Heart of Texas Area Regional
Advisory Council (HOTRAC)
Trauma Service Area (TSA) - M
Regional Trauma Plan
Heart of Texas Regional Advisory Council (HOTRAC)
405 Londonderry, Suite 201
Waco, TX 76712
Email: info@hotrac.org
For the state service delivery area including
Bosque, Falls, Hill, Limestone, and McLennan Counties.
Phone: (254) 761-7890
Fax: (254) 761-7895
HOTRAC Regional Trauma System Plan
Revised May 2010
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Table of Contents
Introduction
Organization
Service Area/Designated Facilities
Regional Plan
Board of Directors
HOTRAC Bylaws
TSA M – EMS Services
TSA M – Air Medical Providers
TSA M – Hospital Facilities
System Participation
System Access
Communications
Regional Medical Oversight & Control
Pre-hospital Triage
Off-line Medical Control Trauma Triage Criteria
Classification of Trauma Patients (Pre-hospital)
Helicopter Activation
Emergency Department Diversion
Facility Bypass
Facility Triage Criteria
Classification of Trauma Patients (Facility)
Inter-hospital Transfers
Regional Trauma Alert Form
System Performance Improvement (PI)
Air Medical PI Form
EMS PI Form
Trauma PI Form
Statement of Confidentiality
Appendix A
EMS Treatment Guidelines (separate Table of Contents)
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Introduction
Organization and Service Area
Organization
The Heart of Texas Regional Advisory Council (HOTRAC) is comprised of the Central Texas counties of Bosque, Falls, Hill,
Limestone, and McLennan. The HOTRAC was organized and completed the incorporation process in 1994, and became
an approved 501 (c)(3) organization in 1995.
The HOTRAC mission is to develop a trauma care network for our five-county area and to improve the level of care
provided to injured persons living or traveling through this region. Together, through the work of its standing committees,
HOTRAC member organizations (hospitals, first responder organizations, EMS providers, air medical providers, emergency
management, public health, etc) work cooperatively to ensure that quality care is provided to ill/injured persons by welltrained, well-equipped pre-hospital and hospital care professionals. The Council provides injury prevention & public
awareness education to the public, and trauma and emergency education to health care providers in each of the five
counties.
Service Area/Designated Facilities
The HOTRAC Service Area is comprised of four rural counties (Bosque, Falls, Hill, and Limestone) and one urban county
(McLennan). The terrain in this region is primarily Black-land prairie with rolling hills located in the Bosque county area.
Interstate 35, a heavily traveled transportation artery, transects McLennan and Hill Counties and is the source of many
multi-vehicular crashes annually. Also heavily traveled State Highway 6 traverses McLennan, Falls and Bosque counties,
while Limestone counties transportation primarily occurs via farm-to-market roads.
Bosque County encompasses 989.3 square miles and has a population of 17,204 lives. Goodall-Witcher Healthcare
Foundation in Clifton is a DSHS-designated Level IV Trauma Facility and is located in the south-central portion of the
county. Goodall-Witcher is a 40-bed acute care facility located in Clifton, Texas and received Level IV Trauma Facility
designation originally in 1995. Goodall-Witcher has surgical capability and was the first hospital to become a designated
trauma facility in TSA-M. One EMS service provides pre-hospital care in Bosque County.
Hill County is located in the northern portion of the region and encompasses 962 square miles. The county population is
32,321 persons. Hill County contains two acute care hospitals: Hill Regional Hospital (a Level IV DSHS-designated trauma
facility), and Lake Whitney Medical Center (a non-designated facility). Lake Whitney Medical Center currently has no plans
of seeking trauma facility designation. Hill Regional Hospital is a 92-bed acute care facility with surgical capability, which
received its Level IV Trauma Facility designation. Lake Whitney Medical Center is located in the western portion of the
county. Lake Whitney Medical Center is a 49-bed acute care facility. Five EMS providers provide pre-hospital care in Hill
County.
Located in the eastern-most portion of the region, Limestone County includes 909 square miles of primarily farm and ranch
land. The population in Limestone County is 22,051 persons. Parkview Regional Hospital received its Level IV designation
originally in 1996 and is a 77-bed acute care facility with surgical capability. Limestone Medical Center is a 20-bed acute
care facility (which does not have surgical capability) and received its Level IV designation originally in 1996. Pre-hospital
care is provided primarily by three EMS services.
Falls County is located in the southern most part of this Region and encompasses 769 square miles. The county population
is 18,576. Falls Community Hospital in Marlin is a DSHS-designated Level IV Trauma Facility with 44 beds and is centrally
located in the county. One EMS service provides pre-hospital care in Falls County.
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McLennan County is the only urban county in the region and covers 1041.9 square miles of Central Texas and has a total
population of 213,517 persons. Waco is the largest city in the county (population approximately 115,000) and contains two
acute care hospitals: Hillcrest Baptist Medical Center (a Level II DSHS-designated trauma facility), and Providence Health
Center (a non-designated facility). Providence Health Center is a 230-bed acute care facility with surgical capability.
Providence Health Center currently has no plans of seeking trauma facility designation. The other three hospitals located in
Waco are psychiatric facilities. These facilities are Central Texas Veterans Healthcare System – Waco Campus, the Waco
Center for Youth (a state facility) and the DePaul Center.
Hillcrest Baptist Medical Center, in Waco, Texas is a 237-bed acute care facility. HBMC has had a functional trauma
program since 1996 and currently has three (3) trauma surgeons on staff, providing 24-hour per day trauma care. Hillcrest
Baptist Medical Center is the lead trauma facility for the HOTRAC region. There are five EMS services and multiple First
Responder Organizations in McLennan County.
Regional Plan
This Plan has been developed in accordance with Texas Department of State Health Services Bureau of Emergency
Management guidelines and procedures for implementation of a comprehensive Emergency Medical Services (EMS) and
Trauma System plan. This plan does not establish a legal standard of care, but rather is intended as an aid to decisionmaking in general patient care scenarios. It is not intended to supersede the physician’s prerogative to order treatment.
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Heart of Texas Regional Advisory Council
TSA - M
2010 Board of Directors
Executive Committee
1.
2.
3.
4.
Chair
Vice Chair
Secretary
Treasurer
Lori Boyett, HBMC
Steve Clinkscales
Joyce McDowell, G-W
Tracy Brand, HBMC
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Other Members
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Immediate Past Chair
Anita Diebenow, Goodall-Witcher
Hillcrest representative
Dr. Ted Smith, HBMC
Providence representative
Eileen Bohanon, Providence
Rural Hospital representative Marcy McFarland, Parkview
Primary EMS agency for City of Waco representative Dale Yates, ETMC-EMS
Rural EMS representative
Linda Catena, North Bosque EMS
FRO representative
Tommy Womack, East Lake Limestone VFD
Emergency Management Member-at-Large
Frank Patterson, Waco-Mclennan County OEM
Physician-at-Large
Dr. John Hamilton, Providence
Community Member-at-Large Diane Fraley
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THE HEART OF TEXAS REGIONAL ADVISORY COUNCIL
Trauma Service Area (TSA) M
BYLAWS
Article I – Name
This organization shall be known as the Heart of Texas Regional Advisory Council (HOTRAC). The HOTRAC Trauma
Service Area includes the counties of Bosque, Falls, Hill, Limestone, and McLennan. The HOTRAC Trauma Service Area is
also referred to as TSA M.
Article II – Mission Statement
To provide the infrastructure and leadership necessary to sustain an inclusive trauma & emergency medical system within
our Trauma Service Area by the following actions:
A. Assist member organizations in achieving the highest level of trauma and emergency care they are capable of
providing, which will result in a decrease in morbidity and mortality and ultimately improve the injured patient’s
outcome.
B. Encourage activities designed to promote cooperation between member organizations and provide a forum to
resolve conflicts regarding the care of the injured patient.
C. Provide and facilitate educational programs for the public to increase awareness regarding an inclusive trauma
system with a heavy emphasis on prevention activities.
D. Assist in the development, acquisition, and operation of facilities to enhance the provision of emergency, trauma,
and acute care in TSA M.
To provide coordination of acute medical services in the mass casualty and disaster settings.
A. Coordinate emergency and disaster preparedness and response activities between area hospitals, EMS providers,
public health, and other healthcare entities.
B. Provide resources to the Office(s) of Emergency Management regarding acute medical services.
C. Participate in the Regional Medical Operations Center and/or the HOTCOG Regional Coordination Center to
coordinate disaster activities between area hospitals and pre-hospital providers.
Article III – Purpose
Section 1. The purpose of this organization is to:
A.
Advance and improve access and delivery of healthcare to patients of all ages in TSA M.
B.
Decrease morbidity and/or mortality which results from traumatic injury and medical emergencies
(ie. stroke,AMI).
C.
Encourage activities designated to promote cooperation and resolve conflicts between
member organizations.
D.
Coordinate funding streams for equipment, education, and programs to assist trauma and
emergency care providers in TSA M.
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E.
Maintain Trauma, Stroke, and Cardiac System Plans for HOTRACbased on standard guidelines for
comprehensive system development.
F.
Improve public awareness of the methods of accessing the trauma care system, and preventing
injury, stroke awareness, etc.
G.
Coordinate responses to mass casualty, evacuation, and disaster events.
Article IV – RAC Membership
Section 1.
HOTRAC membership encompasses a wide range of professionals and citizens concerned about the
health and well-being of the community as it relates to trauma, emergency services and disaster
preparedness. Voting membership requires that the member represent a hospital or disaster service, an
individual who is involved with trauma, emergency, or disaster care, an emergency medical service, an
educational agency involved in training purposes for trauma, emergency, or disaster preparedness, or a
service which provides care to victims of trauma, emergency, and/or disaster. A voting member must
practice and/or reside within the boundaries of TSA M.
Section 2.
Condition of Membership
A. A member entity must complete a Member Information Form.
B. A member who resigns in good standing may reapply for membership. Resignations must be
submitted in writing to the Board of Directors via the Executive Director.
C. A member failing to actively participate in HOTRAC activities as defined by by-laws may be removed
from the membership by a majority vote of the Board of Directors. Said member may appeal this action
for re-instatement to the General Assembly. If re-instatement is approved by two-thirds of voting
entities present at the General Assembly, the issue causing removal must be remedied prior to full reinstatement.
D. Prior to removal from the membership by the Board of Directors, the Executive Director will notify said
member that they are not compliant with HOTRAC bylaws and participation requirements. If
participation does not increase, a certified letter will be sent to that member organization at the last
known mailing address. If the issue continues, the Executive Director will bring said member’s name to
the Board of Directors for removal.
Section 3.
Member entities will be allowed one vote at the General Assembly meetings. The vote may only be cast by
one of the three persons listed on the entity’s Membership Form.
Section 4.
Members are listed in Appendix A.
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Section 5.
A.
Active Participation in the RAC is defined as the following:
EMS Provider Agencies
1.
2.
3.
4.
5.
6.
7.
B.
Hospital Members
1.
2.
3.
4.
5.
6.
7.
8.
9.
C.
Will have representation at 75% of General Assembly Meetings.
Will participate in a minimum of one (1) standing committee and will have representation at
75% of that committee meetings.
Will submit information into the Trauma Registry and attend any meeting when the agency
has a referral on the agenda.
Will demonstrate participation in at least one HOTRAC sanctioned prevention activity
annually and submit documentation of such.
Will submit required Performance Improvement data upon request.
Will have physician representation at 75% of the Physician Advisory Committee meetings.
Will participate in one community disaster preparedness drill per year.
Will have representation at 75% of General Assembly Meetings.
Will participate in a minimum of one (1) standing committee and will have representation at
75% of that committee meetings.
If applicable, will have Trauma Coordinator attend at least 75% of the Hospital Care &
Management Committee as well as participate in the Trauma System Plan development.
If applicable, will have Stroke Coordinator attend at least 75% of the Stroke Committee as
well as participate in the Stroke System Plan development.
Will have physician representation at 75% of Physician Advisory Committee Meetings.
Will demonstrate participation in at least one HOTRAC sanctioned prevention activity
annually and submit documentation of such.
Will submit information into the Trauma Registry and attend any meeting when the agency
has a referral on the agenda.
Will participate in 75% of scheduled preparedness activities.
In the event of emergency healthcare activations, will participate as required by the Health
& Medical Annex of the County Emergency Operations Plans and/or the Health & Medical
Appendix of the Regional Response Plan.
Non-EMS/Hospital Entities
1.
2.
3.
Will have representation at 75% of General Assembly Meetings.
Will participate in a minimum of one (1) standing committee and will have representation at
75% of that committee meetings.
Will participate in at least one (1) scheduled regional preparedness activity.
Meeting attendance may be met in person, via conference call, or via webinar.
D.
Each member entity will complete an annual Regional Needs Assessment by the 1st of March of
each year.
E.
Membership Dues must be paid in full by each member by the 1 st of March of each year.
Membership dues is charged as follows:
Hospitals - $500.00
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9-1-1 EMS Providers (including Air Medical) - $250.00
Other Members (i.e., FROs, Emergency Management, etc.) - $50.00
Individuals - $25.00
F.
Exceptions to the above requirements may be considered by the Board on an individual basis. An
entity seeking such an exception must submit, in writing, a request for the exception and provide
documentation to support the request.
Article V – The Board of Directors
Section 1.
The Board of Directors shall consist of the following:
Executive Committee
5.
6.
7.
8.
Chair
Vice Chair
Secretary
Treasurer
Other Members
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Immediate Past Chair
Hillcrest representative
Providence representative
Rural Hospital representative
Primary EMS agency for City of Waco representative
Rural EMS representative
FRO representative
Emergency Management Member-at-Large
Physician-at-Large
Community Member-at-Large
Employees (including the Executive Director) of the HOTRAC may not serve as a member of the Board of
Directors.
Section 2.
Quorum:
A quorum will be established by the presence of two-thirds of the board members in person or by video
teleconference and must include at least one (1) Executive Committee member.
An alternate representative (as defined in Section 4) will not count towards the constitution of a quorum.
Section 3.
Meetings (to include face-to-face, audio or video conference calls, and webinars):
The Board of Directors shall be held monthly. Additional meetings will be scheduled as needed.
The Chair may call a special meeting at any time with a 72 hour advance notice to the Board of Directors.
This notice may be sent by the Chair or the Executive Director electronically. A quorum is required for a
special called meeting.
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Section 4.
Attendance:
Board Members must attend at least 75% of the Board meetings per year. An alternate representative may
be designated to attend a Board meeting by the member. Alternate representatives may not cast that
entity’s vote and may not attend more than 25% of the scheduled board meetings.
Section 5.
Resignation/Succession
In the event that the Chairperson resigns or is removed from office prior to the term expiration, the Vice
Chair will immediately succeed the resigned/removed Chair.
A Board Member who does not comply with assigned responsibilities may be relieved of office by a majority
vote of the Board. Appointment of a replacement shall be made by the Chair with a majority vote of the
Board present at the meeting.
Any vacancies shall be filled for the balance of the unexpired term by the Chair with a majority vote of the
Board or be deferred to the General Assembly for decision. The Board Member who serves the unexpired
term will be eligible for reappointment twice.
Section 6.
Elections:
All Board Members shall serve 2-year terms.
Elections shall be held in November or December of each calendar year. Terms shall begin January 1 st of
the following year.
The Executive Committee will rotate on and off as follows:
A.
The Chair and Secretary positions will be elected in even numbered years.
B.
The Vice-Chair and Treasurer positions will be elected in odd numbered years.
C.
Election of Board members will be done by roll call at General Assembly
Nominations for all open board positions can be submitted to the Executive Director beginning thirty (30)
days prior to the November/December General Assembly. Additional nominations will also be accepted
from the floor the night of the elections.
Section 7.
The Board of Directors shall be empowered to employ personnel to conduct the business of the HOTRAC.
Section 8.
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The Board shall establish a Budget & Finance Committee. The Treasurer will serve as Chair of the Budget
& Finance Committee.
Section 9.
The Board of Directors shall develop and maintain policy statements that guide the functioning of the
HOTRAC. A policy shall receive final approval of the Board with a majority vote of those members present.
Copies of such policy statements shall be provided to the General Assembly upon final approval of the
Board of Directors at the following General Assembly meeting.
Article VI – Duties of Board Members (listed but not limited to)
Section 1.
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Section 2.
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Section 3.
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Executive Committee
Prepares & performs Executive Director’s evaluation at least annually (with input of Board)
Monitors credit card expenditures
Develops and reviews policies to present to the Board
Serves as the Committee for the Executive Director to take personnel issues
Serves as employee dispute arbitration
Approves grant application submission (Board would continue to approve contracts for signature)
Is responsible for interviewing an Executive Director when needed
Board of Directors:
Defines “active participation” of membership
Determines removal of RAC membership status
Reviews and accepts resignations of membership
Recommends & approves items for Executive Director’s evaluation
Accepts proposed bylaw revisions from membership
Serves as Fund Raising Committee
Reviews the Articles of Incorporation for any changes
Initiates bylaw changes as necessary
Is responsible for choosing an Executive Director when needed
The Chair shall:
Preside at all meetings of the General Assembly, Board of Directors, and any special meetings.
Facilitate development and achievement of organizational goals.
Make interim appointments as needed with the approval of the Board of Directors.
Sign all contracts, agreements, and other legal documents as needed after approval of the Board
of Directors.
Represent this organization at the Texas Department of State Health Services RAC Chair’s
Meeting or identifies a designee.
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Section 4.
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Section 5.
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Section 6.
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The Vice Chair shall:
Preside over HOTRAC activities in the absence of the Chair.
Perform duties as assigned by the Chair.
Assist in preparing any necessary reports or documentation required.
The Secretary shall:
Present the minutes of all proceedings of the Board and General Assembly meetings.
Handle all correspondence of the organization in the absence of the Executive Director.
Assist in preparing any necessary reports or documentation required.
The Treasurer shall:
Review and certify all financial business conducted by the HOTRAC including bank reconciliation.
Perform financial duties in the absence of the Executive Director.
Serve as Chair of the Board Budget and Finance Committee.
Assist in preparing any necessary reports or documentation required.
Article VII – Duties of the Executive Director
Section 1.
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The Executive Director shall:
Maintain a record of all financial business conducted by the HOTRAC in accordance with HOTRAC
polices/procedures and common accounting practice.
Prepare and submit financial reports to the Board and General Assembly at each of their meetings,
respectively.
Ensure that Board of Directors & General Assembly meeting minutes are made available to all
RAC membership and the Department of State Health Services EMS & Trauma Systems
Coordination as requested.
Make available copies of bylaws and the Trauma System Plan annually as requested.
Actively assist in seeking funding sources for the activities of the organization.
Prepare necessary reports or documentation required by government agencies or grant sponsors.
Gather information from the Committee Chairs and present to the Board
Prepare and submit annual budget projections to the Board and General Assembly.
Preside over meetings in which the Chair and Vice Chair are not available when a quorum is
present.
Article VIII – Standing and Ad Hoc Committees/Task Forces
Section 1.




The Committee Chairs shall:
Organize and conduct meetings as defined in the bylaws.
Facilitate the development and achievement of goals for their committee.
Ensure that written agendas and minutes are provided to committee members.
Provides the agendas, minutes, and sign-in sheets to the Executive Director for maintenance
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
Section 2.
A.
Assist in preparing any necessary reports or documentation required.
The Standing Committees and their missions are as follows:
Pre-hospital Committee

B.
Hospital Care & Management Committee

C.
To serve as a liaison for pre-hospital providers within TSA M to include the monitoring of
system development, coordination of activities, performance improvement, and pre-hospital
training.
To serve as a liaison between health care facilities within TSA M to include the monitoring of
system development, coordination of activities, performance improvement, and hospital
training.
Physicians Advisory Committee (a quorum constitutes a majority of serving physicians)




To monitor the performance of identified performance improvement indicators as it relates to
the quality of patient care.
Make recommendations regarding system enhancement and/or improvements.
Inter-local liaison committees may be formed to provide comprehensive review of issues with
greater local participation. Information/inquiries may be originated at either the Physicians
Advisory Committee or the other committees.
These meetings are closed since this committee is acting as the HOTRAC’s Quality
Improvement Committee.
D. Education/Injury Prevention Committee


To provide guidance for training within the Region to enhance trauma care standards in this
Region.
To provide guidance within the Region for injury prevention activities.
E. Emergency Preparedness & Response Committee

To coordinate preparedness and responses to acute medical mass casualty, evacuation, and
disaster situations.
F. Stroke Committee
a. To serve as a liaison to the acute care facilities and pre-hospital providers for initiatives issued
by the State of Texas to include but not limited to stroke care, facility designations, public
education, and training.
G. Pediatric Committee

To serve as a liaison to the acute care facilities and pre-hospital providers for initiatives issued
by the State of Texas to include but not limited to pediatric emergency care.
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To provide oversight and guidance for the Region regarding the Pediatric Objectives issued by
the State of Texas.
H. Cardiac Committee

