
Yes
H a n d le G e n tly
Hypothermic patients in
cardiac arrest should
receive only one
defibrillation and only one
round of medications until
temp is
> 85 F
Hot Packs and
B la n k e ts
I
IV P r o to c o l
I
No
B
O b ta in B G L
A p p r o p r ia te
P r o to c o l
B
M
C o n ta c t M e d ic a l
C o n tr o l
M
Pearls:





Exam: Mental Status, Lung, Heart, Abdomen, Extremities, Neuro.
NO PATIENT IS DEAD UNTIL THEY ARE WARM AND DEAD!!!!!!!
Defined as core temperature < 35 C (95 F).
Extremes of age are more susceptible (i.e. young and old).
With temperature less than 31 C (88 F) ventricular fibrillation is common cause of death. Handling
patients gently may prevent this (rarely responds to defibrillation).

If the temperature is unable to be measured, treat the patient based on the suspected temperature.

Hypothermia may produce severe bradycardia.

Shivering stops below 32 C (90 F).
Revised:
07/11/2011
M. Stover, MD

Hot packs can be activated and placed in the armpit and groin area if available.

Care should be taken not to place the packs directly against patient’s skin.
 Consider withholding CPR if patient has organized rhythm. Discuss with medical control.
65
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
EMT
Intermediate
Paramedic
Medical Control
Multiple Trauma
History:

Time and mechanism of injury

Damage to structure or vehicle

Location in structure or vehicle

Others injured or dead

Speed and details of MVC

Restraints / protective equipment

Past medical history

Medications
Signs and Symptoms:
 Pain, swelling
 Deformity, lesions, bleeding
 Altered mental status or
unconscious
 Hypotension or shock
 Arrest
Differential: (Life threatening)
 Chest: Tension Pneumothorax
Flail chest
Pericardial tamponade
Open chest wound
 Intra-abdominal bleeding
 Pelvis / Femur fracture
 Spine fracture / Cord injury
 Head injury (see Head Trauma)
 Extremity fracture / Dislocation
 HEENT (Airway obstruction)
 Hypothermia
U n iv e r s a l P a tie n t
C a r e P r o to c o l
F
R
R a p id T r a u m a
A ssessm ent
F
R
C o n s id e r r a p id a ir
tr a n s p o r t /
T r a n s p o r t to
tr a u m a c e n te r
F
R
S p in a l
P r o to c o l
F
R
I
IV P r o to c o l
I
V ita l S ig n s /
P e r fu s io n
A b n o rm a l
I
N S B o lu s
N o rm a l
O n g o in g
A ssessm ent
I
R eassess
A ir w a y P r o to c o l
P
C o n tin u e d H y p o te n s io n
W itn e s s e d T r a u m a tic A r r e s t
C o n s id e r C h e s t D e c o m p r e s s io n
M
P
C o n ta c t M e d ic a l
C o n tr o l
M
Pearls:




Exam: Mental Status, Skin, HEENT, Heart, Lung, Abdomen, Extremities, Back, Neuro.
Mechanism is the most reliable indicator of serious injury.
In prolonged extrications or serious trauma, consider air transportation for transport times and
the ability to give blood.
Do not overlook the possibility of associated domestic violence or abuse.
Revised: 07/11/2011
M. Stover, MD
66
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
EMT
Intermediate
Paramedic
Medical Control
Spinal Immobilization Clearance
Neuro Exam: Any focal deficit?
Yes
No
Patient > 65 or < 5 with SIGNIFICANT
traumatic mechanism?
Yes
No
Alertness: Any mental alteration in
patient?
Yes
No
Intoxication: Any evidence of
drugs or alcohol?
Yes
No
Distracting Injury: Any painful
injury that might distract the
patient from the pain of a spinal
injury?
Yes
No
P
Spinal Exam: Point tenderness or
P
pain to ROM in spinal process?
Yes
No
P Spinal Immobilization Not Required P












Spinal Immobilization Required
Exam: Mental Status, Skin, Neck, Heart, Lungs, Abdomen, Back, Extremities, Neuro
Significant mechanism includes high-energy events such as ejection, high falls, and abrupt deceleration crashes and may indicate the need
for spinal immobilization in the absence of symptoms.
Range of motion (ROM) should NOT be assessed if patient has midline spinal tenderness. Patient’s range of motion should not be assisted.
The patient should touch their chin to their chest, extend their neck (look up), and turn their head from side to side (shoulder to shoulder)
without spinal process pain.
The acronym “NSAIDS” should be used to remember the stops in this protocol.
“N” = Neurologic exam. Look for focal deficits such as tingling, reduced strength, or numbness in an extremity
“S” = Significant mechanism in extremes of age
“A” = Alertness. Is patient oriented to person, place, time, and situation? Any change to alertness with this incident?
“I” = Intoxication. Is there any indication that the person is intoxicated (impaired decision making ability)?
“D” = Distracting injury. Is there any other injury which is capable of producing significant pain in this patient?
“S” = Spinal exam. Look for point tenderness in any spinal process or spinal process tenderness with range of motion.
The decision to NOT implement spinal immobilization in a patient is the responsibility of the paramedic.
In very old and very young patients, a normal exam may not be sufficient to rule out spinal injury.
Revised: 07/11/2011
M. Stover, MD
67
Georgetown County Emergency Services
Patient Care Protocols and Standing Orders
FR
EMT
Intermediate
Paramedic
Medical Control
WMD-Nerve Agent Protocol
History:
 Exposure to chemical, biologic,
radiologic, or nuclear hazard
 Potential exposure to unknown
substance/hazard
Signs and Symptoms:
 Visual Distrubances
 Headache
 Nausea/Vomiting
 Salivation
 Lacrimation
 Respiratory Distress
 Diaphoresis
 Seizure Activity
 Respiratory Arrest
Differential:
 Nerve agent exposure (e.g.,
VX, Sarin, Soman, etc)
 Organophosphate exposure
(pesticide)
 Vesicant exposure
(e.g.,Mustard Gas, etc.)
 Respiratoy irritant Exposure
(e.g., Hydrogen Sulfide,
Ammonia, Chlorine, etc.)
Ensure Scene Safety and Proper PPE
Universal Patient Care Protocol
Obtain history of exposure
Observe for specific toxidromes
Initiate triage and/or decontamination as
indicated.
Minor symptoms:
Salivation, Lacrimation,
Visual Disturbances
P
Atropine 2mg IV/IM q 5 min.
(0.02-0.05 mg/kg)
P
Until symptoms resolve
Mark One Kit IM
x 3 rapidly
(See Pediatric Doses Below)
Monitor for appearance of
major symptoms




Major Symptoms:
Altered Mental Status,
Seizures, Respiratory Distress,
Respiratory Arrest
Assess for presence of major or minor
symptoms
P
If Seizures:
Valium 5mg IV/IM/PR
may repeat up to 10mg
P
P
Atropine 2mg IV/IM q 5 min.
(0.02-0.05 mg/kg)
Until symptoms resolve
P
In the face of a bona fide attack, begin with 1 Mark One kit for patients less than 7 years of age, 2 Mark one kits from 8 to 14 years of
age, and 3 Mark One kits for patients 15 years of age and over.
For patients with major symptoms, there is no limit for atropine dosing.
Carefully evaluate patients to ensure they are not suffering from exposure to another agent (e.g., narcotics, vesicants, etc.)
In the absence of Mark One kits, 0.5 mg Atropine pt < 40 lbs., 1 mg dose pt between 40-90 lbs., and 2 mg dose for pts > 90 lbs.
Revised: 07/11/2011
M. Stover, MD
68