Section 3.
To serve as a liaison to the acute care facilities and pre-hospital providers for initiatives issued
by the State of Texas to include but not limited to cardiac care, STEMI, public education, and
training.
Election of Committee Chairs and Vice Chairs
Each standing committee shall have an identified Chair and Vice Chair which will be selected by the
membership of that committee each year. This process will occur in November/December of each year in
conjunction with the election of open positions on the Board of Directors.
A. Each entity present will only have one vote.
B. Nominated individuals must leave the room during the voting process.
Section 4.
Each standing committee shall have at least 4 meetings per year and keep minutes of each meeting.
Meeting minutes may be obtained by any HOTRAC member from the Executive Director. The minutes may
be provided either in hard copy or electronically.
Section 5.
Each Standing Committee shall have a standing agenda item for Emergency Healthcare System Issues.
Section 6.
Ad Hoc Committees/Task Forces may be established and/or dissolved at the discretion of the Board. Ad
Hoc Committees/Task Forces are utilized to address issues that are limited in duration or cyclic in nature.
Article IX – General Assembly Meetings
Section 1.
Quorum
At least five (5) hospitals and six (6) EMS providers must be represented in addition to the one (1)
Executive Committee member and three (3) Board of Directors to constitute a quorum for a General
Assembly meeting.
Section 2.
Meetings
The General Assembly shall meet at least four (4) times per year on the Thursday following the Governor’s
EMS & Trauma Advisory Council (GETAC) meetings. When the General Assembly meeting falls on a
federal holiday, the meeting will be held the following Thursday.
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Any member of the Executive Committee or the Executive Director may call a special meeting with a
majority vote of the Board of Directors. A minimum of a two (2) week notice will be provided electronically
to all members on the General Assembly email list serve.
Section 3.
Attendance
See Article IV, Section 5 for the attendance requirements.
Article X – Funding
Section 1.
State mandated funds shall be allocated according to contract received by HOTRAC from the Department
of State Health Services. Any entity eligible according to State guidance must be classified as an active
participant as stated in Article IV, Section 5, in order to receive any funding.
Section 2.
Any grant funds received by the HOTRAC will be made available to those only member entities that are
active participants in HOTRAC as stated in Article IV, Section 5, in order to receive any funding.
Section 3.
Any member entity receiving funds through and/or from HOTRAC must provide required reports, support
documents, etc. as stated at the time the funds are received by the member entity. Failure to comply will
result in ineligibility of funding through and/or from HOTRAC for a period of not less than one (1) fiscal year
funding cycle.
Section 4.
Failure to comply with Article IV, Section 5 shall cause a member entity to become ineligible for funding
through and/or from HOTRAC for a period of not less than six (6) months and not more than twelve (12)
months.
Section 5.
All grant funds shall be considered “restricted”. “Restricted funds” are defined as those funds that must be
utilized as provided in a fully executed contract, grant application and/or award notice, or directed donation.
Any funds received that have not been “restricted” shall be considered “unrestricted” and may be utilized for
any type of expenditure. “Unrestricted funds” shall include but not limited to dues, donations, etc.
Article XI - Finance and Fiscal Responsibility Standards
Section 1.
The Heart of Texas Regional Advisory Council’s fiscal and operational years shall follow the calendar year.
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Section 2.
Budget preparation is achieved through needs assessments provided by the HOTRAC committees as well
as strategic direction provided by the Board. The Budget will be completed by the Executive Director and
the Board Budget and Finance Committee then presented for ratification at the November General
Assembly meeting.
Section 3.
All Checks must have two signatures. These signatures may be any combination of the Chair, Vice Chair,
Secretary, Executive Director, and one additional Board member to be determined by a majority vote of the
Board. The HOTRAC will maintain a minimum of two (2) checking accounts (“restricted” & “unrestricted”)
and may establish additional accounts as needed with approval of the Board of Directors.
Section 4.
Approval of expenditures must conform to the following schedule:
Amount
Approval Required
A.
$ 0 - $ 10,000.00
Executive Committee
B.
$ 10,000.01 – 100,000.00
Board only
C.
$ 100,000.01 or more
General Assembly
Any purchases and/or leases of real property, land, buildings, and vehicles shall be approved by a majority
vote of the General Assembly present at the meeting.
Section 5.
The Executive Director shall have the authority to establish charge accounts with advance approval the
Board of Directors.
The Executive Director shall have authority to maintain and utilize HOTRAC’s secured credit card with a
limit not to exceed $ 5,000.00 (five thousand dollars). A report must be provided upon request of the
Executive Committee. A report shall be provided to the Board and General Assembly as a part of the
financial statements.
Section 6.
The Executive Director may authorize expenditures associated with a specific grant if a budget was
submitted as part of the grant application process and the grant application was approved by the Board of
Directors upon completion or at notice of award.
Section 7.
Distribution of funds will be in accordance with State and Federal regulations.
HOTRAC Regional Trauma System Plan
Revised May 2010
Page 16
Section 8.
Annually an external audit shall be completed in accordance with State and Federal regulations.
Article XII – Alternative Dispute Resolution (ADR) Process
Section 1.
A. Any provider or individual representing a provider, service, or hospital that has a dispute in connection
with another provider or the HOTRAC itself (e.g., bylaws, trauma system plan, guidelines and
protocols, etc.) may formally voice its disapproval in writing. The written document will be addressed
by the Chair of the HOTRAC and/or the Executive Director.
B. A formal protest must contain the following information: a specific statement of the situation that
contains the description of each issue and a proposed solution to resolve the matter(s).
C. A neutral or impartial group with no vested interest in the outcome of the dispute will be assembled to
review the issue. This group may solicit written responses to the dispute from interested parties. If the
dispute is not resolved by mutual agreement, the group will issue a written determination, within thirty
(30) days of receipt of all pertinent data.
D. Party or parties may appeal the determination by the group and ask that the issue be brought before
the General Assembly for a final determination. The party or parties have no later than ten (10)
working days after the determination to submit the request for secondary review. The secondary review
will be limited to the original determination. The appeal must be mailed or hand-delivered in a timely
manner. In the event the appeal is not timely in delivery, it will not be considered. If not considered,
the party or parties will be notified in writing. The request must be submitted in writing to the following
address:
HOTRAC
405 Londonderry, Suite 201
Waco, TX 76712
Article XIII - Amendments
Section 1.
Bylaws
Proposed amendments and revisions to the bylaws must be submitted to the Executive Director and
approved by a majority vote of the Board of Directors in order for them to be submitted to the General
assembly.
All proposed bylaw revisions and/or changes will be submitted to the General Assembly Membership via
United States Postal Service and/or electronically (30) days prior to action. The proposed bylaws will also
be submitted to all individuals that participate in the HOTRAC email list-serve.
A roll-call vote shall be taken and there must be an affirmative vote of two-thirds of the General Assembly
present for the revisions to the bylaws to be ratified.
HOTRAC Regional Trauma System Plan
Revised May 2010
Page 17
The bylaws shall be reviewed/amended/revised at least once per calendar year.
Section 2.
Trauma System Plan
The HOTRAC will maintain a Trauma System Plan Workgroup that will annually update the HOTRAC
Regional Trauma System Plan. This Workgroup shall have membership from hospitals and pre-hospital
providers and will be presided over by the Executive Director.
The Trauma System Plan shall be provided to the Department of State Health Services (DSHS) EMS &
Trauma Systems Coordination by November 1st of each year. The Plan shall be approved by the
Physicians Advisory Committee, the Board of Directors, and General Assembly.
A majority vote of Physicians Advisory Committee and a majority vote of the Board of Directors shall
constitute approval of the Trauma System Plan. And a majority vote of the General Assembly members
shall constitute their approval of the Trauma System Plan.
Article XIV – Administrative Operations
Section 1.
Robert’s Rules of Order shall be used as a guide for all meetings administered by the HOTRAC.
Section 2.
HOTRAC members may obtain copies of financial records, 990s, audit findings, etc. from the Executive
Director or Chair. A request must be submitted in writing. The request must include what items wish to be
reviewed and when the member would like to schedule a time to review requested documents. Original
documents may not be removed from the HOTRAC offices without written approval of the Chair and/or
Executive Director. Some documents may not be available for copying.
RAC Chair
Date
Executive Director
Date
HOTRAC Regional Trauma System Plan
Revised May 2010
Page 18
APPENDIX A
(of Bylaws)
Members
Members (those completing a Member Information Sheet and in good-standing) include but are not limited to:
Air Evac Lifeteam
Bellmead Fire Department
Blum VFD
Bosque County Emergency Management
Bruceville-Eddy EMS First Responders
Capital Ambulance
CareFlite
City of Waco
Clifton VFD
Crawford EMS, Inc.
Dennis, Wayne
DePaul Center
ETMC-EMS
East Lake Limestone VFD
Elm Mott Fire/ Rescue
Falls County Volunteer Firefighters Association
Falls County Emergency Management
Falls County EMS
Falls Community Hospital & Clinic
Fraley, Diane
Goodall-Witcher Healthcare Foundation
Groesbeck VFD
HOTCOG
Hill County ESD #2
Hill County Emergency Management
Hill Regional Hospital
Hillcrest Baptist Medical Center
Hillsboro Fire & Rescue
Hillsboro Office of Emergency Management
Kosse VFD & First Responders
Lake Mexia VFD
Lake Whitney Medical Center EMS
LifeStar
Limestone Medical Center
HOTRAC Regional Trauma System Plan
Revised May 2010
Limestone Medical Center EMS
Limestone County Emergency Management
McLennan County
McGregor Volunteer EMS
Mart EMS, Inc.
Mexia Fire/EMS
Mexia State School
North Bosque EMS
PHI Air Med 6/STAT I
Parkview Regional Hospital
Prairie Hill VFD & First Responders
Providence Health Center
Rural Hill EMS
Tarbet, Robert
Tehuacana VFD
Waco, City of
West EMS
West Lake Limestone VFD
West Shore FRO/VFD
Whitney VFD
Page 19
TSA M – EMS PROVIDERS (Ground)
CareFlite EMS
Mark Kessler – Title
Local Office Address
City, State ZIP
Phone
Fax
Geographic Service Area – Hill County with the exception of the Cities of Hillsboro, Whitney, Hubbard and Mt. Calm
Level of Service – ALS/MICU
Medical Director –
Number of Vehicles Primary Radio Frequency Crawford EMS
Marilyn Judy, President
P.O. Box 341
Crawford, Texas 76638
(254) 486-2101
Fax – 486-2198
Dispatch – Through McGregor PD
Geographic Service Area – Western corner of McLennan County – Approximately 250 square miles.
Level of Service - BLS
Medical Director – Dr. George Smith
Number of Vehicles - 1
Primary Radio Frequency – 154.250
Falls EMS
Jim Lyon - Owner
403 Bridge
Marlin, TX 76661
(254) 883-5445
Fax – (254) 803-2320
Dispatch – (254) 803-3745 (non-emergency)
Geographic Service Area – Falls County
Level of Service – BLS w/ MICU capability
Medical Director – Dr. Karlan Downing
Number of Vehicles – 4
Primary Radio Frequency – UHF
Hillsboro Fire Dept. & EMS
Greg Markwardt, Operations Chief
P.O. Box 568
Hillsboro, Texas 76645
(254) 582-2401
Fax – (254) 582-9155
Dispatch – (254) 582-2141(emergency number) or 911
Geographic Service Area – 6 miles in each direction from Hillsboro.
HOTRAC Regional Trauma System Plan
Revised May 2010
Page 20
Level of Service – BLS with ALS
Medical Director – Dr. Richard Jackson
Number of Vehicles – 2
Primary Radio Frequency – 154.325 (Receive) 155.950 (Transmit)
ETMC – EMS
Dale Yates – Regional Director
1501 Hogan Lane, Ste. H
Waco, TX 76705
(254) 799-7718
Fax – (254) 799-2363
Dispatch (800) 255-2011
Geographical Service Area – mainly central McLennan County
Level of Service – MICU
Medical Director – Dr. William Moore
Number of vehicles – 13
Primary Radio Frequency – 800 MHz
Lake Whitney Medical Center EMS
Jimmy Hoskins – Director
103 N. Colorado Street
Whitney, Texas 76692
(254) 694-9706
Fax –(254) 694-9708
Dispatch – Through the 911 System.
Geographic Service Area – City of Whitney
Level of Service - BLS with MICU capabilities
Medical Director – Dr. Richard Jackson
Number of Vehicles - 3
Primary Radio Frequency – 155.340
Limestone Medical Center EMS
Shelton Chapman - Director
701 McClintic Dr.
Groesbeck, Texas 76642
(254) 729-3097
Fax – (254) 729-3532
Dispatch – Through 911 Service.
Geographic Service Area – ½ mile north of Navasota River to FM 164 and from FM 114 to just
this side of Mart (see map attached).
Level of Service – BLS w/ MICU capabilities
Medical Director – Dr. Mark Hoeschele
Number of Vehicles - 3
Primary Radio Frequency – 154.160
McGregor EMS
William Heath, President
PO Box 237
McGregor, Texas 76657
HOTRAC Regional Trauma System Plan
Revised May 2010
Page 21
(254) 840-2528
Fax – (254) 840-4362
Dispatch – 911 or by McGregor Police Dept.
Geographic Service Area – 139.6 square miles
Level of Service – BLS with MICU capability
Medical Director – Dr. Jon Daniell
Number of Vehicles - 2
Primary Radio Frequency – 154.250
Mart EMS
Tonja Vogt
P.O. Box 335
Mart, Texas 76664
(254) 876-3322
Fax – (254) 876-3332
Dispatch – 911 System
Geographic Service Area - McLennan County, Limestone County and half of Falls County
Level of Service - MICU
Medical Director – Dr. Jon Daniell
Number of Vehicles - 2
Primary Radio Frequency – 365.250
Mexia Fire Dept & EMS
Mike Clements – EMS Director
P.O. Box 207
Mexia, Texas 76667
(254) 562-4188
Fax – (254) 562-2569
Dispatch – Limestone S.O. dispatches county 911
Mexia Police Department dispatches city of Mexia 911
Mexia Fire Department dispatches itself after receiving calls from the above two agencies.
Geographic Service Area – See map attached.
Level of Service – BLS with MICU capabilities
Medical Director – Dr. Yong Chin
Number of Vehicles – 3 Ambulances
Primary Radio Frequency – 154.205, PL 100 fire
North Bosque EMS
Linda Catena – EMS Director
P.O. Box 119
Meridian, Texas 76665
(254) 435-2070
Fax – (254) 435-2560
Dispatch – Through the 911 System
Geographic Service Area – Approximately 1000 square miles
Level of Service – BLS with MICU capabilities
Medical Director – Dr. Kevin Blanton
Number of Vehicles – 3 Ambulances; 2 reserve
Primary Radio Frequency – 155.250
HOTRAC Regional Trauma System Plan
Revised May 2010
Page 22
Rural Hill EMS
Vicki Roberts – EMS Director
PO Box 363
Hubbard, TX 76648
(254) 576-1543
Fax – (254)
Dispatch – Hill County Sherriff’s Office
Geographic Service Area – City of Hubbard & southeast Hill County
Level of Service – BLS with some ALS
Medical Director – Dr. William Mitchell
Number of Vehicles – 3
Primary Radio Frequency –
Scott & White EMS
Charles Pearson
2401 S. 31st Street
Temple, TX 76508
(254) 724-8080
Fax – (254) 724-0019
Dispatch –
Geographical Service Area – Cities of Bruceville-Eddy & Moody
Level of Service – BLS with MICU capabilities
Medical Director – Dr. Robert Greenberg
Number of vehicles- 16 (total)
Primary Radio Frequency West Volunteer Ambulance Service
Tom Marek – Supervisor
P.O. Box 461
West, Texas 76691
(254) 826-3779
Fax – (254) 826-3231
Dispatch – (254) 826-3778
Geographic Service Area – From Abbott to Gholson and as far out as Ross Road – They also assist ETMC –EMS when
needed in the Waco area.
Level of Service – BLS with MICU capabilities
Medical Director – Dr. George Smith
Number of Vehicles - 3
Primary Radio Frequency – 155.295
HOTRAC Regional Trauma System Plan
Revised May 2010
Page 23
TSA M – AIR MEDICAL PROVIDERS
Air Evac LifeTeam – West (AEL 51)
Steven Clinkscales, Regional Manager
Cell (417) 293-2626
Base – (254) 826-0521
Fax –
Dispatch –
Geographic Service Area – see attached map
Level of Service - MICU
Medical Director – Dr. Brian Price
Primary Radio Frequency –
Air Evac LifeTeam – Fairfield (AEL 53)
Steven Clinkscales, Regional Manager
Cell (417) 293-2626
Base Fax –
Dispatch –
Geographic Service Area – see attached map
Level of Service - MICU
Medical Director – Dr. Brian Price
Primary Radio Frequency –
Air Evac LifeTeam – Ennis (AEL 74)
Steven Clinkscales, Regional Manager
Cell (417) 293-2626
Base Fax –
Dispatch –
Geographic Service Area – see attached map
Level of Service - MICU
Medical Director – Dr. Brian Price
Primary Radio Frequency –
Air Evac LifeTeam - Glenrose (AEL 69)
Martha Nichols, Base Manager
Cell – (417) 274-8722
Base – (254) 897-2691
Fax – (254) 897-2693
Dispatch – 800-568-6806
Geographic Service Area – see attached map
Level of Service - MICU
Medical Director – Dr. Robert Genzel
Primary Radio Frequency –
HOTRAC Regional Trauma System Plan
Revised May 2010
CareFlite Base Fax –
Dispatch –
Geographic Service Area – see attached map
Level of Service - MICU
Medical Director – Dr.
Primary Radio Frequency –
PHI STAT Air 1 – Killen Skylark Field
Brittany Misercola, Business Relations Supervisor
Base - (254) 680-3644
Fax – (254) 680-3573
Dispatch – 800-456-7477
Geographic Service Area – see attached map
Level of Service - MICU
Medical Director – Dr.
Primary Radio Frequency –
PHI STAT Air 2 – Georgetown
Traci Forister, Business Relations Supervisor
Base (512)
Fax –
Dispatch – 800-456-7477
Geographic Service Area – see attached map
Level of Service - MICU
Medical Director – Dr.
Primary Radio Frequency –
PHI Air Medical 6 – Corsicana
Dawn Traylor
Base (903)
Fax –
Dispatch – 877-435-9744
Geographic Service Area – see attached map
Level of Service - MICU
Medical Director – Dr. Roy Yamada
Primary Radio Frequency –
PHI Air Medical 12 – Bryan
Billy Rice, Base Supervisor
Base (936)
Fax –
Dispatch –
Geographic Service Area – see attached map
Level of Service - MICU
Medical Director – Dr.
Primary Radio FrequencyPage 24
Air Evac LifeTeam – 51 (West)
HOTRAC Regional Trauma System Plan
Revised May 2010
Page 25
Air Evac LifeTeam – 53 (Fairfield)
HOTRAC Regional Trauma System Plan
Revised May 2010
Page 26
Air Evac LifeTeam – 74 (Ennis)
HOTRAC Regional Trauma System Plan
Revised May 2010
Page 27
Air Evac LifeTeam – 69 (Glen Rose)
HOTRAC Regional Trauma System Plan
Revised May 2010
Page 28
PHI STAT Air 1 (Killeen Skylark Airfield)
*divide the air miles by 2 for approximate ETA in minutes (i.e., 30 miles = 15 min ETA).
HOTRAC Regional Trauma System Plan
Revised May 2010
Page 29
PHI STAT Air 2 (Georgetown)
*divide the air miles by 2 for approximate ETA in minutes (i.e., 30 miles = 15 min ETA).
HOTRAC Regional Trauma System Plan
Revised May 2010
Page 30
PHI Air Medical 6 (Corsicana)
*divide the air miles by 2 for approximate ETA in minutes (i.e., 30 miles = 15 min ETA).
HOTRAC Regional Trauma System Plan
Revised May 2010
Page 31
PHI Air Medical 12 (Bryan)
*divide the air miles by 2 for approximate ETA in minutes (i.e., 30 miles = 15 min ETA).
HOTRAC Regional Trauma System Plan
Revised May 2010
Page 32
Heart of Texas Regional Advisory Council – TSA M
TSA-M Hospital Facilities
Facility
DePaul Center
(254) 776-5970
Fax: (254) 751-4769
ATTN: Kent Keahey
Falls Community Hospital
(254) 803-3561
Fax: (254)883-6066
Goodall-Witcher
Healthcare Foundation
(254) 675-8322
FAX- (254) 675-2246
Hill Regional Hospital
(254) 582-8500
FAX- (254) 582-2144
Hillcrest Baptist Medical
Center
(254) 202-5300
FAX-(254) 202-8879
Lake Whitney Medical
Center
(254) 694-3165
FAX-(254) 694-3299
Limestone
Medical Center
(254) 729-3281
FAX-(254) 729-3080
Parkview Regional Hospital
(254) 562-5332
FAX-(254) 562-9279
Location
301 Londonderry Drive
Waco, TX 76712
McLennan County
60 beds
PO Box 60
Marlin, TX 76661
Falls County
44 beds
PO Box 549
101 South Ave. T
Clifton, TX 76634
Bosque County
40 Beds
101 Circle Drive
Hillsboro, Texas 76645
Hill County
92 Beds
100 Hillcrest Medical
Blvd
McLennan County
237 Beds
PO Box 458
Whitney, Texas 76692
Hill County
49 Beds
701 McClintic
Groesbeck, TX 76642
Limestone County
20 Beds
600 S Bonham
Mexia, Texas 76667
Limestone County
59 Beds
Providence Health Center
(254) 751-4000
Fax: (254) 751-4769
ATTN: Kent Keahey
6901 Medical Parkway
Waco, TX 76712
McLennan County
230 beds
Waco VA
(254) 752-6581
Fax – (254) 756-5215
4800 Memorial Drive
Waco, TX 76711
McLennan County
346 beds
HOTRAC Regional Trauma System Plan
Revised May 2010
AVERAGE
DAILY
CENSUS
HOSPITAL-BASED
EMS SERVICE
Trauma
MEDICAL
DIRECTOR
ED MEDICAL
DIRECTOR
Administrator
DESIGNATION
Status
Trauma Coordinator
20
No
N/A
N/A
Kent Keahey
President & CEO
N/A
N/A
15-20
No
Dr. Dileep Bhateley
Dr. Dileep Bhateley
Willis Reese
CEO
Designated
Level IV
Tammy Samford, RN
12
No
Dr. Kevin Blanton
Dr. Kevin Blanton
Clarence Fields
President & CEO
Designated
Level IV
Casandra Cox, RN, BSN
30
No
Dr. Michael Charles
Dr. Jeffrey Sterling
Jan McClure
CEO
Designated
Level IV
Janice Markwardt, RN
160
No
Dr. Ted Smith
Dr. ---
Glenn A. Robinson
President & CEO
Level II Trauma
Center
Lead Facility
Lori Boyett, RN, BSN
10-15
Yes
Dr. Aman Shah
Dr. Aman Shah
Ruth Ann Crow
Administrator
Non-designated
N/A
10
Yes
Dr James Wood
Dr James Wood
Penny Gray
CEO
Designated
Level IV
Temperance Johnson, RN
30
No
Dr Jeremy Chester
Dr Jeremy Chester
Jimmy Stewart
CEO
Designated
Level IV
175
No
N/A
Dr. John Hamilton
Kent Keahey
President & CEO
Non-designated
Eileen Bohannon, RN
ED Director
Not given
No
N/A
N/A
N/A
N/A
N/A
Page 33
Marcy McFarland, RN
System Participation
All HOTRAC General Assembly meetings are open to any interested persons. Meeting notices and reminders
are emailed to the membership well in advance of all meetings, and meeting notices are posted on the HOTRAC
website. Minutes of all meetings are emailed and provided at each meeting, along with a meeting agenda.
Active Participation in the RAC is defined as the following:
A.
EMS Provider Agencies
1.
2.
3.
4.
5.
6.
7.
B.
Hospital Members
1.
2.
3.
4.
5.
6.
7.
8.
9.
C.
Will have representation at 75% of General Assembly Meetings.
Will participate in a minimum of one (1) standing committee and will have representation at 75%
of that committee meetings.
Will submit information into the Trauma Registry and attend any meeting when the agency has
a referral on the agenda.
Will demonstrate participation in at least one RAC sanctioned prevention activity annually and
submit documentation of such.
Will submit required Performance Improvement data upon request.
Will have physician representation at 75% of the Physician Advisory Committee meetings.
Will participate in one community disaster preparedness drill per year.
Will have representation at 75% of General Assembly Meetings.
Will participate in a minimum of one (1) standing committee and will have representation at 75%
of that committee meetings.
If applicable, will have Trauma Coordinator attend at least 75% of the Hospital Care &
Management Committee as well as participate in the Trauma System Plan development.
If applicable, will have Stroke Coordinator attend at least 75% of the Stroke Committee as well
as participate in the Stroke System Plan development.
Will have physician representation at 75% of Physician Advisory Committee Meetings.
Will demonstrate participation in at least one RAC sanctioned prevention activity annually and
submit documentation of such.
Will submit information into the Trauma Registry and attend any meeting when the agency has
a referral on the agenda.
Will participate in 75% of scheduled preparedness activities.
In the event of emergency healthcare activations, will participate as required by the Health &
Medical Annex of the County Emergency Operations Plans and/or the Health & Medical
Appendix of the Regional Response Plan.
Non-EMS/Hospital Entities
1.
2.
3.
Will have representation at 75% of General Assembly Meetings.
Will participate in a minimum of one (1) standing committee and will have representation at 75%
of that committee meetings.
Will participate in at least one (1) scheduled regional preparedness activity.
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 34
Meeting attendance may be met in person, via conference call, or via webinar.
D.
Each member entity will complete an annual Regional Needs Assessment by the 1st of March of each
year.
E.
Membership Dues must be paid in full by each member by the 1 st of March of each year. Membership
dues is charged as follows:
Hospitals - $500.00
9-1-1 EMS Providers (including Air Medical) - $250.00
Other Members (i.e., FROs, Emergency Management, etc.) - $50.00
Individuals - $25.00
Participation from each organization is encouraged. The Bylaws are reviewed each year and revised as
appropriate. Each component of the Regional Trauma Plan is presented, discussed, and approved by the
HOTRAC General Assembly, Board of Directors, and Physicians Advisory Committee. All revisions are reviewed
and approved through the same process. Once approved, complete copies of the Regional Trauma Plan will be
distributed to the HOTRAC membership.
System Access
Goal
The Goal for System Access within TSA-M is two-fold. First, rapid access to notification of the need for
emergency and trauma care at any location within TSA-M must be available to all persons in the Region.
Second, Emergency Medical Services (EMS) must be rapidly available to provide quality health care to injured
or ill persons in each HOTRAC Community. In portions of this Region, First Responder Organizations (FRO)
may provide initial treatment pending EMS arrival.
Objectives
1. To ensure that all persons located in Trauma Service Area M will have the availability to access Emergency
Dispatch for EMS services.
2. To ensure emergency healthcare providers have communication equipment available.
3. To strive to maintain an adequate number of First Responders and EMS providers that have the knowledge,
skills, and equipment needed to provide emergency care to persons requesting assistance within the
Region.
Discussion
The 9-1-1 communications system provides a dedicated phone line allowing direct routing of emergency calls
through a telephone company central office to a Public Safety Answering Point (PSAP). Routing is based on the
specific telephone exchange area rather than municipal boundaries. Enhanced 9-1-1 can include Automatic
Number Identification (ANI) and/or Automatic Location Identification (ALI). Enhanced 9-1-1 also automatically
routes emergency calls to a pre-selected answering point based upon the geographical location from which the
call originated. Each of the five HOTRAC counties has enhanced 9-1-1 with ANI/ALI capability.
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 35
The 9-1-1 Advisory Committee of the Heart of Texas Council of Governments is responsible for the
development, performance evaluation, and administration of the 9-1-1 system in rural HOTRAC counties.
Representatives from each county meet on a regular basis to discuss system problems, plan educational
activities, and work cooperatively to develop and implement the 9-1-1 Strategic Plan. In McLennan County, the
McLennan County 9-1-1 District provides the same services to the entire McLennan County area.
There is free public access to 9-1-1 throughout TSA-M. Public education programs such as the Red E. Fox
program are used to educate consumers. Training sessions are provided at Community Health Fairs, schools,
Auxiliaries, hospitals, Sheriff’s departments, and EMS providers.
Emergency Care providers for accessing emergency communications use a variety of methods, such as 800
MHz, VHF, and UHR frequencies. HOTRAC strives to ensure interoperable communications at all times.
Communications
Goal
The Goal for Communications within TSA-M is to ensure communication capability between EMS
providers, medical control, receiving facilities; and other First Responders entities. Rapid dispatch and
notification of the need for emergency and trauma care at any location within TSA-M must be available to
all persons in the region.
Objectives
1. To facilitate regional communications, all EMS & First Responder Units as well as hospital emergency
personnel will have a list of the communication devices & operating frequencies of the EMS and emergency
care providers operating in the HOTRAC region.
2. To ensure that all EMS providers, First Responders, and hospital facilities in the HOTRAC region have
functional communications equipment in order to communicate information related to the patient’s condition,
the need for medical, EMS, or helicopter back-up, and to receive and communicate information related to
patient care and disposition.
3. To ensure that emergency dispatch within the HOTRAC region is accomplished by persons who have the
knowledge, skills, and equipment necessary to rapidly mobilize the appropriate level of emergency care to
persons requesting assistance throughout the region.
Discussion
The communications network in TSA-M is comprised of UHF, VHF, and 800 MHz radio devices combined with
telephone links, both cellular and base site. In some instances individual EMS providers utilize UHF, VHF, 800
MHz, and cellular phones to ensure communications capability. The use of multiple communications systems
ensures regional communications are maintained between public and private EMS agencies, police, fire, and
hospital entities.
Dispatch - Emergency dispatch in each of the five HOTRAC counties is accomplished through various methods
(i.e., sheriff’s office, local police department, or county 911 service). Many rural providers utilize alpha pagers to
notify emergency personnel of dispatch communications.
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 36
Pre-hospital Care Providers – Most of the EMS Providers utilize the VHF frequency while ETMC-EMS in
McLennan County utilizes 800 MHz.
Hospital Care Providers - All HOTRAC hospital facilities maintain communications capability with pre-hospital
care providers through the use of UHF emergency radios, cellular phones, or standard phone lines. HOTRAC
purchased each facility a HAM radio that is programmed as follows:
HAM Radio Frequencies:
CH
Alpha/Numeric
Out
In
Tone
Location
Type Service
0
W5BEC - ????
147.140
147.740
123.0
Bell
Amateur
1
W5BCR - Clifton
147.180
147.780
123.0
Bosque
Amateur
2
KC5QHO - Comanche
146.680
146.080
110.9
Comanche
Amateur
3
N5DDR - Gatesville
146.960
146.360
Coryell
Amateur
4
WD5DDH - Waxahachie
145.410
144.810
Ellis
Amateur
5
KB5TPP - Stephenville
147.360
147.960
110.9
Erath
Amateur
6
WB5YJL - Fairfield
145.110
144.510
146.2
Freestone
Amateur
7
WM5L - Hillsboro
146.780
146.180
123.0
Hill
Amateur
8
WD5GIC - Granbury
147.080
147.680
110.9
Hood
Amateur
9
KC5PGV - Cleburne
145.490
144.890
88.5
Johnson
Amateur
10
W5ZMI - Mexia
145.390
144.790
146.2
Limestone
Amateur
11
W5ZDN - Hewitt
146.890
146.290
123.0
McLennan
Amateur
12
W5ZDN - Moody
145.150
144.550
123.0
McLennan
Amateur
13
AA5RT - Waco
146.660
146.060
123.0
McLennan
Amateur
14
W5ZDN - Waco
146.880
146.280
123.0
McLennan
Amateur
15
WA5BU - Waco
147.160
147.760
McLennan
Amateur
16
AA5RT - Waco
147.360
147.960
123.0
McLennan
Amateur
17
N5DDC -Corsicana
145.290
144.690
146.2
Navarro
Amateur
18
WD5GND - Glen Rose
145.270
144.670
110.9
Somervell
Amateur
19
WD5GIC - Glen Rose
147.020
147.620
110.9
Somervell
Amateur
25
Simplex Point to Point
146.400
Amateur
26
Simplex Point to Point
146.410
Amateur
27
Simplex Point to Point
146.420
Amateur
28
Simplex Point to Point
146.430
Amateur
29
Simplex Point to Point
146.440
Amateur
30
Simplex Point to Point
146.450
Amateur
31
Simplex Point to Point
146.460
Amateur
32
Simplex Point to Point
146.470
Amateur
33
Simplex Point to Point
147.480
Amateur
34
Simplex Point to Point
146.490
Amateur
35
Simplex Point to Point
146.500
Amateur
36
Simplex Point to Point
146.510
Amateur
37
National Calling Frequency
146.520
Amateur
38
Simplex Point to Point
146.530
Amateur
20
24
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 37
39
Simplex Point to Point
146.540
Amateur
40
Simplex Point to Point
146.550
Amateur
41
Simplex Point to Point
146.560
Amateur
42
Simplex Point to Point
146.570
Amateur
43
Simplex Point to Point
146.580
Amateur
CH
Alpha/Numeric
Out
In
Tone
Location
Type Service
49
50
Simplex Point to Point
147.420
Amateur
51
Simplex Point to Point
147.430
Amateur
52
Simplex Point to Point
147.440
Amateur
53
Simplex Point to Point
147.450
Amateur
54
Simplex Point to Point
147.460
Amateur
55
Simplex Point to Point
147.470
Amateur
56
Simplex Point to Point
147.480
Amateur
57
Simplex Point to Point
147.490
Amateur
58
Simplex Point to Point
147.500
Amateur
59
Simplex Point to Point
147.510
Amateur
60
Simplex Point to Point
147.520
Amateur
61
Simplex Point to Point
147.530
Amateur
62
Simplex Point to Point
147.540
Amateur
63
Simplex Point to Point
147.550
Amateur
64
Simplex Point to Point
147.560
Amateur
65
Simplex Point to Point
147.570
Amateur
66
85
86
TX Fire 3
154.2950
NOTE: Receive only
Public Service
87
TX Fire 2
154.2650
88
TX Fire 1
154.2800
89
TX Air 2
151.3850
90
TX Med 1
155.3400
Public Service
91
TX Law 3
155.4750
Public Service
92
TX Law 2
155.3700
Public Service
93
TX Law 1
154.9500
Public Service
94
Freestone EOC
155.7975
Public Service
95
Limestone EOC
155.9325
Public Service
96
Falls EOC
154.0025
Public Service
97
McLennan EOC
158.7750
Public Service
98
Hill EOC
155.6925
Public Service
99
Bosque EOC
155.8875
Public Service
on Public Service Bands
Public Service
Public Service
127.3
Public Service
HOTRAC is an active participant in the interoperability planning efforts being address by the Heart of Texas
Regional Council of Governments. HOTRAC strives to remain at Level 4 interoperability. HOTRAC follows the
HOTCOG Regional Communications Plan. Please see that specific plan for additional detailed information
regarding communications in the Region.
HOTRAC Regional EMS Guidelines
Rev. 5.10
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Regional Medical Oversight & Control
Goal
The goal for Regional Medical Control in TSA-M is multifaceted.
- to ensure strong physician leadership and supervision for pre-hospital care providers in both on-line and
off-line functions.
- to secure medical involvement in regional planning and educational program development.
- Provide for the development and implementation of regional guidelines and system plan components, as
well as in systems evaluation.
.
Objectives
1. To evaluate regional trauma care from a systems perspective, under the direction of representatives of
HOTRAC medical staff throughout the region.
2. To involve HOTRAC medical staff in all phases and at all levels of the leadership and planning activities of
regional development.
3. To ensure appropriate medical oversight of all pre-hospital care providers through a Performance
Improvement (PI) process and other administrative processes.
4. To identify and educate regional medical control resources, standardize treatment guidelines, and analyze
accessibility of medical control resources.
5. To identify and educate HOTRAC EMS providers and sources of on-line and off-line medical control.
Discussion
The HOTRAC region includes both rural and urban hospital and emergency care providers with varying levels of
medical capability. There is no single EMS medical director for EMS providers; however there is one EMS
medical director for multiple EMS providers within each county. All EMS medical directors are members of the
HOTRAC Physician Advisory Committee, which meets on a quarterly basis.
Physician Involvement in Regional Plan Development - The Physician Advisory Committee meets on a quarterly
basis to conduct its usual business and to review and approve regional planning components, policies, and
guidelines related to medical care. Each EMS medical director, trauma surgeon, and physician from each
HOTRAC hospital has representation on this standing committee. Any interested HOTRAC physician is invited
to attend committee meetings.
Medical Direction of Pre-hospital Care Providers - In accordance with DSHS guidelines, all HOTRAC prehospital care providers function under medical control. Regional EMS guidelines are printed and distributed to
all EMS providers for incorporation into local protocols. (Please see the Appendix for ALS and BLS guidelines).
Periodic reviews and updates are completed and upon approval are distributed as necessary. These guidelines
serve as a baseline and individual Medical Directors may adapt for their local community.
A tiered system of patient care based on severity of injury utilizes First Responder Organizations and EMS
providers with varying level of capability to ensure the rapid assessment and initial care of the trauma patient
and transport to the appropriate level of care. Off-line medical control guidelines direct EMS provider
interventions. On-line medical control from the receiving HOTRAC facility is also utilized when the patient’s
condition or scene conditions cannot be addressed by off-line protocols.
HOTRAC Regional EMS Guidelines
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Regional Performance Improvement - The Physician Advisory Committee meets quarterly to conduct its usual
business and to carry out regional Performance Improvement activities. The Trauma Coordinators/ED
Directors/EMS representatives meet in conjunction with the Physician Advisory Committee to review patient care
and evaluate outcomes from a systems perspective. (Please see System PI section for more details). PI
indicators include a review of all deaths, transfers out of region, and pediatric filters. (See forms) Hospitals and
EMS Providers have separate PI indicator tools but many of the indicators are utilized for both areas.
Pre-hospital Triage
Goal
Patients will be identified, rapidly and accurately assessed, and based on identification of their actual or potential
for serious injury, will be transported to the nearest appropriate TSA-M trauma facility.
Purpose
In order to ensure the prompt availability of medical resources needed for optimal patient care, each patient will
be assessed for the presence of abnormal vital signs, obvious anatomic injury, mechanism of injury, and
concurrent disease/predisposing factors.
Definition
Trauma Patient—the patient is a victim of an external cause of injury that results in major or minor tissue
damage or destruction caused by intentional or unintentional exposure to thermal, mechanical, electrical, or
chemical energy, or by asphyxia, submersion, or hypothermia.
System Triage
1. Unless immediate stabilization (ABC’s, cardiac arrest, etc.) is required, patients in TSA-M with the following
injuries, with significant mechanism of injury, should be taken directly to Hillcrest Baptist Medical Center or
another appropriate trauma facility offering resources not available to Hillcrest Baptist Medical Center:











Penetrating injuries to head, neck, and torso
Respiratory Compromise/obstruction
GCS less than 13
O2 sat less than 90%
Adult Patients with a SBP less than 100
Child less than one year with SBP less than 70 or heart rate less than 100 or more than 190
Child 1-9 years with SBP less than 70 + 2 x age in years or heart rate less than 80 or more than 150
Suspected Amputation proximal to the wrist or ankle
Suspected Two or more proximal long bone fractures (Femur, Humerus)
Suspected Pelvic fractures
Burns more than or equal to 20% BSA or more than 10% if under 6 years old
HOTRAC Regional EMS Guidelines
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

Temperature less than or equal to 95◦F
Patients with traumatic paralysis
2. If ground transport time to Hillcrest Baptist Medical Center is greater than 30 minutes or if lifesaving
interventions (e. g. airway stabilization, chest tube insertion, etc.) are required for safe transport, contact
medical control and/or take the patient to the nearest medical facility and call for the helicopter transport
to meet you at the closest agreed upon landing zone.
Off-line Medical Control Trauma Triage Criteria
Goal
Patients will be identified, rapidly and accurately assessed, and based on identification of their actual or potential
for serious injury, will be transported to the nearest appropriate TSA-M trauma facility where the patient can best
receive definitive care. When on-line medical control is needed but unavailable, EMS personnel will proceed to
the nearest appropriate Trauma facility without delay.
CLASSIFICATION OF TRAUMA PATIENTS for PRE-HOSPITAL
Patients in TSA-M are classified according to severity of injury in order to determine the medical resources which
may be required. EMS personnel will triage and transport trauma patients in TSA-M according to the following
guidelines:
Category 1. Trauma Patients with the most severe injuries are classified as Category 1 patients.
Patients with the following problems are included in this category and will require the medical resources
available at a TSA-M Level II Trauma Facility. When EMS personnel are unable to establish on-line
medical control, these patients should be transported directly to Hillcrest Baptist Medical Center (or
another more appropriate Level I or Level II Trauma facility) unless the patient’s condition requires
resuscitation and stabilization at the nearest appropriate acute care facility.







Gun Shot Wound to head, neck or torso
Respiratory Compromise/obstruction
GCS less than 8
O2 sat less than 85%
Adult Patients with a SBP less than 90
Child less than one year with SBP less than 70 or heart rate less than 100 or more than 190
Child 1-9 years with SBP less than 70 + 2 x age in years or heart rate less than 80 or more than 150
Category 2. Trauma Patients with the serious injuries are classified as Category 2 patients.
Patients with the following problems are included in this category and will require the medical resources
available at a TSA-M Level II Trauma Facility. When EMS personnel are unable to establish on-line
medical control, these patients should be transported directly to Hillcrest Baptist Medical Center (or
HOTRAC Regional EMS Guidelines
Rev. 5.10
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another more appropriate Level I or Level II Trauma facility) unless the patient’s condition requires
resuscitation and stabilization at the nearest appropriate acute care facility.












Penetrating injuries to head, neck, and torso (non-GSW)
Suspected Amputation proximal to the wrist or ankle
Suspected Two or more proximal long bone fractures (Femur, Humerus)
Suspected Open fracture (humerus, femur, tibia)
O2 sat less than 90%
Suspected Pelvic fractures
Burns more than or equal to 20% BSA or more than 10% if under 6 years old
Temperature less than or equal to 95◦F
GCS less than 13
Adult SBP 90-100
Heart rate more than 140
Patients with traumatic paralysis
Category 3. Category 3 trauma patients are those with injuries not classified as Category 1 or Category
2. When EMS personnel are unable to establish on-line medical control, these patients should be
transported directly to the nearest appropriate TSA-M trauma facility for physician evaluation. Level IV
Trauma Facilities after stabilization should make the decision whether to transfer to the Level II Trauma
Facility if the patient has any mechanism listed and one or any findings listed.
Mechanism of Injury








Motor Vehicle Collision
- With ejection
- High speed more than 40 mph
- Unrestrained more than 20 mph
- Death in same car
- Extrication more than 20 minutes
- Rollover
MCC/ATV/Bike/Large animal
- Separation of rider
- Crash speed more than 20 mph
Falls (greater than 10 feet or 2x child’s height if under 6 years old)
Assault/child abuse
Auto/Pedestrian
Burns (partial or full thickness)
Hanging/Immersion
Crush injury (not hands or feet)
Findings

Head
HOTRAC Regional EMS Guidelines
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




- Suspected skull fracture
- Documented LOC greater than 5 minutes
Neurologic
- GCS less than 14
- Focal deficit
- Traumatic paresis
Musculoskeletal
- Suspected Femur fracture
- Suspected Spine fracture
- Suspected Pelvic fracture
- Pulseless extremity
Abdomen
- Severe abdominal pain
- Seat belt “abrasions”
Burns
- Suspected Inhalation injury
- More than or equal to 5% or less than or equal to 20% BSA
Chest
- O2 sat less than 92%
- Suspected Multiple (more than 2) rib fractures
- Sub Q air
- Suspected Pneumothorax/Hemothorax
- Significant neck and/or chest “abrasions”
Category 4. Category 4 trauma patients are those with injuries not classified as Category 1, 2, or 3.
When EMS personnel are unable to establish on-line medical control, these patients should be
transported directly to the nearest TSA-M acute care facility for physician evaluation.






GCS less than 15
Falls (less than 10 feet or less than 2x child’s height if under 6 years old)
Snakebites
Injured diabetic patients taking insulin
Injured pregnant patients not classified as 1, 2, or 3
Toxic substance at scene in contact with the patient
Helicopter Activation
Goal
TSA-M regional air transport resources will be appropriately utilized in order to reduce delays in providing
optimal trauma care for severely injured trauma patients.
HOTRAC Regional EMS Guidelines
Rev. 5.10
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Decision Criteria
1. Helicopter activation/scene response should be considered when it can reduce transportation time for
patients meeting the following criteria. Should there be any question whether or not to activate TSA-M
regional air transport resources, on-line medical control should be consulted for the final decision.














Penetrating injuries to head, neck, and torso
Respiratory Compromise/obstruction
GCS less than 13
O2 sat less than 90%
Adult Patients with a SBP less than 100
Child less than one year with SBP less than 70 or heart rate less than 100 or more than 190
Child 1-9 years with SBP less than 70 + 2 x age in years or heart rate less than 80 or more than 150
Suspected Amputation proximal to the wrist or ankle
Suspected Two or more proximal long bone fractures (Femur, Humerus)
Suspected Open fracture (humerus, femur, tibia)
Suspected Pelvic fractures
Burns more than or equal to 20% BSA or more than 10% if under 6 years old
Temperature less than or equal to 95◦F
Patients with traumatic paralysis
2. Additionally helicopter activation/scene response should be considered when:
o Patient extrication time will be prolonged (> 20 minutes).
o Multiple patients on scene
o Ejection from MVC
3. Patients being transported via helicopter should be taken to the nearest Level I or Level II Trauma Facility.
Emergency Department Diversion
Goal
TSA-M trauma facilities will communicate “Emergency Department diversion” status promptly and clearly to
regional EMS and trauma facilities through EMSystem in order to ensure that trauma patients are transported to
the nearest appropriate alternate trauma system hospital.
System Objectives
1. To ensure that trauma patients will be transported to the nearest appropriate TSA-M trauma facility.
2. To ensure that diversion of ambulance traffic will occur only by pre-arrangement.
3. To develop system guidelines for regional facility and trauma diversion status (see EMSystem
guidelines and protocols):
 Situations which would require the facility to go on diversion
HOTRAC Regional EMS Guidelines
Rev. 5.10
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

Notification/activation of facility diversion status
Procedure for termination of diversion status
4. Each facility will develop a mass casualty plan. Facility plans will reference the appropriate use of TSAM disaster resources, if needed.
5. Regional trauma care problems associated with facility diversion will be assessed through the Physician
Advisory Committee PI process.
6. All facilities and pre-hospital providers will use EMSystem to notify and track diversion statuses.
Facility Bypass
Goal
Patients who have been assessed and determined to be medically unstable, unconscious, or at high risk of
multiple and/or severe injuries (Category 1 and 2 patients) will be safely and rapidly transported to the Regional
Trauma Center. Category 3 patients will be safely and rapidly transported to the nearest appropriate trauma
facility within TSA M. Category 4 patients will be safely and transported to the nearest appropriate acute care
facility within TSA M.
Decision Criteria
Regional transport guidelines ensure that patients who meet the triage criteria for activation of the TSA-M
Regional Trauma System Plan will be transported directly to the nearest appropriate trauma facility rather than to
the nearest hospital except under the following circumstances:
1. If unable to establish and/or maintain an adequate airway, or in the case of traumatic cardiac arrest, the
patient should be taken to the nearest acute care facility for stabilization.
2. A Level III or Level IV trauma facility may be appropriate if the expected scene to Level II Trauma
Center transport time is excessive (> 30 minutes) and there is a qualified physician available at the
facility’s Emergency Department capable of delivering definitive care.
3. Medical Control may wish to order bypass in any of the above situations as appropriate, such as when a
facility is unable to meet hospital resource criteria or when there are patients in need of specialty care.
4. If expected transport time to the nearest appropriate Trauma Center is excessive (> 30 minutes) or if a
lengthy extrication time (> 20 minutes) is expected, medical control or the EMS crew on scene should
consider activating air transportation resources.
HOTRAC Regional EMS Guidelines
Rev. 5.10
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Note: Should there be any question regarding whether or not to bypass a facility, on-line medical control should
be consulted for the final decision from the receiving facility.
Facility Triage Criteria
Goal
The goal of establishing and implementing facility triage criteria in TSA-M is to ensure that all regional hospitals
use standard definitions to classify trauma patients in order to ensure uniform patient reporting and facilitate
inter-hospital transfer decisions.
Objectives
1. To ensure that each trauma patient is identified, rapidly and accurately assessed, and based on
identification and classification of their actual or potential for serious injury, transferred to the nearest
appropriate TSA-M trauma facility.
2. To ensure the prompt availability of medical resources needed for optimal patient care at the receiving
trauma facility.
3. To develop and implement a system of standardized trauma patient classification definitions.
Discussion
Trauma patients in TSA-M are assessed and classified by severity of injury. The classification of trauma
patients is based on a standard definition of “the trauma patient” which is applied in a consistent manner in both
the pre-hospital and hospital setting.
The Trauma Patient - The definition of the trauma patient in TSA-M is derived from the American College of
Trauma Surgeon’s definition of trauma. In TSA-M, the trauma patient is defined as one who is a victim of an
external cause of injury that results in major or minor tissue damage or destruction caused by intentional or
unintentional exposure to thermal, mechanical, electrical, or chemical energy, or by asphyxia, drowning, or
hypothermia.
Facility Triage Criteria - Trauma patients are assessed in the pre-hospital setting and transferred to the nearest
appropriate trauma facility in accordance with the TSA-M Pre-hospital Trauma Triage Criteria. Upon admission
to the hospital emergency department, trauma patients receive initial treatment and re-assessment of their
condition. The severity of injury and classification of trauma patients in the initial treating emergency department
determines the optimal level of trauma care needed. Inter-hospital transfer is initiated as appropriate according
to TSA-M facility triage decision criteria.
CLASSIFICATION OF TRAUMA PATIENTS for FACILITIES
Patients in TSA-M are classified according to severity of injury in order to determine the medical resources which
may be required. EMS personnel will triage and transport trauma patients in TSA-M according to the following
guidelines:
HOTRAC Regional EMS Guidelines
Rev. 5.10
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Category 1. Trauma Patients with the most severe injuries are classified as Category 1 patients.
Patients with the following problems are included in this category and will require the medical resources
available at a TSA-M Level II Trauma Facility. When EMS personnel are unable to establish on-line
medical control, these patients should be transported directly to Hillcrest Baptist Medical Center (or
another appropriate Level I or Level II Trauma facility) unless the patient’s condition requires
resuscitation and stabilization at the nearest appropriate acute care facility.








Gun Shot Wound to head, neck or torso
Respiratory Compromise/obstruction
Trauma patient receiving blood or blood products
GCS less than 8
O2 sat less than 85%
Adult Patients with a SBP less than 100
Child less than one year with SBP less than 70 or heart rate less than 100 or more than 190
Child 1-9 years with SBP less than 70 + 2 x age in years or heart rate less than 80 or more than 150
Category 2. Trauma Patients with the serious injuries are classified as Category 2 patients.
Patients with the following problems are included in this category and will require the medical resources
available at a TSA-M Level II Trauma Facility. When EMS personnel are unable to establish on-line
medical control, these patients should be transported directly to Hillcrest Baptist Medical Center (or
another appropriate Level I or Level II Trauma facility) unless the patient’s condition requires
resuscitation and stabilization at the nearest appropriate acute care facility.












Penetrating injuries to head, neck, and torso (non-GSW)
Amputation proximal to the wrist or ankle
Two or more proximal long bone fractures (Femur, Humerus)
Open fracture (humerus, femur, tibia)
O2 sat less than 90%
Pelvic fractures with displacement
Burns more than or equal to 20% BSA or more than 10% if under 6 years old
Temperature less than or equal to 95◦F
GCS less than 13
Adult SBP 90-100 or heart rate more than 130
Patients with traumatic paralysis
Injury to extremity with absence of a pulse
Category 3. Category 3 trauma patients are those with injuries not classified as Category 1 or Category
2. When EMS personnel are unable to establish on-line medical control, these patients should be
transported directly to the nearest appropriate TSA-M trauma facility for physician evaluation. Level IV
Trauma Facilities after stabilization should make the decision whether to transfer to the Level II Trauma
Facility if the patient has one or more mechanism listed and one or more positive finding.
HOTRAC Regional EMS Guidelines
Rev. 5.10
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Mechanism of Injury








Motor Vehicle Collision
- With ejection
- High speed more than 40 mph
- Unrestrained more than 20 mph
- Death in same car
- Extrication more than 20 minutes
MCC/ATV/Bike/Large animal
- Separation of rider
- Crash speed more than 20 mph
Falls
Assault/child abuse
Auto/Pedestrian
Burns (partial or full thickness)
Hanging/Immersion
Crush injury (not hands or feet)
Positive Findings






Head
- Any skull fracture
- Abnormal brain CT
Neurologic
- GCS less than 14
- Focal deficit
- Traumatic paresis
Musculoskeletal
- Femur fracture
- Spine fracture
- Pelvic fracture without displacement
Abdomen
- Solid organ injury
- Gross hematuria
- Abnormal abdominal/pelvic CT
Burns
- Inhalation injury
- More than or equal to 5% or less than 20% BSA
Chest
- O2 sat less than 92%
- Multiple (more than 2) rib fractures
- Sub Q air
- Pneumothorax
- Hemothorax
HOTRAC Regional EMS Guidelines
Rev. 5.10
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Category 4. Category 4 trauma patients are those with injuries not classified as Category 1, 2, or 3.
When EMS personnel are unable to establish on-line medical control, these patients should be
transported directly to the nearest TSA-M acute care facility for physician evaluation.






GCS less than 15
Same heights falls
Snakebites
Injured diabetic patients taking insulin
Injured pregnant patients less than 23 weeks that are not classified as 1, 2, or 3
Toxic substance at scene in contact with the patient
Inter-Hospital Transfers
Goal
The goal for establishing and implementing inter-hospital transfer criteria in TSA-M is to ensure that those
trauma patients requiring additional or specialized care and treatment beyond a facility’s capability are identified
and transferred to an appropriate facility as soon as possible.
Objectives
1. To ensure that all regional hospitals make transfer decisions based on standard definitions which
classify trauma patients according to TSA-M facility triage criteria.
2. To identify trauma treatment and specialty facilities within and adjacent to TSA-M.
3. To establish treatment and stabilization criteria and time guidelines for TSA-M patient care facilities.
Discussion
Hillcrest Baptist Medical Center is the Lead Trauma Facility in TSA-M and accepts all Category 1, 2, and 3
transfer patients from any requesting TSA-M facility. A toll-free number has been established and distributed to
all TSA-M emergency medical and hospital providers:
Hillcrest Trauma Transfer Phone Line: 1 – 888 – 872 – 8626
Medical personnel calling this number receive an “automatic acceptance” for these trauma patients. The time
guideline for trauma patient transfers in TSA-M is to transfer Category 1 & 2 trauma patients immediately to the
TSA M Lead Level II Trauma Facility. Category 3 trauma patients should be initially transported to the closest
trauma facility for stabilization. If admission is necessary, the patient should be transferred to the Lead Level II
Trauma Facility within four (4) hours from the time the patient arrived at that facility. Category 4 trauma patients
HOTRAC Regional EMS Guidelines
Rev. 5.10
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should be transported to the closest acute care facility for treatment and can be admitted to that facility if
necessary. These criterions (see attached Regional Trauma Alert Form) are monitored through the regional PI
program.
Identification of Trauma Patients & Trauma Transfers - Trauma patients and their treatment requirements for
optimal care are identified in the TSA-M facility triage criteria and pre-hospital triage criteria. Written transfer
agreements are available between all TSA-M hospital facilities, and hospital facilities in adjacent regions.
Trauma patients with special needs may be transferred to the Lead Trauma Facility for assessment and initial
treatment by the trauma team. When resources beyond its capability are needed, transfer to another trauma
designated facility outside TSA M should be expedited. The TSA-M initial-receiving hospitals may also choose
to transfer patients with special needs directly to these facilities, bypassing the Lead Level II Trauma Facility
when appropriate. Below are lists of possible facilities that may be utilized outside TSA M:






Baylor University Medical Center (Level I Trauma) – TSA E
Children's Medical Center of Dallas (Level I Trauma/Pediatric) – TSA E
John Peter Smith Hospital (Level I Trauma) – TSA E
Parkland Health & Hospital System (Level I Trauma/Burn) – TSA E
Scott and White Memorial Hospital (Level I Trauma/Pediatric) – TSA L
Dell Children’s Medical Center of Central Texas (Level I Trauma/Pediatric) – TSA O
Trauma Patient Transport - Trauma patients in TSA-M are transported according to patient need, availability of
air transport resources, and environmental conditions. Ground transport via BLS, ALS, or MICU ground
ambulance is available throughout the Region. Air Medical transport (fixed and roto wing) is also available in
this Region.
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System Performance Improvement
Goal
The goals for system performance improvement in TSA-M are to establish a method for monitoring and
evaluating system performance over time and to assess the impact of trauma system development on regional
morbidity and mortality.
Objectives
1. To ensure that all TSA-M hospital and pre-hospital care providers are uploading the essential trauma
data set to the state trauma registry.
2. To identify regional trauma data filters which reflect the process and outcome of trauma care in TSA-M.
3. To provide a multidisciplinary forum for trauma surgeons and trauma care providers to evaluate trauma
patient outcomes from a system perspective and to assure the optimal delivery of trauma care.
4. To facilitate the sharing of information, knowledge, and scientific data.
5. To provide a process for medical oversight of regional trauma and EMS operations.
Discussion
In order to assess the impact of regional trauma development, system performance must be monitored and
evaluated from an outcomes perspective. A plan for the evaluation of operations is needed to determine if
system development is meeting its stated goals.
Direction - The direction for the development of a HOTRAC Regional Trauma PI program is derived from the
Texas EMS Rules: Section 157.124 Regional EMS Trauma Systems: (3)(K) of the EMS Rules (effective 2/17/92)
requires the development of a “performance management program that evaluates outcome from a system
perspective”.
Authority - The authority and responsibility for regional performance improvement rests with the Regional
Advisory Council. This will be accomplished in a comprehensive, integrated manner through the work of the
Physician Advisory, Hospital Care and Management, and Pre-hospital Care committees.
Scope & Process - The Physician Advisory Committee with the Hospital Care and Management Committee
serves as the oversight committee for regional performance improvement. Referrals for follow-up and feedback
to & from the Pre-hospital Care Committee and providers ensure system-wide, multidisciplinary performance
improvement.
The Physicians Advisory Committee approves, with input from other committees, the type of data and manner of
collection, set the agenda for the PI process within the regularly-scheduled quarterly meetings of the committee,
and identify the events and indicators to be evaluated and monitored. Indicator identification will be based on
high risk, high volume, and problem prone parameters. Indicators will be objective, measurable markers that
reflect trauma resources, procedural/patient care techniques, and or systems/process outcomes.
Occurrences will be evaluated from a system, outcomes prospective and sentinel events will be evaluated on a
case by case basis. Activities and educational offerings will be presented to address knowledge deficits and
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case presentations or other appropriate mediums will be designed to address systems and behavioral problems.
All actions will focus on the opportunity to improve patient care and systems operation. The results from
committee activities will be summarized and communicated to the RAC membership. Problems identified that
require further action will be shared with the persons and entities involved, for follow-up and loop closure.
Summary reports will be communicated on a standard format to the appropriate committee (see attached).
The functions and effectiveness of HOTRAC performance improvement process will be evaluated on an annual
basis in conjunction with the annual evaluation of the HOTRAC bylaws. All PI activities and committee
proceedings are strictly confidential. Individuals involved in performance management activities will not be asked
to review cases in which they are professionally involved, but will be given the opportunity to participate in the
review process.
Data Collection - PI data will be collected by the Trauma Coordinators, ED Directors, and 9-1-1 EMS Providers
as well as from the state trauma registry when operational. Quarterly reports are submitted for each HOTRAC
facility and 9-1-1 EMS Provider. Sentinel events will be used to focus attention on specific situations/occurrences
of major significance to patient care outcomes. TSA-M providers upload the required data set directly to the
state trauma registry.
Confidentiality - All information and materials provided and/or presented during PI meetings are strictly
confidential. See attached form.
HOTRAC facility and 9-1-1 EMS Provider data related to the following PI indicators are reviewed during the
quarterly Physician Advisory meetings. See attached PI forms. The PI Forms are reviewed and updated
annually.
Reporting Quarters.
HOTRAC regional PI data-reporting quarters are as follows:
First Quarter:
Second Quarter:
Third Quarter:
Fourth quarter:
Jan-Feb-Mar
April-May-June
July-August-Sep
Oct-Nov-Dec
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Reporting at:
Reporting at:
Reporting at:
Reporting at:
May meeting
August meeting
November/December meeting
February meeting
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HOTRAC Regional Performance Improvement
Statement of Confidentiality
Medical Performance Improvement provides an objective mechanism to evaluate trauma and
emergency care, facilitates the sharing of information, knowledge, and scientific data, and provides
a forum for medical directors and other physicians to review the performance of the regional
systems to assure the optimal delivery of trauma and emergency care. The direction of the
committee comes from the Texas EMS Rules: Section 157.124 Regional EMS Trauma Systems: (3)
(k) of the EMS Rules (effective 2/17/92) requires the development of a “performance management
program that evaluates outcome from a system perspective”
Committee members engaged in medical care review have protection from disclosure of
proceedings, under Section 773.095 RECORDS OF PROCEEDINGS CONFIDENTIAL of the Texas
Health and Safety Code as follows:
(a) The proceedings and records of organized committees of hospitals, medical societies,
emergency medical service providers, or first responder organizations relating to the
review, evaluation, or improvement of an emergency medical services provider, a first
responder organization, or emergency medical services personnel are confidential and
not subject to disclosure by court subpoena or otherwise.
(b) The records and proceedings may be used by the committee only in exercise of proper
committee functions.
(c) This section does not apply to records made or maintained in the regular course of
business by an emergency medical services provider, a first responder organization, or
emergency medical services personnel.
Section 773.096 IMMUNITY FOR COMMITTEE MEMBERS
“A member of an organized committee under Section 773.095 is not liable for damages to a person
for an action taken or recommendation made within the scope of the functions of the committee if
the committee member acts without malice and in the reasonable belief that the action or
recommendation is warranted by the facts known to the committee member.”
CONFIDENTIALITY
As a participant in this HOTRAC regional performance improvement process, I understand and agree
that all information and materials provided and/or presented during the meeting are strictly
confidential.
Meeting & Date: Physicians Advisory Meeting –
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APPENDIX A
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Treatment Guidelines
These guidelines are valid October 1, 2009
Through December 31, 2013
Heart of Texas Regional Advisory Council (HOTRAC)
Trauma Service Area M
____FOR
HOTRAC Regional EMS Guidelines
Rev. 5.10
EMS PROVIDERS
_____
Page 61
TABLE OF CONTENTS
INTRODUCTION ....................................................................................................................... 5
DEVELOPMENT AND AUTHORITY ........................................................................................ 5
OPERATIONAL POLICIES ...................................................................................................... 5
AUTHORIZATION TO PROVIDE PRE HOSPITAL CARE ...................................................... 5
Purpose ......................................................................................................................................5
Authorization ..............................................................................................................................5
To Obtain Authorization .............................................................................................................6
Deauthorization ..........................................................................................................................6
Geographic Limitations of Authorization ....................................................................................6
Authorization of Non-EMS Personnel ........................................................................................6
RESTRAINTS POLICY ............................................................................................................. 6
Safety Restraint Policy ...............................................................................................................6
Policy for Control of Violent Patients ..........................................................................................6
HELICOPTER ACTIVATION .................................................................................................... 7
Medical Patients .........................................................................................................................7
Trauma Patients .........................................................................................................................7
Decision Criteria .........................................................................................................................7
DESTINATION POLICY ........................................................................................................... 8
PRE-HOSPITAL TRAUMA TRIAGE ........................................................................................ 8
DNR CONDITIONS ................................................................................................................... 9
REFUSAL TO TRANSPORT .................................................................................................. 10
General Statement .................................................................................................................. 10
Procedure For Refusal ............................................................................................................ 11
SPINAL MOTION RESTRICTION GUIDELINES ................................................................... 11
Assessment Guidelines ........................................................................................................... 12
Short Board/KED Use ............................................................................................................. 12
AUTHORIZED MEDICATIONS .............................................................................................. 13
Adenosine ............................................................................................................................... 13
Albuterol .................................................................................................................................. 13
Amiodarone ............................................................................................................................. 13
Aspirin ..................................................................................................................................... 13
Atropine ................................................................................................................................... 14
Dextrose 5% ............................................................................................................................ 14
Dextrose 50% .......................................................................................................................... 14
Diazepam ................................................................................................................................ 14
Diltiazem .................................................................................................................................. 14
Diphenhydramine .................................................................................................................... 14
Dopamine ................................................................................................................................ 15
Epinephrine ............................................................................................................................. 15
Furosemide ............................................................................................................................. 15
Glucagon ................................................................................................................................. 16
Glucose, Instant ...................................................................................................................... 16
Labetalol .................................................................................................................................. 16
Lactated Ringers…………………………………………………………………………………….. 16
Lidocaine ................................................................................................................................. 16
Magnesium Sulfate.................................................................................................................. 17
Midazolam ............................................................................................................................... 18
Morphine Sulfate ..................................................................................................................... 18
Naloxone ................................................................................................................................. 18
Nitroglycerine .......................................................................................................................... 18
Norcuron .................................................................................................................................. 19
Normal Saline .......................................................................................................................... 19
Oxygen .................................................................................................................................... 19
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Promethazine .......................................................................................................................... 19
Succinylcholine........................................................................................................................ 20
Sodium Bicarbonate ................................................................................................................ 20
Terbutaline .............................................................................................................................. 20
Thiamine.................................................................................................................................. 20
PROCEDURES ....................................................................................................................... 21
Automatic External Defibrillator ............................................................................................... 22
Cricothyrotomy ........................................................................................................................ 23
Defibrillation/Cardioversion ..................................................................................................... 23
Drug Administration ................................................................................................................. 23
Esophageal Intubation with a Multilumen Airway.................................................................... 24
Intraosseous Infusion .............................................................................................................. 24
Musculoskeletal Motion Restriction ......................................................................................... 25
Nasotracheal Intubation .......................................................................................................... 26
Needle Chest Decompression ................................................................................................ 26
Orotracheal Intubation ............................................................................................................. 27
Pacing ..................................................................................................................................... 28
Peripheral Venipuncture .......................................................................................................... 29
Rapid Sequence Intubation ..................................................................................................... 30
Spinal Motion Restriction ........................................................................................................ 30
Wound Care ............................................................................................................................ 31
AIRWAY MANAGEMENT ...................................................................................................... 33
General Principles ................................................................................................................... 33
Airway Management Algorithm ............................................................................................... 34
Foreign Body Airway Obstruction ............................................................................................ 35
COMMUNICATIONS GUIDELINES ....................................................................................... 36
ABDOMINAL PAIN/NAUSEA AND VOMITING GUIDELINE ................................................ 37
ALLERGIC REACTION / ANAPHYLAXIS ............................................................................. 39
ALTERED LEVEL OF CONSCIOUSNESS ............................................................................ 40
General Considerations .......................................................................................................... 40
Seizure Activity ........................................................................................................................ 41
Syncope/Fainting..................................................................................................................... 42
With Neuro Signs .................................................................................................................... 43
SUSPECTED ACUTE MYOCARDIAL INFARCTION ............................................................ 44
BRADYCARDIA...................................................................................................................... 45
HYPERTENSIVE CRISIS………………………………………………… ................................... 46
HYPOTENSION/SHOCK…………………………………….. ................................................... 47
ECA/EMT - CARDIAC EMERGENCIES................................................................................. 48
Apneic & Pulseless.................................................................................................................. 48
Tachycardia - Unstable With Pulses ....................................................................................... 49
Tachycardia - Stable ............................................................................................................... 50
Tachycardia - Ventricular Fibrillation/Pulseless V. Tach (VF/VT) .......................................... 51
PARAMEDIC - CARDIAC EMERGENCIES ........................................................................... 52
Tachycardia ............................................................................................................................. 53
Cardiac Arrest - Ventricular Fibrillation/Pulseless V. Tach (VF/VT) ....................................... 54
Asystole ................................................................................................................................... 55
Pulseless Electrical Activity (PEA) .......................................................................................... 56
Post-Resuscitation .................................................................................................................. 57
RESPIRATORY DISTRESS MEDICAL .................................................................................. 58
General Considerations .......................................................................................................... 58
Asthma & COPD ..................................................................................................................... 59
Pulmonary Edema ................................................................................................................... 60
Suspected Epiglottitis .............................................................................................................. 61
VENTILATOR GUIDELINE (for AutoVent 2000/3000 Portable Ventilators)………….………..62
TASER REMOVAL GUIDELINE ............................................................................................ 63
SNAKEBITE............................................................................................................................ 64
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POISONING & OVERDOSE ................................................................................................... 65
INTOXICATION AND BEHAVIORAL EMERGENCIES ......................................................... 66
HYPERTHERMIA.................................................................................................................... 67
Heat Exhaustion ...................................................................................................................... 67
Heat Stroke ............................................................................................................................. 68
HYPOTHERMIA ...................................................................................................................... 69
OBSTETRICS ......................................................................................................................... 70
Normal Delivery & General Considerations ............................................................................ 70
Prolapsed Cord ....................................................................................................................... 71
Nuchal Cord ............................................................................................................................ 72
Breech Presentation ................................................................................................................ 73
PEDIATRIC NEWBORN RESUSCITATION .......................................................................... 74
OBSTETRICS/GYNECOLOGY .............................................................................................. 75
Vaginal Bleeding ..................................................................................................................... 75
TRAUMA ................................................................................................................................. 76
General Procedures ................................................................................................................ 76
Classification Of Trauma Patients ........................................................................................... 77
Category 1 Trauma ................................................................................................................. 77
Category 2 Trauma ................................................................................................................. 77
Category 3 Trauma ................................................................................................................. 77
Category 4 Trauma ................................................................................................................. 79
Head Injury & Spinal Trauma .................................................................................................. 80
Respiratory Distress With Chest Injury ................................................................................... 81
Abdominal Trauma .................................................................................................................. 82
Amputated Parts...................................................................................................................... 83
Isolated Fractures, Dislocations, & Sprains ............................................................................ 84
Burns ....................................................................................................................................... 85
Near Drowning ........................................................................................................................ 86
APPENDIX .............................................................................................................................. 87
EMS Patient Refusal Checklist (SAMPLE) ............................................................................. 88
Refusal of Care Information Sheet (SAMPLE) ........................................................................ 89
Pre-Hospital Thrombolytic Screen (SAMPLE) ........................................................................ 90
Pediatric & Neonatal Assessment ........................................................................................... 91
ChemPack Standard Delagation Order (SAMPLE) ................................................................ 92
Antidote Administration for ChemPack ................................................................................... 93
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INTRODUCTION
These guidelines identify the procedures that may be performed in the field by EMS personnel. The off line medical
control for EMS activities are not intended to supersede an emergency physician's prerogative to order treatment.
The primary responsibility for the Emergency Care Provider at every level is to render prompt, efficient and proficient
care to the ill and injured. The treatments and procedures listed are intended to be carried out without contact with
medical control, unless the requirement to "Contact Medical Control" is part of the guideline. At any time that EMS
personnel feel the need to clarify or obtain orders, they are encouraged to do so.
The pre-hospital healthcare providers in our system have demonstrated an outstanding degree of competence and
dedication to one of the toughest jobs imaginable. It is our hope that these guidelines will make their job easier.
Development and Authority
The Medical Director for each individual agency is responsible for the entire aspect of patient care, which is defined as
from the time the call is received in dispatch until the patient arrives at the destination. The Texas State Board of Medical
Examiners and the Medical Practice Act mandate this authority.
The HOTRAC EMS Guidelines should serve as a basis for EMS agencies. HOTRAC EMS Guidelines will be reviewed
as needed or at least every licensure cycle. The individual agency medical directors, clinical staff, and HOTRAC Staff are
responsible for the review. An original signature page must be in the front of every Protocol/Standing Delegated Order
manual. When singular changes are made they will be signed by the medical director and placed in each EMS Protocol
book. These changes will be sent to the Texas Department of State Health Services.
Operational Policies
1.
2.
3.
4.
5.
6.
7.
History should not be obtained at the expense of delivering urgently needed care. Life-threatening problems noted in
the primary survey must be adequately managed first.
Trauma cardiac arrest is not treated by medical arrest standards. Trauma arrest patients require immediate transport
with control of external hemorrhage, neck immobilization if indicated. IV's are to be established in route. Cardiac
arrest drugs may be given if there is a history of heart disease.
Orders received from physicians other than those providing Medical Control should be verified with on line Medical
Control if they deviate from the protocols. If a licensed physician at the scene properly identifies himself and has
established a physician-patient relationship, agrees to accept responsibility for the patient's care and agrees to
accompany the patient to the hospital, EMS personnel may accept orders from that physician.
A run report must be provided for Medical Control on all runs within 24 hours.
If the patient's condition does not seem to fit a Protocol or Protocols, always contact Medical Control.
If you are asked to perform a hospital-to-hospital transfer of an unstable patient, call Medical Control.
Always maintain Universal Precautions body substance isolation, and personal safety.
Authorization to Provide Pre Hospital Care
Purpose



To ensure that the Provider is in compliance with the Texas State Board of Medical Examiners rule number 197.
To define “authorization” to function as Pre-hospital Care Providers within the Medical Control System
To ensure that each individual knows the requirements pertaining to obtaining and maintaining authorization
Authorization


Authorization is separate from certification. Every provider must have a current certification. The Medical Director
is responsible for granting authorization.
Authorization is required to provide pre-hospital or out-of-hospital care to any patient within the HOTRAC Region.
Certification level does not necessarily dictate authorization level. The Medical Director may authorize any provider
to function at any level as per DSHS Rule 157.
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
At no time may any provider provide pre-arrival instructions without prior approval of the Medical Director. This
includes personnel at any and all levels.
To Obtain Authorization

Prior to allowing any provider to function in a patient care delivery or dispatch role, the service shall notify the
Medical Director or designee and provide the following information:
o The individual’s name, date of birth, address, social security number, and home phone number
o The position for which the individual is applying
o A copy of the most current DSHS certification
o The copy must clearly show the applicant’s name, certification number, and expiration date.
o EMT-Paramedic applicants shall also provide legible copies with signatures and expiration or date of course
for the following:
 Advanced Cardiac Life Support (ACLS) course completion card from a nationally accredited
program
 International Trauma Life Support (ITLS) or Pre-hospital Trauma Life Support (PHTLS) may be
substituted, may be obtained within 180 days from medical authorization date.
 Pediatric Education for Pre-hospital Professionals (PEPP) or Pediatric Advanced Life Support
(PALS) may be obtained within 180 days from medical authorization date.
o EMT-Basic and EMT-Intermediate applicants should provide legible copies with signatures and expiration
dates/date of course for:
 ITLS and/or PHTLS or equivalent within 180 days of medical authorization.
o All EMS personnel working within TSA M are required to have the appropriate OSHA and/or CBRNE
training required to where the PPE (personal protective equipment) carried on many of the ambulances.
Geographic Limitations of Authorization



While on duty authorized individuals will retain authorization regardless of location
While off duty authorized individuals will retain authorization within the bounds of TSA M
This is not intended to encourage off duty personnel to stock their vehicles like an ambulance, but is instead
intended to allow some flexibility in the care of patients on scene of an emergency when that individual has
responded to render aid to the on duty crew
Authorization of Non-EMS Personnel
Individuals that are not authorized by the above policy will not be allowed to provide patient care under these EMS
Guidelines or under the License of the Medical Director. Licensed Physicians and Registered Nurses as well as other
allied health professionals may provide care in situations where they are part of a transport team. They must follow the
orders of the transferring physician. This does not negate the requirement to have two authorized personnel on board the
ambulance or to have one of those attending the patient. In instances of specialty transport the overall responsibility for
the patient falls with the transport team and the transferring physician.
RESTRAINTS POLICY
To Control Patients with Physical Restraints . . . Restraints are used in two senses during patient transport. The first is for
safety in the non-violent patient. The second is for control of the violent patient.
Safety Restraint Policy
All patients who are transported per stretcher will have lap belt, chest, and shoulder restraints (if available) at all times.
All patients who are ambulatory, but being transported by ambulance, must have standard seat belt restraints at all times.
Policy for Control of Violent Patients
The decision to restrain a violent patient should be made carefully and thoughtfully. Once the decision has been made
then it should be done swiftly and completely.
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In general, it is important that the patient in restraints can be immediately placed in a position allowing airway control and
the possibility of resuscitation.
1. Request help as necessary.
2. Plan your actions ahead of time.
3. Use only the amount of force necessary. Excessive force should never be used.
Always maintain control of the situation so that suction can be administered if necessary to prevent aspiration.
Never place a patient in restraints of any kind with a lock that requires a key to undo, unless you are in possession of the
key and are capable of immediate release of the restraint if necessary.
Supine or lateral positions may be elected by EMS personnel and are a matter of judgment at the time.
HELICOPTER ACTIVATION POLICY
(These recommendations are based on the Air Medical Dispatch Position Paper, National Association of EMS Physicians)
Medical Patients
Helicopter scene response is appropriate if it can reduce transport time over ground transport in certain circumstances.
The same is true if considering time to obtain ALS support. When ground transport time and ALS support is going to be
significantly longer (> 20 minutes) than air transport, helicopter "back-up" to scene response may be initiated.
The following medical conditions may warrant helicopter dispatch:
 Heart or Respiratory Patients who require rapid transport to a facility
 Acute Stroke patients with recent onset of symptoms
Trauma Patients
The following guideline applies to trauma patients receiving pre-hospital care in TSA-M (McLennan, Bosque, Falls, Hill,
and Limestone Counties). The goal in the management of the trauma patient is to appropriately utilize regional air
transport resources in order to reduce delays in providing optimal trauma care for severely injured trauma patients.
Always contact medical control at the trauma hospital destination if possible. They can also assist in the decision to
dispatch the helicopter.
Decision Criteria
Helicopter activation/scene response should be considered when it can reduce transportation time for TRAUMA patients
meeting the following criteria. Should there be any question whether or not to activate TSA-M regional air transport
resources, on-line medical control should be consulted for the final decision.













Penetrating injuries to head, neck, and torso
Respiratory Compromise/obstruction
GCS less than 13
O2 sat less than 90%
Adult Patients with a SBP less than 100
Child less than one year with SBP less than 70 or heart rate less than 100 or more than 190
Child 1-9 years with SBP less than 70 + 2 x age in years or heart rate less than 80 or more than 150
Suspected Amputation proximal to the wrist or ankle
Suspected Two or more proximal long bone fractures (Femur, Humerus)
Suspected Any open long bone fracture (femur, tibia, femur)
Suspected Pelvic fractures
Burns more than or equal to 20% BSA or more than 10% if under 6 years old
Temperature less than or equal to 95◦F
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
Patients with traumatic paralysis
Additionally helicopter activation/scene response should be considered when:
o Patient extrication time will be prolonged (> 20 minutes).
o Multiple patients on scene
o Ejection from MVC
Patients transported via helicopter should be taken to the nearest Level I or Level II Trauma Facility.
DESTINATION POLICY
General Guidelines
The primary objective to be met is to ensure that each patient is taken rapidly to the nearest appropriate hospital.
Patients who have been assessed and determined to be medically unstable, unconscious, or at high risk of multiple and/or
severe injuries (Category 1 and 2 patients) will be safely and rapidly transported to the Regional Trauma Center.
Category 3 patients will be safely and rapidly transported to the nearest appropriate trauma facility within TSA M.
Category 4 patients will be safely and transported to the nearest appropriate acute care facility within TSA M.
Regional transport guidelines ensure that patients who meet the triage criteria for activation of the TSA-M
Regional Trauma System Plan will be transported directly to the nearest appropriate trauma facility rather than to the
nearest hospital except under the following circumstances:

If unable to establish and/or maintain an adequate airway, or in the case of traumatic cardiac arrest, the
patient should be taken to the nearest acute care facility for stabilization.

A Level III or Level IV trauma facility may be appropriate if the expected scene to Level II Trauma Center
transport time is excessive (> 30 minutes) and there is a qualified physician available at the facility’s
Emergency Department capable of delivering definitive care.

Medical Control may wish to order bypass in any of the above situations as appropriate, such as when a
facility is unable to meet hospital resource criteria or when there are patients in need of specialty care.

If expected transport time to the nearest appropriate Trauma Center is excessive (> 30 minutes) or if a
lengthy extrication time (> 20 minutes) is expected, medical control or the EMS crew on scene should
consider activating air transportation resources.
Note: Should there be any question regarding whether or not to bypass a facility, on-line medical control should be
consulted for the final decision from the receiving facility.
**Patients that are in active labor and less than 35 weeks gestation should be taken directly to a NICU-capable facility.
In TSA M, that facility is Hillcrest Baptist Medical Center. All other pregnant patients shall follow the regional
transport guidelines that have been established in TSA M.
PRE-HOSPITAL TRAUMA TRIAGE
Goal
Patients will be identified, rapidly and accurately assessed, and based on identification of their actual or potential for
serious injury, will be transported to the nearest appropriate TSA-M trauma facility.
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Purpose
In order to ensure the prompt availability of medical resources needed for optimal patient care, each patient will be
assessed for the presence of abnormal vital signs, obvious anatomic injury, mechanism of injury, and concurrent
disease/predisposing factors.
Definition
Trauma Patient—the patient is a victim of an external cause of injury that results in major or minor tissue damage or
destruction caused by intentional or unintentional exposure to thermal, mechanical, electrical, or chemical energy, or by
asphyxia, submersion, or hypothermia.
System Triage
1.
Unless immediate stabilization is required, patients in TSA-M with the following injuries, with significant
mechanism of injury, should be taken directly to Hillcrest Baptist Medical Center or another appropriate trauma
facility offering resources not available to Hillcrest Baptist Medical Center, unless immediate stabilization is
required:














Penetrating injuries to head, neck, and torso
Respiratory Compromise/obstruction
GCS less than 13
O2 sat less than 85-90%
Adult Patients with a SBP less than 100
Child less than one year with SBP less than 70 or heart rate less than 100 or more than 190
Child 1-9 years with SBP less than 70 + 2 x age in years or heart rate less than 80 or more than 150
Suspected Amputation proximal to the wrist or ankle
Suspected Two or more proximal long bone fractures (Femur, Humerus)
Suspected Any open long bone fracture (femur, tibia, femur)
Suspected Pelvic fractures
Burns more than or equal to 20% BSA or more than 10% if under 6 years old
Temperature less than or equal to 95◦F
Patients with traumatic paralysis
2.
If ground transport time to Hillcrest Baptist Medical Center is greater than 30 minutes with protocols, or if lifesaving
interventions (e. g. airway stabilization, chest tube insertion, etc.) are required for safe transport, contact medical
control and/or take the patient to the nearest medical facility and call for the helicopter transport to meet you at
the closest agreed upon landing zone.
3.
When on-scene EMS personnel are unable to establish on-line contact with medical control at the receiving TSA-M
facility, off-line medical trauma triage criteria will be followed.
DNR CONDITIONS
The following procedures are not to be performed on patients with DNR orders:
 CPR
 Endotracheal intubation or other advanced airway management
 Artificial ventilation
 Defibrillation
 Transcutaneous cardiac pacing
 Administration of cardiac resuscitation medications
The following conditions are considered to be automatic DNR in which there is no need to contact medical control; if
there is any doubt, you may contact Medical Control. It is better to err on the side of resuscitation. Appropriate DNR
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documentation should be completed in all cases. Documentation of position patient found in and any other pertinent
information should be included.
 Decapitation
 Rigor Mortis
 Total incineration
 Decomposition
 Dependent lividity
 Mass Casualty Incident where triage principles preclude CPR from being initiated on every victim.
 Traumatic arrest resulting from blunt injury presenting apneic and pulse less
 DNR order by patients' physician:
 Direct phone contact*
 Written DNR order signed by physician
 State authorized form, properly signed
 State authorized bracelet or necklace
*If you receive DNR orders from a patient's private physician, via direct phone contact, the orders will be honored. (Even
if resuscitative efforts are in progress.) The physician, however, must provide to you their full name, a telephone number
where they may be reached for the next 60 minutes and their State License Number. This information will be provided to
law enforcement on scene and documented in the patient care report.
If there is a DNR dispute, contact Medical Control.
In QUESTIONABLE DEATH, with Police request, you may draw red and purple top tubes for police investigation.
First, DNR orders must have been received and documented. Then, obtain the signature of the officer requesting the lab.
The run record should include:
 Assessment of the patient's condition
 The method of identification of DNR order or condition
 Any problems relating to implementation of the DNR order
 Identification of persons used to identify the patient
You may accept an out of state DNR order if there is no reason to question the authenticity of the order.
DNR orders do not apply if the patient is pregnant.
REFUSAL TO TRANSPORT
General Statement
The following is an outline of legal principles that may assist with determining an individual’s right to refuse treatment
and or transport against medical advice.
1) Consent
a) The patient has the responsibility to consent or to refuse treatment. If he is unable to do so, a responsible relative
or guardian has this right.
b) When waiting to obtain lawful consent from the person authorized to make such consent would present a serious
risk of death, serious impairment of health or would prolong severe pain or suffering of the patient, treatment
may be undertaken to avoid those risks without consent. In no event should legal consent procedures be allowed
to delay immediately required treatment.
c) In non-emergency cases, consent should be obtained from the patient or a responsible party prior to undertaking
any treatment.
d) Age: Patient must be 18 years of age or older, or between 14 and 17 years and "emancipated" (i.e., living apart
from parents).
e) If the patient is under age, consent should be from a natural parent, adopted parent, or legal guardian.
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2) Mental Competence
a) A person is mentally competent if he or she:
i) Is capable of understanding the nature and consequences of the proposed treatment.
ii) Has sufficient emotional control, judgment, and discretion to manage his or her affairs.
b) Ascertaining that the patient is oriented, has an understanding of what happened and may possibly happen if
treated or not treated, and a plan of action, such as which he will call for transportation home, should be adequate
for these determinations. (i.e., patients with impaired cerebral perfusion, in shock, postictal, or under the
influence of drugs/alcohol will be unlikely to fulfill these criteria.)
c) If the patient is not mentally competent under these guidelines, consent should be obtained from another
responsible party, who must be mentally competent and must be 21 years of age, in the following order of
preference:
i) Spouse
ii) Adult son or daughter
iii) Parent
iv) Adult brother or sister
v) Legal guardian
d) If the patient is not mentally competent and none of the above persons can be reached, the person should be
treated and transported to a medical facility. It is preferable under such circumstances to obtain concurrence of a
police officer in this course of action.
e) If the patient himself is not competent to consent and a responsible person is present, and if that responsible
person is of age and competent, he or she has the same right to consent or refuse treatment as the patient himself.
His wishes can not be ignored in a non-life-threatening situation.
Procedure for Refusal
If a patient wishes to refuse treatment, examination, or transportation, the following steps will be taken:
1) The provider will complete a Patient Refusal Checklist. This includes assessment of the patient's level of orientation,
level of consciousness, whether there is a head injury, or whether the patient is under the influence of drugs and/or
alcohol.
2) If any of the above conditions are present, and the patient refuses care, medical control will be contacted; the contact
and what the orders were will be documented. If unable to contact, document why.
3) The patient will be advised that further harm could result without treatment and evaluation, and that transport by
means other than ambulance could be hazardous in light of the patient's injury or illness.
4) The type of refusal that is involved should be documented, whether the patient has used all EMS services, refused
transport but accepted field treatment, refused field treatment but accepted transport whether released in the custody
of themselves, law enforcement, or others.
5) The patient will be provided with a refusal information sheet. A copy of this sheet will be signed by the patient and
kept with the file. It will be noted whether the patient refused this sheet on the checklist. The signed information
sheet as well as the refusal checklist will be kept with the patient file.
SPINAL MOTION RESTRICTION GUIDELINES
Injury to the spine, especially the cervical and thoracic spine can have catastrophic consequences. Because of this, any
guidelines for field immobilization criteria must be extremely conservative. The consequences of any other approach can
be devastating.
Primary Injury to the spinal cord occurs at the time of impact or injury. Secondary injury occurs later from swelling,
ischemia, or movement of bony fragments or the cord itself. In the field, we must be sure to do all we can to prevent any
secondary injury.
There are two reasons only to remove a helmet in the field:
1. Urgent airway problem that requires helmet removal for evaluation & management
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Rev. 5.10
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2.
A helmet that is obviously too large that prohibits the ability to package the patient and restrain the head and
neck.
Motorcycle helmets may cause airway obstruction and should then be removed per ITLS protocol
Note that in other scenarios, helmet removal in the field could lead to delay and to possible medico-legal consequences.
Assessment Guidelines
1) Mechanism of Injury
a) Positive mechanism is any history or evidence of impact forces that could be capable of damaging the spinal
column.
b) Negative mechanism is that given the impact and forces involved, there is no reasonable possibility that the spine
might be injured.
c) Uncertain mechanism is when the actual impact and forces or injury are uncertain.
2) Assessment
a) Pain. When asked, the patient can tell you he/she has pain. If there is any other distracting injury, then this is
not a valid criterion for assessment.
b) Neurologic assessment. Motor and sensory functions including strength and touch and pain sensation reflect
injury to the cord. In the field, positive findings are valid. Negative findings may not be valid depending on the
field situation. Most of the time, a complete neurologic exam cannot be done in the field.
c) Head injury. In any patient with abnormal mental status or level of consciousness, the assessment should be
considered unreliable.
For all patients with a positive mechanism of injury, full spinal motion restriction is required.
In unimpaired patients with a negative mechanism of injury and negative assessment, spinal motion restriction may be
omitted.
If the mechanism is uncertain, and the patient has any signs or symptoms that could be related to spinal injury, full spinal
motion restriction is required.
In cases with unreliable history or exam for any reason, full spinal motion restriction is required.
Very small children may be immobilized in a car seat with towels, bandage, etc. if possible to maintain immobilization.
Sometimes this may prevent unnecessary movement of the spine.
Short Board/KED Use
The short board / KED should be used for patients who are in a position (such as an automobile) that does not allow for
the use of the long backboard and requires full spinal motion restriction.
Although this is the best way to extricate anyone with a possible spinal injury, there are certain situations where a more
rapid method should be used.
Situations Requiring Rapid Extrication
 The scene is unsafe, for example:
 Fire or immediate danger of fire
 Danger of explosion
 Rapidly rising water
 Structure in danger of collapse
 Continuing toxic exposure
 The primary survey reveals a condition that requires immediate intervention that cannot be done in the vehicle, for
example:
 Airway obstruction that you cannot relieve by jaw thrust or finger sweep
 Cardiac or respiratory arrest
 Chest or airway injuries requiring ventilation or assisted ventilation
 Deep shock or bleeding you cannot control
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Rev. 5.10
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Authorized Medications
ADENOSINE
Indications
Administration
Contraindications
Precautions
Side Effects and Special
Notes

First drug for supraventricular tachycardia

Wide complex tachycardia after Lidocaine
Adult: Rapid IV bolus over 1-2 seconds of 6mg initially, followed immediately by 20ml saline over 5-10
seconds. A second dose of 12mg in 1-2 minutes if needed using the same technique. A third dose of
12mg may be given if necessary after contacting medical control, again using the same technique.
Pedi: Rapid IV 0.2 mg/kg initial dose followed immediately with 10ml saline over 10-15 seconds. A
second identical dose may be given if necessary.

Known hypersensitivity to the drug.

Second and third degree heart block.
Adverse effects include flushing, dyspnea, chest pain, anxiety, bradycardia, and occasionally
hemodynamic disturbances – all of which are short lived.

Whenever possible establish the IV at the antecubital.

Caffeine and theophylline antagonize adenosine’s effects. Larger doses may be required.

Warn patients to expect a brief sensation of chest discomfort.

If patient is hemodynamically unstable, use the Tachycardia, Unstable With Pulses guideline.
ALBUTEROL
Indications
Administration
Contraindications
Precautions
Side Effects and Special
Notes
Asthma, acute wheezing, dyspnea with wheezing
Solution
Adult: 2.5mg diluted to 3ml with NS nebulizer. May repeat to total of three doses.
Pedi: Same as for adult
Known hypersensitivity to the drug.

Albuterol has sympathomimetic effects. Discontinue immediately if patient develops chest pain or
dysrhythmia.

Inhaled, Albuterol can result in paradoxical bronchospasm, which can be life threatening. If this
occurs, the nebulizer should be discontinued immediately.

Monitor blood pressure, heart rate/rhythm closely and contact medical control if any concerns arise.

Medications such as MAO inhibitors and tricyclics may potentiate tachycardia and hypertension.
AMIODARONE
Indications
Administration
Contraindications
Precautions
Side Effects and Special
Notes

Stable wide-complex tachycardia (systolic BP > 80, weakness, no altered LOC)
Adult: 150mg Slow IVP over 10 minutes (15mg/min). Mix 150mg with 100cc D5W (infuse at 10ml/min).
Pedi: not indicated by these guidelines.

Heart block

Cardiogenic shock

Allergic to Amiodarone

Nausea and vomiting are common reactions, be prepared to administer Promethazine as needed.

Hypotension is common, monitor blood pressure frequently.

Flushing, edema, sinus arrest, hypotension, nausea & vomiting
ASPIRIN
Indications
Administration
Contraindications

Chest pain of suspected cardiac origin

Suspected congestive heart failure
Four 81 mg (Total: 324mg) chewable aspirin to chew and swallow only.
Known hypersensitivity to Aspirin or other NSAID (Like Motrin®)
GI bleeding
ATROPINE
Indications



Administration




HOTRAC Regional EMS Guidelines
Rev. 5.10
First drug for symptomatic bradycardia.
Second drug for asystole or bradycardic PEA.
Antidote for some insecticide exposures (i.e. organophosphate with symptoms of excess cholinergic
stimulation: salivation, lacrimation, urination, defecation, increased GI motility, and emesis.
(SLUDGE)
Asystole
Adult: 1 mg IV, repeat every 3-5 minutes. Max dose 0.04 mg/kg
Pedi: 0.02 mg/kg IV, minimum 0.1 mg
Symptomatic Bradycardia
Adult: 0.5-1.0 mg IV, repeated if needed at 3-5 minute intervals to a dose of 3 mg; not to exceed 0.04
mg/kg (stop at ventricular heart rate which provides adequate mentation, B/P –aim for HR =
60/minute)
Pedi: 0.02 mg/kg IV, minimum 0.1 mg
Consider Pacing if bradycardia persists after 2 doses
May be given through ET tube at 2 times the IV dose. Max ET dose is 6mg.
For symptomatic insecticide exposures: Contact medical control for dosage (usually begin with 1mg
Page 73
Contraindications
Precautions
Side Effects and Special
Notes
IV and titrate until breath sounds are clear; total required dose may be massive).
Known hypersensitivity to the drug

Avoid in hypothermia

Can cause increased cardiac O2 consumption

Remember that in cardiac arrest situations that atropine dilates pupils

Will not work in patients with heart transplants
DEXTROSE 5%
Indications
Administration
Precautions
Side Effects and Special
Notes
IV solution to keep vein open. Vehicle for mixing medications for IV delivery.

Adult: See Amiodarone.

Pedi: same as above
Patients at risk for elevated I.C.P. Elevated blood glucose concentrations.
Local venous irritation.
DEXTROSE 50%
Indications
Administration
Precautions
Side Effects and Special
Notes
Blood Glucose concentration < 50 mg/dL; IV solution to keep vein open; Vehicle for mixing medications
for IV delivery.

Adult: See Amiodarone.

Pedi: same as above

Use with caution with stroke specific symptoms. (Unilateral weakness, paralysis, and paresis)

Extravasations of glucose can cause tissue necrosis. Ensure IV patency before and during
administration

One bolus should raise the blood sugar 50-100 mg/ml and, therefore, will be adequate for most
patients

Effect may be delayed in elderly patients with poor circulation

Do not administer dextrose to a patient who is seizing due to trauma

Dextrose 50% should be diluted 1:1 with normal saline (to create D25) for patients 8 years and
younger
DIAZEPAM
Indications
Administration
Contraindications
Precautions
Side Effects and Special
Notes
First drug for status epilepticus
Sedation prior to cardioversion, pacing, or other painful procedure
Seizure:
Adult: 0.1 mg/kg IV
Pedi: 0.1 mg/kg IV
Sedation:
Adult: 2.5 – 5 mg IVP repeat as necessary. (No more frequently than q 2 min)
Pedi: Not given for sedation
Known hypersensitivity to drug
Shock, coma, and acute alcohol intoxication
May cause changes in heart rate and BP
May cause  respiratory rate or APNEA
Headache, over sedation, drowsiness, amnesia, nausea, vomiting, hiccups
DILTIAZEM
Indications
Administration
Contraindications
Precautions
Side Effects and Special
Notes
Drug of second choice for SVT and rapid atrial fib or flutter after contacting medical control
Adult: 5-10 mg IV over 2 minutes
Pedi: 0.2 mg/kg do not exceed 10mg over 2 minutes

Severe hypotension or cardiogenic shock

Second or third degree AV block (except with a functioning pacemaker)

Sick sinus syndrome (except with a functioning pacemaker)

Severe CHF (unless secondary to SVT)

Wolff-Parkinson-White, or Lown-Ganong-Levine syndromes

Wide complex tachycardia

Known hypersensitivity to drug
Do not give with IV beta blockers (Labetalol)

May cause hypotension, bradycardia, dizziness, headache, and rarely seizures

In elderly patients drug must be given over 3 minutes to reduce untoward effects

In controlled studies in the US about 60% of patients with SVT converted to a sinus rhythm within
10 minutes of IV Diltiazem. Uncontrolled studies reported in the world literature describe a
conversion rate of about 80%.

The effect of a single injection lasts for 30 to 60 minutes when conversion to sinus rhythm does not
occur.
DIPHENHYDRAMINE
Indications
Second drug for anaphylaxis and severe allergic reactions
First drug to counteract dystonic reactions to antipsychotic drugs
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Rev. 5.10
Page 74
Administration
Contraindications
Precautions
Side Effects and Special
Notes
Anaphylaxis
Adult: 50 mg slow IV push or deep IM
Pedi: 1-2 mg/kg slow IV (max 50 mg total)
Dystonic reaction
Adult: 25 mg slow IV push or deep IM
Pedi: 1 mg/kg slow IV (max 25 mg total)
Do not administer to newborns and neonates or breast feeding patients
May cause drowsiness which may be potentiated by alcohol or depressants

Not the first line drug for allergic reactions, but may be useful for long transports.

May see CNS stimulation in children

Side effects include dry mouth, dilated pupils, flushing, and drowsiness.

Diphenhydramine should be used with caution in patients with Asthma/COPD, glaucoma, and
bladder obstruction, as all of these can be exacerbated by its administration.
DOPAMINE
Indications
Administration
Contraindications
Precautions
Side Effects and Special
Notes
Significant hypotension and signs of shock
Hypovolemic shock only after fluid replacement

Dosage per medical control then use drip rate table below

Use premixed solution with gtt set and Exacdrop™ or similar device.
Known hypersensitivity

Dopamine may induce tachy-dysrhythmia. If the heart rate exceeds 140, the infusion should be
stopped

At low doses, decreased B/P may occur due to peripheral vasodilatation. Increasing the rate will
correct this.

Should not be mixed with sodium bicarbonate

Extravasations at the IV site can cause skin sloughing due to vasoconstriction; assure IV patency
before initiating an infusion.
Drip Rate Table
(1600 g/ml)
g/kg/ min
5
10
15
20
110
10
20
30
40
132
10
25
35
45
Patient weight in lbs
154
176
198
15
15
15
25
30
35
40
45
50
50
60
70
gtt per minute (or ml/hr)
220
20
35
55
75
242
20
40
60
85
EPINEPHRINE
Indications
Administration
Cardiac arrest with VF, Pulse less VT, Asystole, PEA
Anaphylaxis

Cardiac Arrest
Adult: 1mg IV q 3 min
Pedi: First dose: 0.1 mg/kg IV (0.1 ml/kg of 1:1,000 solution)
Subsequent doses 0.2 mg/kg IV (0.2 ml/kg of 1:1,000 solution)

Anaphylaxis
Adult: 0.3 - 0.5 mg (0.3 ml of 1:1,000) SQ or 0.1 - 0.5mg (1:10,000) IV very slowly
Pedi: 0.01 mg/kg (0.01 ml/kg 1:1,000) SQ or IV
ET tube doses at 2 to 2½ times the IV dose
Contraindications
Precautions
Side Effects and Special
Notes
Epi Auto-injectors (both adult and pediatric) may be utilized and should be used as directed by the
service’s medical director.
None in cardiac arrest
Dysrhythmia, coronary insufficiency, organic brain damage
Do not add to solutions containing bicarbonate
Increase in myocardial oxygen demand can cause angina or MI in patients with CAD
Use with caution in hyperthyroidism, peripheral vascular disease, or cerebrovascular disease

Anaphylactic shock is a systemic allergic reaction with cardiovascular collapse. Angioedema
involves swelling of the mucous membranes; potential exists for airway compromise. Mild or
moderate allergic reactions with urticaria or wheezing may progress to anaphylaxis or severe
angioedema. Monitor patient carefully and treat according to patient status.

Epinephrine comes in two strengths. Use of the wrong formulation will result in a ten-fold
difference in dosage. Be sure you use the right one.

Anxiety, tremor, palpitations, vomiting, and headache are common side effects

Services with full time paramedic staffing are not required to stock auto injectors
FUROSEMIDE
Indications
Administration
Adjunctive therapy for acute pulmonary edema and hypertensive crisis

Adult: 0.5 – 1 mg/kg IV slow push over 1-2 minutes
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Rev. 5.10
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Contraindications
Side Effects and Special
Notes





Pedi: 1mg/kg IV slow push over 1-2 minutes
Known hypersensitivity to the drug
Patients with anuria
Possible side effects include, hypotension, EKG changes, chest pain, dry mouth, hypochloremia,
hypokalemia, hyponatremia, and hyperglycemia
Onset occurs within 5 minutes of administration, peak effects occur within 30 minutes of
administration
GLUCAGON
Indications
Administration
Contraindications
Precautions
Side Effects
Hypoglycemia, after two unsuccessful IV attempts
Procedure
Adult: 1 mg IM
Pedi: 0.1 mg/kg IM
Known hypersensitivity to drug

Only effective if there are stores of liver glycogen

Return to consciousness may take between 5 and 20 minutes

Use with caution in patients with a history of cardiovascular or renal disease
Glucagon exerts a positive inotropic action on the heart and decreases renal vascular resistance
GLUCOSE, INSTANT
Indications
Administration
Contraindications
Hypoglycemia in patients who can protect their own airway
Administer entire contents of a 15 gm tube PO
Semiconscious patients
Unconscious patients
LABETALOL
Indications
Administration
Contraindications
Precautions
Side Effects and Special
Notes
Second drug for hypertensive crisis B/P  110 diastolic
Adult: 20 mg IV push over 2 minutes. May repeat with 40 mg PRN q 10 min with approval of medical
control
Patients with bronchial asthma, congestive heart failure, high degree AV block, bradycardia, or
cardiogenic shock.
When administering Labetalol stay alert for signs and symptoms of CHF, bradycardia, shock, heart block,
or bronchospasm. If any of these appear discontinue the drug immediately.
Supine B/P should be monitored immediately before the injection, at 5 minutes and 10 minutes after the
injection. These should be documented.
Postural hypotension should be anticipated
LACTATED RINGERS
Indications
Administration
Contraindications
Precautions
Side Effects/Special
Notes
Suspected volume depletion due to thermal burns
Adult: IV fluid therapy due to thermal burns: 2-4ml x burn % x weight (kg) up to 2 liters
Pedi: same as above.
Pulmonary edema
Fluid overload; Potentially sensitive patients may include those with renal failure, pregnancy, neardrowning and CHF
Fluid overload; pulmonary edema
LIDOCAINE
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 76
Indications
Administration
Following successful defibrillation
Recurrent or refractory VF or VT
Ventricular or wide complex tachycardia with pulses
Premedication for intubation of patient with head trauma
Cardiac Arrest (Pulse less VF or VT)
Adult: 1.5 mg/kg IV bolus repeat 0.5 mg/kg IV bolus q 3 min up to 4/mg/kg
Pedi: 1.5 mg/kg IV bolus repeat 0.5 mg/kg IV bolus q 3 min up to 4 mg/kg
VT or Wide Complex Tach with pulse
Adult: 1 mg/kg IV
Pedi: 1 mg/kg IV
Premedication for intubation of head trauma
Adult: 1 mg/kg IV (No drip necessary)
Pedi 1 mg/kg IV (No drip necessary)
ET tube doses at 2 to 2½ times the IV dose
Infusion
Adult: Use a premixed infusion at 4 mg/ml concentration with a micro drop set and a Exacdrop™ or
similar device. Then use chart below.
Lidocaine Drip
Bolus dosage
1 mg/kg
1-2 mg/kg
2-3 mg/kg
mg/min
2
3
4
gtt/min, or ml/hr
30
45
60
Dosage
Pedi: Use a premixed infusion at 4mg/ml concentration with a gtt set and a Exacdrop™ or similar
device. Then use chart below.
Pedi Lidocaine Drip
3
3
Weight
15lb
22lb
44lb
55lb
66lb
77lb
88lb
99lb
l
b
30
3
5
7
9
11
14
16
18
20
g/min
40
4
6
9
12
15
18
21
24
27
g/min
1
50 g
5
8
15
19
23
26
30
34
1
/min
gtt/min

Known hypersensitivity to drug

Severe SA, AV or interventricular blocks in the absence of artificial pacemaker.

High grade AV block is relative contraindication

Do not treat ventricular escape beats or accelerated idioventricular rhythm with Lidocaine

Lidocaine is metabolized in the liver; elderly patients and those with liver disease or poor liver
perfusion secondary to shock or CHF are more likely to experience side effects

Side effects include drowsiness, confusion, convulsion, hypotension, bradycardia, and tachycardia.

Head trauma requires careful airway management. If endotracheal intubation is appropriate,
pretreatment with Lidocaine may help avoid further increase in intracranial pressure, if time permits.

Resist the urge to treat every PVC. Lidocaine is a toxic drug. PVCs outside the setting of acute MI
should not be treated. Hypoxia can generate PVCs, and Lidocaine will not help; treat the cause.

Best available evidence currently indicates that prophylactic Lidocaine (in the setting of MI without
PVCs) may actually increase mortality.

For patients over 70, or with liver dysfunction, the usual adult loading dose will be utilized. This
dose will then be followed by half of the usual maintenance dose of Lidocaine.
Contraindications
Precautions
Side Effects and Special
Notes
MAGNESIUM SULFATE
Indications
Administration
Contraindications
Precautions
Side Effects and Special
Notes

First drug for torsades de pointes.

First drug for seizures due to eclampsia
Torsades de pointes: 2gm over 2 minutes; draw up 2 gm into a 20 ml syringe then draw up normal saline
to fill the syringe to the 20 ml mark. Invert the syringe several times to mix the medication then give 10
ml of the solution every 6 seconds.
Eclampsia: Mix 4 gm in a 50 cc bag of D5W and infuse over 20 minutes

None in cardiac arrest

Active labor

AV Block

Decrease in respiratory or cardiac function

Eclampsia is defined as pregnancy > 20 weeks with the following
1. Blood Pressure > 180 mm systolic or > 120 diastolic with altered mental status, or
2. Seizures with B/P > 140/90

Principle side effect is respiratory depression, ventilator assistance may be needed

Not for pediatric use
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Rev. 5.10
Page 77
MIDAZOLAM
Indications
Administration
Contraindications
Precautions
Side Effects and Special
Notes
Sedation prior to cardioversion, pacing, or other painful procedure
Sedation:
Adult: 2.5 – 5 mg IVP repeat as necessary. (No more frequently then q 2 min)
Pedi: Not given for sedation
Known hypersensitivity to drug
Shock, coma, and acute alcohol intoxication
May cause changes in heart rate and BP
May cause  respiratory rate or APNEA
Headache, over sedation, drowsiness, amnesia, nausea, vomiting, hiccough
M ORPHINE SULFATE
Indications
Administration
Contraindications


Chest pain with anxiety
Extremity injury where severe pain is present: to be given only in the absence of any evidence of
head, chest, or abdominal injuries. If you think MS should be given for any other reason contact
medical control

Severe burns after contacting medical control
Adult: 2 mg IV or IM initially; repeat q 3-5 PRN up to 10mg. The goal is decreased anxiety and patient
comfort. Contact medical control for additional doses.
Pedi: 0.1 – 0.2 mg/kg IV slowly
Known hypersensitivity to drug

Precautions
Hypotension is a contraindication to use. Remember, some people will be hypotensive in response
to pain itself. Smaller doses are less likely to cause or aggravate hypotension.

Contact medical control first if head, chest, or abdominal trauma is also a relative contraindication
to morphine use, since the analgesic effect removes the clinical signs that need to be observed

Do not use in the presence of major blood loss. The body’s compensatory mechanisms will be
suppressed by the use of morphine and the hypotensive effect will be very prominent.

May cause  respiratory effort or even APNEA
May cause vomiting; administer slowly.
It is not necessary to stock Morphine Sulfate if Nalbuphine is carried.
Side Effects and Special
Notes
NALOXONE
Indications
Administration
Contraindications
Precautions
Side Effects and Special
Notes




Narcotic and synthetic narcotic overdose
Coma of unknown origin
Adult or Pedi: 2mg IV, IM or IO
If no response is observed this dose may be repeated after 5 minutes if narcotic overdose is strongly
suspected.

May be given via ET tube at 2 times the IV dose.
Known hypersensitivity to drug
In patients physically dependant on narcotics, violent withdrawal symptoms may be precipitated. Be
prepared to restrain the patient. Titrate the dose (1-2 mg at a time) to reverse cardiac and respiratory
depression but to keep the patient groggy.

May need large doses (8-12 mg) to reverse propoxyphene (Darvon) overdose

The duration of some narcotics is longer than Naloxone and the patient must be monitored closely.
Repeated doses of Naloxone may be required. Patients who have received this drug must be
transported to the hospital because coma may reoccur when Naloxone wears off.

With an ET tube in place and assisted ventilation, narcotic overdose patients may be safely managed
without Naloxone. Think twice before totally reversing coma; airway may be lost, or (worse) the
patient may become violent and may refuse transport.
NITROGLYCERINE (NTG)
Indications
Administration
Contraindications
Precautions
Side Effects and Special
Notes

Chest pain of suspected cardiac origin

Hypertensive crisis

Pulmonary edema
Chest Pain (Systolic  100) & Hypertensive Crisis (Diastolic  100)
Adult: 1 NTG 0.4 mg SL q 5 minutes max of 3 doses (Must check B/P prior to each dose)
Pulmonary Edema (Systolic  100)
Adult: 2 NTG 0.4 mg SL q 5 minutes max of 3 doses (Must check B/P prior to each dose)
Known hypersensitivity to nitrates
May cause profound hypotension and reflex tachycardia

Common side effects include throbbing headache, flushing, dizziness, and burning under the tongue.

Less common: orthostatic hypotension, sometimes marked

Because nitroglycerine causes generalized smooth muscle relaxation, it may be effective in relieving
chest pain caused by esophageal spasm.
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 78

May be effective even in patients using paste, disks, or oral long acting nitrate preparations
NORCURON
Indications
Administration
Contraindications
Precautions
Side Effects and Special
Notes
Indications
Administration
Contraindications
Precautions
To achieve paralysis to facilitate endotracheal intubation
Adult: Defasiculating Dose: 0.01 mg/kg IVP
Maintaining Paralysis: 0.1 mg/kg IVP
Pedi: not indicated
Patients with known hypersensitivity
Endotracheal intubation equipment must be ready

Increased intracranial and intraocular pressure

Hypertension and hypotension

Respiratory depression

Bradycardia
NOTE: Norcuron is packaged with a vial of sterile water but in the absence of sterile water, normal
saline may be used for reconstitution.
NORMAL S ALINE
Hypotension (Systolic B/P  90), Altered LOC, Cardiac Arrest, V-Tach and Wide complex Tach with a
pulse, Hyperthermia, Category 1 or 2 trauma, trauma with significant blood loss potential, vaginal
bleeding
TKO = 5-10 gtt/min


Side Effects and Special
Notes
In hemorrhagic shock, volume expansion with blood is the treatment of choice. Normal saline will
temporarily expand intravascular volume and “buy time”, but it does not increase the O2 carrying
capacity, and is not sufficient in severe shock. Because of this rapid transport is still needed to treat
severely Hypovolemic patients who need blood and possible surgical intervention.
Volume overload is a constant danger, particularly in cardiac patients. Keep a close eye on your IV
rate during transport

Flow rate through a 14g cannula is twice the rate through an 18g cannula, and volume
administration in trauma patients can be accomplished more rapidly. If the patient has
poor veins, a smaller bore is better than no IV at all.

IVs in unstable trauma patients should be placed en route, and may be left to the emergency
department for short transports. Do NOT delay transport in critical patients for IV attempts.
If you are unable to start in two attempts, another qualified attendant may try, or you may leave the
IVs for the emergency department.

OXYGEN
Indications
Administration
Precautions
Side Effects and Special
Notes





Chest Pain

O2 Sat < 90%
Dyspnea

Suspected closed head injury
Category 1 & 2 trauma

Suspected carbon monoxide poisoning
Cyanosis

Hypotension from any cause
Altered LOC (from baseline for the

Suspected hypoxemia
patient)
High flow O2 (12-15 liters/min via non or partial rebreather mask) is indicated for the conditions listed
above.
Otherwise administer O2 with the appropriate adjuncts at your discretion.

If the patient is not breathing adequately, the treatment of choice is ventilation, not just oxygen.

A small percentage of patients with chronic lung disease breathe because they are hypoxic.
Administration of O2 will inhibit their respiratory drive. Do not withhold O2 because of this
possibility. Be prepared to assist ventilation if needed.
Oxygen toxicity is not a hazard of short-term use.
Always note O2 Sat before and after administering O2
If pulse oximeters are not available clinical signs of perfusion must be monitored and documented.
PROMETHAZINE
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 79
Indications
Administration
Contraindications
Precautions
Side Effects and Special
Notes
Persistent vomiting with long transport time ( 15 min)
Adult: Dilute 12.5 mg in 20 ml syringe (1 ml Promethazine to 19 ml NS) and give slow IV push over 2
minutes (1 ml every 6 seconds) Can repeat once PRN
Pedi: Not given to pediatric patients
Altered level of consciousness
Traumatic injury
Pregnancy or Lactation
Can cause dystonic reaction in some individuals
Use with caution if patient ever had adverse reactions to phenothiazine
May cause localized burning and irritation upon administration
May cause drowsiness, confusion, disturbed coordination, restlessness, tremors, transient hypotension,
blurred vision, dry mouth, dry nose, dry throat, irregular respiration, photosensitivity
Incompatible with Morphine Sulfate and Nalbuphine
SUCCINYLCHOLINE
Indications
Administration
Contraindications
Precautions
Side Effects and Special
Notes
To facilitate intubation
Adult: 1 mg/kg IV push over 10 to 30 seconds
Pedi: Not given to pediatric patients
Inability to control airway and/or support ventilations with oxygen and positive pressure.
Hypersensitivity
May cause cardiac dysrhythmia
May cause hypotension
Onset: Less than 1 minute. Duration: 3 to 10 minutes after initial IV dose
Succinylcholine has no effect on consciousness or pain.
May only be given and carried by those specifically trained and certified by the medical director.
SODIUM BICARBONATE
Indications
Administration
Contraindications
Precautions
Side Effects and Special
Notes
Tricyclic Overdose
Adult: 1 mEq/kg IV after contacting medical control
Pedi: Not given to pediatric patients
Known metabolic or respiratory alkalosis, known hypocalcaemia

Addition of too much sodium bicarbonate may result in alkalosis. Alkalosis is very difficult to
reverse and can cause as many problems as acidosis.

May increase cerebral acidosis

Incompatible with almost every other drug.
Sodium bicarbonate’s lack of proven efficacy and its numerous adverse effects have lead to the
reconsideration of its role in cardiac resuscitation. Effective ventilation and circulation of blood during
CPR are the most effective treatments for acidemia associated with cardiac arrest.
Sodium bicarbonate may be considered for the dialysis patient in cardiac arrest due to suspected
hyperkalemia.
TERBUTALINE
Indications
Administration
Contraindications
Precautions
Severe wheezing and bronchospasm
Adult: 0.25 mg SQ May repeat dose in 15-30 minutes after contacting medical control
Pedi: Not given to pediatric patients
Known hypersensitivity to drug
Tachydysrhythmias, coronary insufficiency
May cause tachydysrhythmias or hypertension
Monitor V/S closely
THIAMINE
Indications
Administration
Contraindications
Precautions
Side Effects
Coma of unknown origin especially associated with alcohol
Adult: 100 mg IVP
Pedi: Rarely indicated and not by these guidelines
None in emergency setting

Precede D50W in administration sequence.

Rare anaphylactic reactions have been reported.

Rare, if any (hypotension and dyspnea)
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 80
PROCEDURES
These descriptions of procedures do not constitute the total list of
procedures that an EMT, EMTI or Paramedic may be required to
proficiently perform. They are intended to be guidelines for
interventions that are used, and the list is not all-inclusive. Each
member of the EMS team is expected to be proficient in these
procedures (as appropriate per level of provider). These
procedures must be demonstrated and skills-proficiency tested and
documented on at least an annual basis.
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 81
AUTOMATIC EXTERNAL DEFIBRILLATOR GUIDELINE
Note: The following guideline is written presuming that only BLS and the AED are available during a cardiac arrest. If a Paramedic
unit is available, then the Paramedic will follow the cardiac arrest guidelines. He/she may utilize the AED but should convert to their
monitor/defibrillator before transport when possible.
1.
Confirm cardiac arrest (apneic & pulse less). DO NOT put an AED on a patient who has a pulse or is breathing. Have the AED
available for patient’s experiencing severe chest pain or shortness of breath that may go into cardiac arrest.
2.
If witnessed cardiac arrest and AED is available, attach AED immediately and turn on. Follow AED instructions.
3.
If witnessed cardiac arrest with no AED immediately available (2 – 3 minutes), or if patient is found in cardiac arrest with
unknown down time, begin CPR for 2 minutes. CPR should be conducted in accordance with 2006 Emergency Cardiac Care
(ECC) standards (30 compressions to 2 rescue breaths for all patients over 1 year of age).
4.
After 2 minutes of CPR attach the AED and turn on. Follow AED instructions.
5.
Move patient to a firm surface before beginning CPR.
6.
Ensure patient is not lying in/on or touching standing water.
7.
Check patient for any of the following:







Remove any excessive chest hair by using a disposable razor or shears.
Dry patient’s chest if wet.
Place pads 1” above or below a pacemaker, internal IV port, central line, or AICD.
Remove any medication patches from chest area using a gloved hand.
Make sure no one is touching patient prior to pushing defibrillation button.
All clothing must be removed from the patient’s chest area, including bras or medical support devices.
Remove any jewelry from chest or around neck.
8.
DO NOT USE AED on patient’s less than one year of age (infants).
9.
If patient is less than 9 years of age use pediatric pads if available or adjust AED for pediatric patient if possible. If pediatric pads
or device is not available adult pads and device may be used.
10. Ensure pads do not touch and are at least 1” apart. DO NOT cut adult pads to make them fit pediatric patient. If pads are too large
for pediatric patient place one in the center of the patient’s chest and the other in the center of the patient’s back.
11. Conduct 2 minutes of CPR between shocks. If no shock advised continue CPR in accordance with 2006 ECC standards.*
12. DO NOT STOP CPR to check for pulse after shocking. Continue CPR for 2 minutes. Check ABC’s every 2 minutes or after 5
sets of CPR (30 compressions to 2 rescue breaths).
13. All uses of AED require (by State Law) review of the case, so provide Medical Director the trip summary and recording.
*Newer models of AEDS are programmed in accordance with 2006 ECC standards. Older AEDS may require
to be reprogrammed by the manufacturer. If using an older model AED that has not been programmed with
the newer standards follow the AED prompts. DO NOT turn the AED off and on during CPR.
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 82
CRICOTHYROTOMY
Level
Indication
Contraindication
Technique
Notes
Documentation
Paramedic with special clearance by the medical director

Inability to ventilate with a BVM and an inability to establish airway by any other means

Acute upper airway obstruction which cannot be relieved by obstructed airway maneuvers

Upper airway trauma with inability to ventilate the patient with severe respiratory insufficiency
Ability to ventilate the patient by any other means.
1. Open the package, remove the device, and familiarize yourself with its contents.
2. Place the patient in a supine position. Assure stable positioning of the neck region (place a pillow or piece of
clothing under the patient’s shoulders) and hyperextend the neck.
3. Secure the larynx laterally between the thumb and forefinger.
4. Locate the cricothyroid membrane by palpating the patient’s neck, starting at the top. The first prominence
felt will be the thyroid cartilage, while the second is the cricoids cartilage. The space between these two,
noted by the small depression, is the cricoids membrane. This is the puncture site.
5. Firmly hold the device and puncture the cricothyroid membrane at a 90 angle.
6. Check the entry of the needle into the trachea by aspirating air through the syringe. If air is present the needle
is within the trachea.
7. Change the angle of insertion to 60 and advance the device forward into the trachea to the level of the stopper.
8. Remove the stopper. Be careful not to advance the device further with the needle still attached.
9. Hold the needle and syringe firmly and slide only the plastic cannula along the needle into the trachea until
the flange rests on the neck. Carefully remove the needle and syringe.
10. Secure the cannula with the neck tape, apply the connecting tube to the 15mm connection, and connect the
other end to the BVM.
Because of the sharp tip and conical shape of the needle, an incision of the skin with the scalpel is not necessary.
The opening of the trachea is achieved by dilating through the skin. This reduces the risk of bleeding as only the
smallest opening necessary is made
Do not delay transport to perform the Cricothyrotomy

Justification for utilizing

Name of physician that gave the order

Time

Procedure used to place the trach

Verification of placement and technique used

Verification of adequacy of ventilation

Any change in the patients condition after the procedure
DEFIBRILLATION/CARDIOVERSION
Level
Indication
Contraindication
Technique
Notes
Documentation
Paramedic
Per protocol
Per protocol
1. If possible place the patient in an environment away from pooled water or a metal surface under either the
patient or the rescuer
2. Apply appropriate conductive materials to hand-held electrodes or use monitor-defibrillator pads
3. Turn on the defibrillator
4. Select the appropriate energy level
5. Charge the defibrillator
6. Place the electrodes on the chest; one just to the right of the upper sternum below the right clavicle and the
other just below and to the left of the left nipple, or you may use the anterior/posterior placement.
7. Make sure no personnel are in direct or indirect contact with the patient.
8. If cardioverting assure that the unit is in sync mode
9. Deliver the shock
AHA recommends delivery of the first three shocks in succession without stopping to check a pulse if the monitor
clearly demonstrates VF

Time of shock

Who delivered shock

Rhythm interpretation pre and post shock with associated strips

Level of energy delivered

If cardioverting, verification that the current was given in sync mode
DRUG ADMINISTRATION
Level
Indication
Contraindication
Technique
Per specific protocol and drug
Standing or verbal order for drug administration
Specific to each drug
6 Patient Rights of Drug Administration:
Right Patient
Right Drug
Right Dose
Right Time
Right Route
Right Documentation
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 83
Notes




Documentation







Each route of administration has a slightly different technique.
Injections require adequate preparation of the site and aspiration before delivery to assure that the needle is in
the intended tissue.
IV administration also requires preparation of the site and assured patency of the IV. (Dextrose is not as
effective when administered subcutaneously and may be harmful.)
Auto injectors require you to press the injector firmly against the injection site for ten seconds to assure
complete delivery of medication.
Remember: Right Patient, Right Medication, Right Dosage and Right Route
Medication errors must be immediately reported to the receiving physician and thoroughly documented
Time
Who gave the medication
Medication given
Dosage of medication
Route of administration
ESOPHAGEAL INTUBATION WITH A MULTILUMEN AIRWAY
Level
Indication
Contraindication
Technique
Notes
Documentation
Intermediate, Paramedic

Immediate endotracheal intubation cannot be performed

Attempts at endotracheal intubation have proven unsuccessful

Direct visualization of the larynx is inhibited because of profuse bleeding or vomiting

To ensure airway patency in cases of arrest or in cases where the airway requires continuous protection from
aspiration.

Patients less than 16 years old

Patients under 5 feet tall

Patients with an intact gag reflex

Patients with known esophageal disease

Patients who are known alcoholics (May have esophageal varices)

Patients who have ingested a caustic substance
1. While maintaining ventilator support, oxygenate the patient with 100% O2 (give at least 4 good ventilations
before each attempt)
2. Assemble and check the equipment
3. Position patient with head midline, neutral position. Guard c-spine with trauma patients.
4. Insert the device using the jaw-lift maneuver to the depth indicated by the markings on the tube. The black
rings on the tube should be positions between the patient’s teeth.
5. Once the multilumen airway is in place, inflate its pharyngeal cuff with 100 ml of air. This should firmly seal
the device in the posterior pharynx behind the hard palate.
6. Inflate the distal cuff with 10 to 15 ml of air.
7. Begin ventilation through the longer blue connector (tube number 1).
8. Auscultate both lungs and the stomach. If you hear bilateral breath sounds, begin ventilation through the
shorter clear connector (tube number 2). Confirm bilateral breath sounds and absent gastric sounds after
changing the ventilation tube.
9. Continue ventilation with 100% O2, and periodically reassess the airway.

The multilumen airway should never be the technician’s “First Choice” airway because it is easier to place
than an ET Tube. The multilumen airway should be used in those rare cases where the technician is unable to
intubate after repeated attempts.

It is impossible to suction tracheal secretions when the airway is in the esophageal position

Placement of an endotracheal tube is difficult, but not impossible, with the multilumen airway in place. The
pharyngeal cuff must be deflated leaving the esophageal cuff inflated.

Do not delay transport for placement of the multilumen airway
Each attempt must include the following information:

Time

Who made the attempt
Each successful intubation must also contain the following:

Amount of air used to inflate the pharyngeal cuff

Amount of air used to inflate the esophageal cuff

Verification of placement

Which lumen was used to ventilate the patient

The tube was secured

Verification of placement noting techniques used

Verification of placement after the patient is loaded into the ambulance, unloaded from the ambulance,
and before being moved from EMS’ stretcher to the emergency department’s bed (preferably by a
physician)

Any change in the patients condition after the procedure
INTRAOSSEOUS INFUSION
Level
Indication
EMT-I, Paramedic
Severe illness or injury requiring immediate drugs or fluids, when IV access is impossible or unlikely to be
successful.
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 84
Contraindication
Technique
Notes
Documentation


1.
2.
3.
4.
5.
6.
Available secure IV line
Lower-extremity deformity in same bone as insertion site
Place the patient in the supine position
Put a small towel roll under the knee
Prepare the skin over the insertion site
Use the flat surface of the proximal medial tibia, medial to the tibial tuberosity on the flat side of the bone.
Introduce the IO needle in the skin directed away from the growth plate or pointing toward the foot
Pierce the bony cortex with a firm, twisting motion. Use a back and forth twisting motion to enter the marrow
space. Do not push hard on the needle. A “pop” may be felt as the needle passes through the bone into the
marrow.
7. Remove the stylet and aspirate marrow contents. Keep any bone marrow aspirate for glucose check or for
other tests in the ED. Sometimes marrow cannot be aspirated.
8. Confirm correct placement by infusing 10 ml of normal saline without resistance.
9. Attach IV line to the hub and infuse fluids or drugs directly into interosseous space.
10. Secure to the overlying skin with tape.
11. Monitor the calf to ensure that there is no swelling to indicate leakage of fluid.

Do not delay transport to place IO.

No more than one attempt in the field.

Time

Who made the attempt

Location of attempt

Size of catheter used

If attempt was unsuccessful, description of why attempt failed

Procedure used to verify patency.

Type of fluid attached to catheter.

Any change in the patient’s condition after the procedure.
MUSCULOSKELETAL MOTION RESTRICTION
Level
Indication
Contraindication
Technique
Notes
Documentation
ECA, EMT, EMT-I, Paramedic
Skeletal instability resulting from musculoskeletal strain, sprain, dislocations or fracture
Life threatening conditions must be treated first
1. Assess the “six P’s” Pain, Pallor (pale skin or poor cap refill), Paresthesia (pins and needles sensation), Pulses
(diminished or absent), Paralysis (inability to move), Pressure.
2. Assess the distal pulse, motor function and sensation (before and after movement or application of a MMR
device.)
3. Inspect and palpate the injured area for DCAP-BTLS: Deformity, Contusions, Abrasions, Penetrations, Burns,
Tenderness, Lacerations, Swelling
4. Motion restrict bones or joints in the injured area as well as the joint above and the joint below the injury.
5. Motion restrict open and closed fractures in the same manner covering open fractures to minimize
contamination.
6. Stabilize the extremity with gentle, in line traction to a position of normal alignment.

Motion restrict a long bone fracture in a comfort position as long as a pulse is present that can easily be
splinted.

Motion restrict dislocations in a position of comfort ensuring good vascular supply.

Motion restrict joints as found; joint injuries are only aligned if there is no distal pulse.
7. Apply cold to reduce swelling and pain
8. Elevate the extremity if possible.

The technician should conduct an initial assessment to determine if there is any life threatening conditions.
They should care for those conditions first; never overlook musculoskeletal trauma; and never allow a
horrible looking, but non-critical, injury to distract from the priorities of care.

All skeletal instability should be motion restricted as soon as possible after the ABC interventions are
complete. To achieve and maintain musculoskeletal motion restriction any of the following may be utilized
as appropriate for the patient condition and situation:

Patient’s body – Provides some natural motion restriction when an injury can be secured to a motion restricted
body part (i.e. tying the legs together on a backboard where the non-injured leg is secured to the backboard)

Board splints

Pillow splints – In isolated ankle, foot or hand injuries

Pre-formed splints

Scoop

Traction splints – Traction should be used in closed mid-shaft femur fractures only

The “Six P’s”

Distal pulse, motor and sensation before and after motion restriction.

DCAP-BTLS of the injury and surrounding area.

Time motion restriction was applied and by whom

Any changes in patient condition post procedure
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 85
NASOTRACHEAL INTUBATION
Level
Indication
Contraindication
Technique
Notes
Documentation
Intermediate, Paramedic

Used in the breathing patient requiring intubation

Asthma or pulmonary edema with respiratory failure, where intubation may need to be achieved in a sitting
position

Patients with severe facial trauma

Patients with Apnea

Children under 12 years old
1. Assist ventilations if spontaneous respirations are inadequate
2. Choose correct tube size. Limitation is nasal canal diameter
3. Suction should be available and equipment should be checked.
4. Position patient with head midline, neutral position. Guard c-spine with trauma patients.
5. Copiously lubricate the tube with a water based lubricant
6. With gentle steady pressure, advance the tube through the nose to the posterior pharynx. Use right nostril if
possible.
7. Keeping the curve of the tube exactly midline, continue advancing slowly
8. There will be a slight resistance just before entering the trachea. Wait for an inspiratory effort before final
advance into trachea. Patient may also cough or buck just before breath.
9. Continue advancing until air is exchanging through the tube.
10. Advance about 1 inch further then inflate the cuff.
11. Verify placement with bulb device, by auscultation, and by end tidal CO2 detection.
12. Note proper tube position and tape securely

Often nacres are asymmetrical and one side is much easier to intubate. Avoid inducing bilateral nasal
hemorrhage by forcing a nasotracheal tube on multiple attempts.

Blind nasotracheal intubation is a very “elegant” technique. In the field, the secret of blind intubation is
perfect positioning and gentle patience.
Each attempt must include the following information:

Time

Size of tube

Which nacre

Who made the attempt
Each successful intubation must also contain the following:

Amount of air used to inflate cuff

Centimeter marking at the nacre

The tube was secured and with what device

Verification of placement noting techniques used.

Verification of placement after the patient is loaded into the ambulance, unloaded from the ambulance,
and before being moved from EMS’ stretcher to the emergency department’s bed (preferably by a
physician)

Any change in the patients condition after the procedure
NEEDLE CHEST DECOMPRESSION
Level
Indication
Paramedic with special clearance from the medical director
Presence of pneumothorax AND any one of the following

Severe respiratory distress

Tracheal deviation

Hypotension
Contraindication
None
Technique
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
Assess the patient to make sure their condition is due to pneumothorax
Give the patient high flow O2 and ventilator assistance
Determine that one of the indications for emergency decompression is present; then obtain medical direction
to perform the procedure
Open package and familiarize yourself with the contents
Attach connecting tube to Heimlich valve and stopcock to connecting tube.
Attach syringe to catheter introducer needle
Identify the 2nd or 3rd intercostals space in the midaxillary line on the same side as the pneumothorax.
Quickly prepare the area with an antiseptic
Insert the catheter into the skin over the border of the 2nd or 3rd rib and direct it just over the top of the rib into
the interspace.
Insert the catheter through the parietal pleura you should feel a distinct “pop” as you pierce the pleura.
Attempt to aspirate air into the syringe. With proper placement you should be able to draw air into the
syringe.
Remove the needle and leave the plastic catheter in place.
Attach the stopcock to the catheter and open the stopcock.
Place the blue Molnar disk around the catheter and secure with pull tie.
Tape the Molnar disk to the chest
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Rev. 5.10
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ne
Notes




Documentation







The intercostals artery and vein run around the inferior margin of each rib. Poor needle placement can
lacerate one of the vessels
The internal mammary artery lies about 1-2 fingerbreadths lateral to the sternum. Always enter the chest in
the mid-clavicular line
Creation of a pneumothorax may occur if not already present. If your assessment is incorrect, you may give
the patient a pneumothorax when you insert the needle into the chest.
Laceration of the lung is possible. Poor technique or inappropriate insertion can cause laceration of the lung,
causing bleeding and more air leak.
Do not delay transport to perform needle chest decompression
Supporting clinical signs and symptoms of a pneumothorax that led you to call for procedure.
Name of physician that gave order.
Time procedure performed
Location of insertion site and how it was prepped
How air was confirmed to be exiting from the catheter
Any change in the patients condition after the procedure
OROTRACHEAL INTUBATION
Level
Indication
EMT-I, Paramedic

To ensure airway patency in cases of arrest or in cases where the airway requires continuous protection from
aspiration.

To administer positive pressure when extra fluid is present in the alveoli

To administer drugs during resuscitation for absorption through the lungs
Contraindication
None
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Rev. 5.10
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Technique
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Notes








Documentation
While maintaining ventilator support, oxygenate the patient with 100% O2 (give at least 4 good ventilations
before each attempt)
Place patient in the supine position if possible, neck slightly extended in the sniffing position. Attempt to
maintain in-line spinal mobilization(SMR).
Suction should be available and equipment should be checked: tube, cuff, laryngoscope, blade, and light.
Have assistant apply gentle cricothyroid pressure to prevent aspiration and to assist visualization of the vocal
cords.
Insert laryngoscope to the right of midline. Move it to midline, pushing the tongue to the left and out of view.
Lift straight up on the blade (no levering) to expose the posterior pharynx
Identify the epiglottis: tip of curved blade should sit in vallecula (in front of epiglottis), straight blade should
slip over the epiglottis.
With further gentle traction to straighten the airway, identify trachea from arytenoids cartilages and vocal
cords.
Insert tube from right side of mouth, along blade, into the trachea under direct visualization.
Advance tube so cuff is 1-1.5cm beyond cords.
Inflate tube with 5-10ml of air and hold tube securely in place.
Verify placement by visualizing rise and fall of chests or ventilating with BVM and auscultating breath
sounds and gastric sounds.
Adjust tube position as necessary. Withdraw and re-intubate if tube was placed in the esophagus or withdraw
the tube slightly if the right main stem was intubated.
Secure the tube with an appropriate device.
Re-verify tube placement, and note the tube position.
Do not use intubation as the initial means of controlling the airway in cardiac arrest. Oxygenation prior to
intubation should be accomplished with a BVM.
The use of a stylet is mandatory unless extraordinary circumstances preclude you from doing so.
Intubation should take no more than 15-20 seconds to complete: do not loose track of time. If visualization is
difficult, stop and ventilate before trying again.
Orotracheal intubation can be accomplished in trauma victims if an assistant maintains stabilization and keeps
the neck in a neutral position
Esophageal intubation is not a critical error. Unrecognized esophageal intubation is. Careful, multiple and
documented verification is the key.
The soft tissues of the oropharynx are very susceptible to trauma. Liberally use lubrication and a gentle
technique to avoid trauma.
In cases of head injury premedication with Lidocaine may be appropriate, but do not delay intubation for IV
efforts.
Do not delay transport for intubation
Each attempt must include the following information:

Time

Size of tube and if it had a cuff

Size and type of blade used

Who made the attempt
Each successful intubation must also contain the following:

Amount of air used to inflate cuff

Verification of placement before securing tube

Centimeter marking at the lips

How the tube was secured

Re-verification of placement

Verification of placement after the patient is loaded into the ambulance, unloaded from the ambulance,
and before being moved from EMS’ stretcher to the emergency department’s bed (preferably by a
physician)
Any change in the patient’s condition after the procedure
PACING
Level
Indication
Contraindication
Paramedic
Per Protocol
None
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 88
Technique
Notes
Documentation
1.
In patients with excessive body hair and who are conscious clip, rather than shave, any excess body hair to
avoid tiny nicks in the skin that can increase pain and skin irritation.
2. Attach the appropriate pads. Place the anterior (-) electrode to the left of the sternum and center as closely as
possible to the point of maximal cardiac impulse. Place the posterior (+) electrode on the back, directly
behind the anterior electrode to the left of the thoracic spinal column.
3. Attach monitoring leads and adjust the gain up or down until you have an adequate QRS height, which the
pacemaker may sense and mark. If this is not successful, select another lead or move the ECG electrodes
until sensing occurs.
4. Power the pacemaker module by pressing the “Pacer” soft key and confirm the presence of QRS markers on
the ECG.
5. If not already defaulted, set your initial pacing rate to 80 beats per minute.
6. Press the “Start/Stop” button to begin pacing: Observe for vertical pacing spikes.
7. In bradycardic arrest rapidly increase milliamperes in increments until electrical capture occurs or the
maximum of 200 mA has been reached. Do not reduce milliamperes once capture occurs.
8. Electrical capture is recognized by the presence of consistent and widened QRS, ST segment and T wave
immediately after the pacer spike.
9. In hemodynamically unstable bradycardia slowly increase milliamperes in increments of 5 until electrical
capture occurs. Do not lower milliampere setting once electrical capture occurs.
10. Assess the patient for mechanical capture and response to pacing. Pulses should be assessed at the right
femoral or right carotid artery to avoid confusion between jerking muscle contractions caused by the
pacemaker and a pulse.
11. Closely monitor the patient for any changes.

Mechanical and electrical captures are different things. Once electrical capture has taken place increasing the
milliamperes will not cause mechanical capture to take place. Pacing is merely a way to guide the heart’s
own electrical system. Lack of mechanical capture should be treated like PEA.

The only reason to stop the pacer in the field is because of lack of electrical capture. Do not stop the pacer to
determine the underlying rhythm. V-Fib and V-Tach would indicate loss of electrical capture and would
necessitate immediate defibrillation. Pacing will not stop V-Fib, and we do not perform “overdrive” pacing
for V-Tach in the field.

Do not “switch out” pacers in the ER. If you have electrical capture you will leave your pacing unit with the
patient until an internal pacer or other suitable device can be placed.

You may medicate the conscious patient with Midazolam as per protocol. Do not delay the initiation of
critically needed pacing to medicate the patient.

Time pacing initiated

Who initiated pacing

Rhythm strips to support decision to initiate pacing

Pre and post strips for each setting change i.e.: mA increases or rate increases

Strips supporting electrical capture

Final energy and rate setting

Patient response to treatment
PERIPHERAL VENIPUNCTURE
Level
Indication
Contraindication
Technique
Notes
EMT-I, Paramedic
Vascular access in any patient who needs or may need fluid resuscitation or medications.

Areas where a toxic substance is on the skin

Areas distal to injury that may compromise vasculature
1. Prepare all supplies for procedure.
2. Select suitable peripheral site.
3. Apply venous tourniquet, or in cases of EJ cannulation occlude the proximal portion of the vein with a finger.
4. Cleanse the skin over and around the vein with an antiseptic wipe using the outward spiral pattern. Iodine
preps are ideal but prepped area has to be allowed to dry to be effective.
5. Insert the needle and catheter, bevel up. When you enter the vein you should feel a “pop” and/or see a blood
“flash” in the hub of the catheter.
6. Advance the needle and hub slightly to assure that the end of the catheter is in the vein then advance the
catheter over the needle into the vein.
7. Occlude the end of the cannula by holding pressure with a free finger while completely removing the needle.
If using a safety IV device assure the device is fully locked.
8. Draw labs using appropriate technique if indicated.
9. Attach appropriate infusion device to catheter. (IV line or saline lock)
10. Release tourniquet.
11. Assure flow. Observe for signs of infiltration.
12. Secure site with tape or other appropriate device.

Do not delay transport to obtain IV access.

No more than two attempts per technician for IV access.
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 89
Documentation
Each attempt must include the following information:

Time

Who made the attempt

Location of attempt

Size of catheter used

If attempt was unsuccessful
Each successful venipuncture must also contain the following:

If labs were drawn. If not, why not.

Type of device or type of fluid attached to catheter.

Procedure used to verify patency.

Any change in the patients condition after the procedure
Level
Indication
Paramedic with Approval From Medical Director
Hypoxic (oxygen saturation <90%, and/or cyanotic) and combative such that orotracheal or nasotracheal intubation
is not possible.
 Age <15.
 Use cautiously and in reduced dosage in hypotensive or elderly patients
 Patient who is not vomiting and who can be maintained with BVM or 0 2 mask.
 Patient who can be intubated without the use of RSI.
 Short ETA to a fully staffed ED.
 Patients with penetrating eye injuries.
 Patients with renal failure.
 Patients with musculoskeletal disorders (recent stroke, MS).
 Upper airway obstruction or other problems that are likely to make intubation impossible (major laryngeal
trauma, distorted facial or airway anatomy, etc.).
Contact Medical Control
STEP 1
(a) Pre-oxygenate (avoid gastric distension from excessive pressure).
(b) Monitor – IV – Pulse Oximeter.
(c) Check all drugs and equipment – have suction ready.
(d) Give Norcuron at 0.01 mg/kg slow IVP (defasciculating dose).
(e) Give Atropine 0.01 mg/kg IVP (if pulse <70 bpm).
(f) Give Lidocaine 0.5 mg/kg IVP (if CHI patient with increased BP).
STEP 2
(a) Give Midazolam 2.5-5.0mg slow IVP (up to 10 mg max).
(b) Begin Sellick’s maneuver and continue until intubation is completed and ET bulb is inflated. (Sellick’s pressure
should be equivalent to the amount of pressure needed to cause pain when you press the tip of your own nose).
STEP 3
(a) Give Succinylcholine at 1.5 mg/kg IVP over 30 seconds.
(b) Observe 30-45 seconds and intubate. If unable to intubate within 30-60 seconds, use BVM for 60 seconds and retry
intubation.
(c) Confirm tube placement with visualization of chest rise/fall, ET bulb check, CO2 detector BVM, and increasing
pulse oximeter readings.
STEP 4
(a) If patient begins to move and resists ventilation enroute, maintain paralysis with Norcuron at 0.1 mg/kg IVP,
BUT if transport time is less than 15-20 minutes, maintain paralysis with a repeat dose of 1.0-1.5mg/kg of
Succinylcholine.
STEP 5
(a) If all efforts to intubate fail, use BVM and monitor pulse oximeter.
(b) If unable to ventilate effectively with BVM insert PTL.
Remember that Succinylcholine causes:

Increased Gastric Pressure (Vomiting)

Increased Cranial Pressure (Use caution with head injured patients)
Which physician ordered the RSI
Who implemented procedure and when
All documentation for Intubation (Every attempt)
Neurologic status pre and post procedure
RAPID SEQUENCE INTUBATION
Contraindication
Technique
Notes
Documentation
SPINAL MOTION RESTRICTION
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 90
Level
ECA, EMT, EMT-I, Paramedic
Indication




Technique
1.
2.
3.
4.
5.
6.
7.
Documentation
Any patient presenting with a positive or questionable mechanism of injury (MOI) that indicates the potential for
spinal injury, and for whom it is not possible to clinically rule-out the need, will have spinal motion restriction
(SMR) performed. Patients, for whom SMR is deferred, must meet all exclusionary criteria.
Any unstable patient or potentially unstable patient with positive mechanism of injury is to be rapidly extricated
with SMR without compromising short scene times.
SMR is considered for patient presentation positive for, or suggestive of, traumatic etiology or blunt trauma
above the clavicles. These might include, but are not limited to:
o
Significant injury above the clavicle
o
Falls (of any height)
o
Motor vehicle collisions
o
Direct blunt or penetrating trauma to spine head or neck
o
Any abrupt accelerating, decelerating, or rotational forces
SMR may be omitted when all of the following conditions apply (exclusionary criteria are assessed in order):
1. Patient’s cardiovascular and respiratory systems are stable.
2. Vital Signs are within normal limits
3. Normal peripheral perfusion signs
4. Patient is a reliable historian:
5. Conscious, alert, oriented to person, place, and time.
6. No evidence of acute stress reaction or severe anxiety.
7. No evidence or admission of intoxication or impairment by drug or alcohol use.
8. Patient is between eight (8) and seventy (70) years old.
9. Absence of major painful injuries that could distract the patient’s ability to appreciate pain.
10. If patient can’t cooperate with the assessment they are not considered reliable historians.
11. Normal neurological function in all extremities:
12. Sensory – Pain, pressure, and light touch are present and paresthesias (numbness or tingling) are absent.
13. Motor – Strength is full and symmetrical.
14. Patient denies spine or neck pain.
15. Absence of spine or neck tenderness or deformity elicited upon palpation.
16. Absence of spine or neck tenderness when patient moves head in the coronal, transverse, and sagittal
planes.
Routine BLS care
Determine potential for spinal injury

Significant injury above clavicle

Positive or questionable mechanism of injury (MOI)

Manual spinal stabilization is maintained until need for immobilization is ruled-out
Perform initial assessment

If patient is stable continue

If patient is unstable or has major distracting injuries, stop and implement full SMR

If patient is not considered a reliable historian stop and implement full SMR
Assess neurological function.

If abnormal stop and implement full SMR
Assess for spine or neck pain/tenderness
If at any point in the following exam pain or tenderness discovered, stop and implement full SMR

Patient complains of spine pain

Palpate spine for tenderness and/or deformity

Direct patient to move head in all three planes of motion
SMR decision

If patient has NO positive findings on above examination, may omit SMR

If patient has ANY positive findings on above examination, or if unable to complete examination, full
SMR must be performed
Full SMR consists of placing a rigid or semi-rigid C-Collar on the patient, placing the patient onto a long back board
utilizing the technique that allows the least movement of the spine, securing the patient to the long back board with
straps and securing the patient’s head to the backboard with a cervical motion restriction device.

Who made the decision to implement or not implement SMR and a justification for that decision with all
pertinent exam findings

Names and roles of those assisting with SMR and time of implementation

Any changes in pt condition post procedure
WOUND CARE
Level
Indication
ECA, EMT, EMT-I, Paramedic
Open wounds with or without hemorrhaging
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 91
Contraindication
Life threatening conditions must be treated first
Technique
1.
2.
3.
Examine the wound for bleeding, size, depth, and presence of foreign bodies, amount of tissue lost, edema
and deformity. Inspect the area around the wound for damage to underlying structures, arteries, nerves,
tendons, or muscle.
Assess sensory and motor function of the extremity or area
Examine the wound for bleeding, size, depth, and presence of foreign bodies, amount of tissue lost, edema
and deformity. Inspect the area around the wound for damage to underlying structures, arteries, nerves,
tendons, or muscle.
4.
Notes
Documentation
Examine the wound for bleeding, size, depth, and presence of foreign bodies, amount of tissue lost, edema
and deformity. Inspect the area around the wound for damage to underlying structures, arteries, nerves,
tendons, or muscle.
5. Assess sensory and motor function of the extremity or area
6. Evaluate the perfusion status of the wound and tissue distal to the wound
7. Palpate the injury and associated structures to evaluate capillary refill, distal pulses, tenderness, temperature,
edema, and crepitus (if underlying bony injury is suspected)
8. Properly prepare the wound for dressing. Clean the injured surface of gross contaminants by irrigating the
wound with (in order of preference) sterile normal saline, or sterile water, or tap water. Do not attempt
extensive debridement.
9. Control hemorrhage through direct pressure (you may use an ace bandage over the dressing for this purpose),
then elevation, then pressure points, musculoskeletal motion restriction, and very rarely by the use of a
tourniquet and only with concurrence of medical control.
10. Apply the appropriate dressing and secure in place with bandages or gauze and tape or tuck the loose ends of
the bandage.
11. Assess the tetanus vaccination status of the patient.

The goal of wound care is to control hemorrhage, cleanse major contaminants if possible, protect from further
contaminants, reduce pain, reduce edema, and protect the technicians from further exposure to blood products.
To achieve these objectives the technician may use the above interventions at their discretion.

Do not remove an impaled object unless it causes an airway compromise. Move the impaled object as little as
possible. Sometimes it is necessary to manipulate the impaled object if it is necessary to shorten the object for
extrication or for patient transportation.

In cases of avulsion the area should be cleaned of gross contaminants with a sterile saline irrigation, and the
avulsed tissue should be folded back to its normal position. Appropriate bandaging should continue from that
point.

In cases of amputation wrap the amputated part in gauze moistened with saline solution, seal the part in a
plastic bag and place the sealed bag on crushed ice. If crushed ice is not available place the bag between two,
or more, cold packs. Do not delay transport to find the amputated part. It may be necessary to solicit the
assistance of law enforcement or other health care providers in the search for the amputated part.

Never delay transportation of a multiple trauma patient because of a prolonged wound evaluation.

Assessment of size, depth, location, and extent of contamination of wound as well as any possible damage to
underlying structures.

Assessment of sensory, motor and perfusion status of the extremity or affected area before and after
application of a dressing.

Assessment of cap refill, distal pulses, tenderness, temperature, edema and crepitus of the injury and
surrounding structures.

Method used to prepare the wound for dressing.

Techniques used to control hemorrhage and rationale for proceeding to each different level.

Type of dressing used (Sterile, non-sterile, occlusive, trauma pad, abd pad, or etc)

Tetanus status of the patient.

When wound care was performed and by whom

Any changes in patient condition post procedure
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 92
Airway Management
General Principles
Stepwise procedures for obtaining control of the airway in medical situations have been well accepted and standardized
by AHA protocol as well as practical clinical experience. Use of nasopharyngeal airways in lightly comatose patients
who still require some support for a lax tongue is encouraged. Nasotracheal intubation, particularly in breathing patients
who require intervention, is also encouraged.
When is active control of the airway needed? In many instances, the maximally invasive form of airway management is
chosen because of incorrect judgments about "impending" respiratory arrest. Especially with head injuries, this is hard to
predict, and an irregular-breathing pattern may represent chaotic breathing rather than impending arrest. On the other
hand, despite the obvious risks of active airway management, the risks of inadequate oxygenation are even greater. Both
under treatment and overtreatment may be costly to the patient, but it is better to err on the side of aggressive airway
management to achieve adequate oxygenation.
The unsolved problem of emergency airway management is what to do with the patient who requires active airway
management and in whom there exists great potential for (or actual presence of) a cervical spine injury. Clearly no one
wishes to save a life at the expense of producing a quadriplegic. Nevertheless, if the patient is in full trauma arrest, to
what avail is it to save the spinal cord function, if the patient is vegetated or dies because of prolonged attempts to
perform difficult operative procedures with inadequate experience? Currently, the best method to control the airway is to
intubate orally with an assistant maintaining stabilization (digital intubation, also with stabilization, is an alternative.) In a
non-arrested patient, nasotracheal intubation is an excellent alternative if there is no mid-face trauma. Technical
competence requires good training, adequate practice, and compulsive attention to detail to ensure safe and effective
performance of any procedure. Cricothyrotomy remains the only effective alternative for a small number of patients who
have injuries that preclude routine airway procedures.
The following guidelines are recommended as a guide for approaching difficult medical and trauma airway problems.
They assume that the responder is skilled in the various procedures, and will need to be modified according to training
level. Advanced procedures should only be attempted if simpler ones fail and if the technician is qualified. Individual
cases may require modification of these guidelines.
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 93
Airway Management Algorithm
ECA/EMT
INTERMEDIATE
PARAMEDIC
If necessary open airway using
most efficient appropriate
manual maneuver.

If ventilations are weak or
absent assist ventilation

If complete obstruction or
partial with poor air exchange
follow FBAO protocol

Assess oxygenation; use
supplemental O2 as indicated

Suctioning as needed

Choose least invasive method
to maintain airway patency
during transport
If necessary open airway using
most efficient appropriate
manual maneuver.

If ventilations are weak or
absent assist ventilation

If complete obstruction or
partial with poor air exchange
follow FBAO protocol

Assess oxygenation; use
supplemental O2 as indicated

Suctioning as needed

Choose least invasive method
to maintain airway patency
during transport

In cases of arrest or if airway
requires continued protection
from aspiration intubate

If after 2 attempts intubation is
unsuccessful another qualified
technician may attempt

If after 4 total intubation
attempts follow Cricothyrotomy
protocol
If necessary open airway using
most efficient appropriate
manual maneuver.

If ventilations are weak or
absent assist ventilation

If complete obstruction or
partial with poor air exchange
follow FBAO protocol

Assess oxygenation; use
supplemental O2 as indicated

Suctioning as needed

Choose least invasive method
to maintain airway patency
during transport

In cases of arrest or if airway
requires continued protection
from aspiration intubate

If after 2 attempts intubation is
unsuccessful another qualified
technician may attempt

If after 4 total intubation
attempts follow Cricothyrotomy
protocol

If unable to intubate or
ventilate and qualified, may
follow trach protocol after
contacting medical control
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 94
Foreign Body Airway Obstruction (FBAO)
Early recognition of airway obstruction is the key to a successful outcome.
 Mild Airway Obstruction: Good air exchange, patient is responsive and can cough forcefully. May wheeze between
coughs. As long as good air exchange continues, encourage the patient to continue spontaneous coughing and breathing
efforts. DO NOT interfere with the patient’s own attempts to expel the foreign body.
 Severe Airway Obstruction: Poor to no air exchange, with weak, ineffective or no cough at all. High pitched noise
while inhaling or no noise at all. Increased respiratory effort or difficulty. Possible cyanosis around lips, and unable to
speak. Clutching the neck with hands (universal sign of choking). Unable to move air.
ECA/EMT
INTERMEDIATE
PARAMEDIC
If patient is conscious and > 1 year
of age perform Abdominal Thrusts
(standing) until object is expelled or
patient becomes unresponsive.

If patient is responsive and is < than
1 year of age (infant). Place the
infant across your lap with head
down and alternate between 5 back
blows and 5 chest thrusts until the
object is dislodged or the infant
becomes unresponsive.

If the patient is found unresponsive
or becomes unresponsive, place the
patient in the prone position on the
floor or on a hard surface.

Perform ABC’s. If the patient is not
breathing open airway and look for
the object. If object can be seen,
remove it using your fingers. DO
NOT perform a blind finger sweep.

If patient begins breathing place
them in the recovery position and
administer high-flow O2, assess vital
signs and monitor until ALS
personnel arrive. or transport

If you do not see the object attempt
2 rescue breaths and if airway
remains obstructed begin CPR until
ALS personnel arrive, or transport.

Follow CPR/AED protocol, consider
ALS Intercept
If patient is conscious and > 1 year of
age perform Abdominal Thrusts
(standing) until object is expelled or
patient becomes unresponsive.

If patient is responsive and is < 1
year of age (Infant), place the infant
across your lap with head down and
alternate between 5 back blows and 5
chest thrusts until the object is
dislodged or the infant becomes
unresponsive.

If the patient is found unresponsive or
becomes unresponsive, place the
patient in the prone position on the
floor or on a hard surface.

Perform ABC’s. If patient is not
breathing open airway and visualize
with laryngoscope. If object can be
seen, remove it using your fingers.
DO NOT perform a blind finger
sweep.

If patient begins breathing place them
in the recovery position, administer
high flow 02, assess vital signs, saline
lock, monitor until Paramedic arrives,
or transport.

If you do not see the object attempt 2
rescue breaths and if airway remains
obstructed begin CPR until
Paramedic arrives, or transport.

Follow CPR/AED protocol, consider
Paramedic Intercept
If patient is conscious and > 1 year of
age perform Abdominal Thrusts
(standing) until object is expelled or
patient becomes unresponsive.

If patient is responsive and is < 1 year
of age (infant), place the infant across
your lap with head down and alternate
between 5 back blows and 5 chest
thrusts until the object is dislodged or
the infant becomes unresponsive.

If the patient is found unresponsive or
becomes unresponsive, place the
patient in the prone position on the floor
or on a hard surface.

Perform ABC’s. If patient is not
breathing open airway and visualize
with laryngoscope. If object can be
seen, remove it using magill forceps.
DO NOT perform a blind sweep.

If patient begins breathing place them in
the recovery position, administer high
flow 02, assess vital signs, saline lock,
EKG and transport.

If you do not see the object attempt 2
rescue breaths and if airway remains
obstructed begin CPR and transport.

Follow cardiac arrest protocol
Consider Cricothyrotomy to establish
patent airway.
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 95
COMMUNICATIONS GUIDELINES
Communications with Base Hospital are accomplished by telephone or radio. It is best to contact the receiving facility as
soon after initiation of transport as possible.
Basic Radio Procedures
All communications should be accomplished using plain English.
Organize information before initiating contact. All Transmissions are to be kept short and information must be as precise
as possible. The sequence should always be as follows:
 Identify unit calling then name of individual
 First Statement (Category 1 & 2 Trauma Patients) – deliver information as quickly as possible
 Urgency Code and whether patient is trauma victim
 Give patient’s GCS
 Age, sex, and level of consciousness of patient expressed with AVPU scale
 Chief complaint in 10 words or less
 ETA
 Vital Signs
 Second Statement (Category 3 & 4 Trauma Patients) - in addition to information above.
 Brief history relating to the chief complaint
 Significant physical findings related to the chief complaint
 EKG transmission if monitoring and appropriate for the situation
 Brief summary of interventions, treatments in the field to this point
 Response from Medical Control
 Acknowledge
 Further questions
 Orders
 Lastly, can give additional information, medications, etc.
Communication System failures
If you are unable to contact the hospital per radio, you may relay information through dispatch. Dispatch will then contact
the hospital ED by landline to give information in the same format as described above. If neither of these modes is
operational you can try to contact the other hospital base station. They can relay message by landline.
Base Station Responsibility For Communications



The Emergency Physician on duty or his designated alternate (Nurse) should be immediately available at all
times for providing medical direction to the field in all communications.
Communications with the field shall be completed in a timely organized manner.
All orders from the Base Station must comply with the EMS protocols for the field personnel
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 96
ABDOMINAL PAIN /
NAUSEA & VOMITING
HISTORY












Past medical history.
Past surgical history.
Meds.
Onset & duration of pain (or other
symptoms).
Pain severity (1-10).
Radiation of pain.
Character of pain (cramping, dull,
sharp, etc.).
Fever.
Time of last meal.
Improvement or worsening with
food or activity.
Last bowel movement/emesis.
Menstrual history.
SIGNS & SYMPTOMS












Pain.
Tenderness.
N/V.
Diarrhea.
Dysuria.
Constipation.
Evidence of blood in stool
(melena).
Vaginal bleeding/discharge.
Pregnancy.
Altered LOC/syncope.
Weakness.
General or orthostatic
hypotension.
DIFFERENTIALS














Liver (hepatitis, CHF).
Peptic ulcer disease/gastritis.
Gallbladder disease.
MI.
Pancreatitis.
Kidney stones.
Abdominal aneurysm.
Appendicitis.
Bladder/prostate disorder.
Pelvic (PID, ectopic pregnancy,
ovarian cyst).
Spleen enlargement.
Diverticulitis.
Bowel obstruction.
Gastroenteritis (infectious).
PEARLS:








Document the mental status and V/S’s prior to any administration of Phenergan.
Check blood glucose on all diabetic pts.
ABD pain in women of childbearing years should be treated as an ectopic pregnancy until proven otherwise.
Discourage the use of antacids in pts. with renal disease.
Epigastric abdominal pain should be considered as a possible MI.
Appendicitis presents with vague, peri-umbilical pain that migrates to the RLQ with time.
Abdominal aneurysms should be considered in pts. >50 who have ABD pain.
Never delay transport of pts. with abdominal pain even if they appear stable.
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 97
EMT/ECA
INTERMEDIATE
PARAMEDIC
Check ABC’s

Assess oxygenation; use
supplemental O2 as
indicated

Allow position of comfort. If
actively vomiting provide
emesis bag or lay on side to
keep airway open.

Suction PRN

Transport

Consider ALS intercept
Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

Allow position of comfort. If
actively vomiting provide
emesis bag or lay on side to
keep airway open

Suction PRN

Saline Lock. Consider IV @
TKO with NS if pt. has been
vomiting excessively.

Bolus 20cc/kg if hypotensive

Transport

Consider ALS intercept
Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

Allow position of comfort. If actively
vomiting provide emesis bag or lay
on side to keep airway open.

Suction PRN

Saline Lock. Consider IV @ TKO
with NS if pt. has been vomiting
excessively.

Bolus 20cc/kg if hypotensive

Consider administering antiemetic
to control vomiting or dry heaves.

.Attach EKG and treat dysrhythmias
per protocol.

Transport
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 98
ALLERGIC REACTION / ANAPHYLAXIS
ASSESSMENT
 Usually history of exposure to allergen, often oral ingestion.
 May be from insect sting or drug ingestion. Penicillin is a very common allergen.
 Patient usually has severe itching, hives, generalized Urticaria.
 May have stridor, facial edema, swelling of tongue
ECA/EMT
MANAGEMENT WITH O2 & AIRWAY ADJUNCTS

INTERMEDIATE
PARAMEDIC
Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

Trendelenburg’s Position if BP
< 100 systolic

Administer Epi Pen as
appropriate

Transport
HOTRAC Regional EMS Guidelines
Rev. 5.10
Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

Saline Lock

If BP < 100 systolic, IV Normal
saline and 250 cc bolus. Reevaluate and may repeat 250
cc bolus for BP < 100 systolic

Administer Epi Pen as
appropriate

Transport
Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

Adult Dystonic Reaction:
Diphenhydramine 25 mg slow
IV or deep IM

Pediatric Dystonic Reason:
Diphenhydramine 1 mg/kg
slow IV or deep IM (25mg
max)

Saline Lock

If BP < 100 systolic, IV Normal
saline and 250 cc bolus. Reevaluate and may repeat 250
cc bolus for BP < 100 systolic

Cardiac Monitor

If persistent BP < 100 or 
LOC or respiratory distress,
Epinephrine, 0.3-0.5 SQ. (May
repeat q 5 minutes if long
transport)

Adult Anaphylaxis:
Diphenhydramine 50 mg slow
IV or deep IM (Pediatric is
given 1-2 mg/kg up to 50 mg)

Contact Medical Control

Transport
Page 99
ALTERED LEVEL OF CONSCIOUSNESS
General Considerations
ASSESSMENT
A. Alert
V. Verbal stimuli response (Yes or no, appropriate or not)
P. Painful Stimuli response (Yes or no, appropriate or not)
U. Unresponsive
SPECIFIC ASSESSMENT
 Pupil size and reactivity. Equal or not?
 Vital Signs including orthostatic vital signs
 Skin color, temperature, moist or dry. Note odor of breath
 Focal neurologic deficits, if any, and any evidence of trauma
 Additional information (Medic alert tags)
MANAGEMENT WITH O2 & AIRWAY ADJUNCTS

ECA/EMT
INTERMEDIATE
PARAMEDIC
Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

Full Spinal Motion Restriction
PRN

High flow O2

Treat any injuries

Perform Dextrostix

If Dextrostix < 50 give Instant
Glucose if patient can protect
airway

Transport
HOTRAC Regional EMS Guidelines
Rev. 5.10
Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

Full Spinal Motion Restriction
PRN

High flow O2

Treat any injuries

Perform Dextrostix

Saline Lock

If Dextrostix < 50, Start IV of
normal saline & give D50, 25
gm IV. If no IV access, Instant
Glucose if patient can protect
airway

Transport
Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

Full Spinal Motion Restriction
PRN

High flow O2

Treat any injuries

Perform Dextrostix

Saline Lock

If Dextrostix < 50, Start IV of
normal saline & give D50, 25
gm IV. Thiamin 100 mg IV
PRN should be administered
first if suspected alcohol
abuse. If no IV access, Instant
Glucose if patient can protect
airway; If not, Glucagon I mg
IM

Cardiac Monitor

Narcan 2.0 mg IV PRN

Transport
Page 100
ALTERED LEVEL OF CONSCIOUSNESS
Seizure Activity
ECA/EMT
MANAGEMENT WITH O2 & AIRWAY ADJUNCTS

INTERMEDIATE
PARAMEDIC
Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

Protect patient until seizure
ends and maintain quiet
environment

Follow general Altered LOC
procedures

Transport in lateral recumbent
position

If patient refuses transport do
all possible to not allow to
remain alone or drive
Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

Protect patient until seizure
ends and maintain quiet
environment

Follow general Altered LOC
procedures

Saline lock & start IV Normal
saline if patient actively seizing

Transport in lateral recumbent
position

If patient refuses transport do
all possible to not allow to
remain alone or drive
Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

Protect patient until seizure
ends and maintain quiet
environment

Follow general Altered LOC
procedures

Saline lock & start IV normal
saline if patient actively seizing

Monitor & treat any
Dysrhythmia per protocols

If persistent Seizures and not
an apparent febrile seizure,
Diazepam 5 mg IV and notify
Medical Control

If OB patient (eclampsia) near
term and BP > 140/90, give
Magnesium Sulfate (mix 4 gm
in a 50cc bag of D5W & infuse
over 20 minutes

Transport in lateral recumbent
position

If patient refuses transport do
all possible to not allow to
remain alone or drive
Persistent Seizures refers to seizures lasting more than 5 minutes or those occurring repeatedly (More than twice). This is not
the same as the definition of status epilepticus.
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 101
ALTERED LEVEL OF CONSCIOUSNESS
Syncope/Fainting
EMT/ECA
MANAGEMENT WITH 02 & AIRWAY ADJUNCTS

INTERMEDIATE
PARAMEDIC
Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

Full Spinal Motion Restriction
if suspected head or neck
trauma

Follow general Altered LOC
Procedures

Treat any injuries

Transport
HOTRAC Regional EMS Guidelines
Rev. 5.10
Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

Full Spinal Motion Restriction if
suspected head or neck trauma

Follow general Altered LOC
Procedures

Treat any injuries

Saline lock

Systolic BP < 100 then IV
normal saline & fluid challenge
with 250 cc & repeat evaluation.
Repeat Bolus if Systolic BP <
100

Transport
Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

Full Spinal Motion Restriction if
suspected head or neck trauma

Follow general Altered LOC
Procedures

Treat any injuries

Saline lock

If Systolic BP < 100 then IV
normal saline & fluid challenge
with 250 cc & repeat evaluation.
Repeat Bolus if Systolic BP <
100

Cardiac Monitor & treat
dysrhythmia per protocols

Transport
Page 102
ALTERED LEVEL OF CONSCIOUSNESS
With Neuro Signs
ASSESSMENT
Localized weakness, paralysis, paresis and unilateral facial weakness as well as slurred speech, can all be signs of a stroke
syndrome. Can occur sometimes without an altered LOC
ECA/EMT
MANAGEMENT WITH 02 & AIRWAY ADJUNCTS

INTERMEDIATE
PARAMEDIC
Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

Full Spinal Motion Restriction if
suspected head or neck
trauma

Treat any injuries

Follow general Altered LOC
procedures

Transport
HOTRAC Regional EMS Guidelines
Rev. 5.10
Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

Full Spinal Motion Restriction if
suspected head or neck
trauma

Treat any injuries

Follow general Altered LOC
procedures

IV Saline lock

Transport
Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

Full Spinal Motion Restriction if
suspected head or neck
trauma

Treat any injuries

Follow general Altered LOC
procedures

IV Saline lock

Monitor & Treat any
Dysrhythmia per protocols

Transport
Page 103
SUSPECTED ACUTE MYOCARDIAL INFARCTION
(TO BE USED FOR CHEST PAIN OF SUSPECTED CARDIAC ORIGIN)
ASSESSMENT
 Chest pain lasting more than 5-10 minutes
 Chest pain radiating to neck or jaw and/or arm
 Diaphoresis, Dyspnea, nausea
 Character of pain crushing, heavy, squeezing
 Abdominal pain can also be of cardiac origin
ECA/EMT
INTERMEDIATE
PARAMEDIC
Assess ABC's & Relieve
Anxiety

O2 per high flow mask

Screen for Thrombolytic
Therapy & notify Medical
Control as early as possible

If patient not allergic or history
of active ulcer disease, 4
chewable baby aspirin (or
equivalent) even in absence of
active chest pain

*1 NTG SL 0.4 mg
if BP  100 systolic. Repeat
NTG x 2 PRN if BP remains 
100 systolic

Transport Patient should be
treated at hospital as soon as
possible
Assess ABC's & Relieve
Anxiety

O2 per high flow mask

Screen for Thrombolytic
Therapy & notify Medical
Control as early as possible

If patient not allergic or history
of active ulcer disease, 4
chewable baby aspirin (or
equivalent) even in absence of
active chest pain

1 NTG SL 0.4 mg
if BP  100 systolic. Repeat
NTG x 2 PRN if BP remains 
100 systolic

Saline Lock
No more than 2 IV attempts

Transport. Patient should be
treated at hospital as soon as
possible
Assess ABC's & Relieve
Anxiety

O2 per high flow mask

Screen for Thrombolytic
Therapy & notify Medical
Control as early as possible

If patient not allergic or history
of active ulcer disease, 4
chewable baby aspirin (or
equivalent) even in absence of
active chest pain

1 NTG SL 0.4 mg
if BP  100 systolic. Repeat
NTG x 2 PRN if BP remains 
100 systolic

Saline Lock
. No more than 2 IV attempts

Monitor & treat any
Dysrhythmia per protocols

If chest pain persists &
Systolic BP  100 then
MS 2-4 mg IV

Transport. Patient should be
treated at hospital as soon as
possible
*May NOT be performed by ECA
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 104
BRADYCARDIA
ASSESSMENT
 Refer to Acute MI/Chest Pain Guideline
SPECIFIC ASSESSMENT
 Prolonged capillary refill, diaphoresis, cyanosis
 Chest pain, dyspnea,  LOC, systolic BP < 90, shock, CHF?
IF THE PATIENT IS HEMODYNAMICALLY STABLE

FOLLOW CHEST PAIN GUIDELINES FOR THE STABLE PATIENT
IF THE PATIENT IS HEMODYNAMICALLY UNSTABLE AND HEART RATE < 60

EMT/ECA
INTERMEDIATE
PARAMEDIC
Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

O2 high flow Mask

Assist ventilation PRN

Transport
HOTRAC Regional EMS Guidelines
Rev. 5.10
Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

O2 high flow Mask

Assist ventilation PRN

Intubate PRN

IV normal saline TKO rate

Transport
Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

O2 high flow Mask

Assist ventilation PRN

Intubate PRN

IV normal saline TKO rate

Monitor with pacing pads if
available

Atropine 0.5 mg IV q3 min. up
to 0.04 mg/Kg

Pace at lowest voltage at
which capture takes place.
Consider Midazolam 2.5-5 mg
IV in the awake patient

Contact Medical Control may
request Dopamine
5-10g/Kg/min if hypotensive

Transport
Page 105
HYPERTENSIVE CRISIS
ASSESSMENT
 Refer to Chest Pain Guideline
SPECIFIC ASSESSMENT
 Check BP in both arms
 Signs or symptoms of over hydration?
 Consider head trauma
To qualify as Hypertensive Crisis, BP is usually elevated to over 120 mm Hg. Diastolic. In addition there must be end
organs symptoms and/or signs present. These can be manifested by:
 Severe Headache with Altered LOC but usually not lateralizing signs
 Angina type chest pain
 Congestive heart failure or pulmonary edema.
These patients may have BP lowered to about 110 mm Hg to 100 mm Hg diastolic but not below!
For patients with a stroke with lateralizing signs, we must not lower the BP below 110 diastolic and most of the time
stroke patients do not need to have their BP lowered acutely
ECA/EMT
INTERMEDIATE
PARAMEDIC
Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

High flow O2 & assist
ventilation PRN

Transport
Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

High flow O2 & assist
ventilation PRN

Saline lock

Transport
Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

High flow O2 & assist
ventilation PRN

Saline lock

Cardiac Monitor

As long as diastolic BP > 110,
1 NTG 0.4 mg SL q 5 min up
to 3 doses.

Contact Medical Control
If BP remains > 110 diastolic &
long transport time, request
Labetalol 20 mg IV over 2 min

Transport
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 106
HYPOTENSION/SHOCK (Hypovolemic)
ASSESSMENT
Assess ABC's and note presence or absence of venous distention, rales, pulse volume, capillary refill. Measure BP and
repeat BP measurements during treatment/transport phase. Try to decide if the problem is a volume problem (flat neck
veins, dehydrated, bleeding, poor capillary refill, dry mucous membranes) or a pump problem (distended neck veins,
rales, pulmonary edema, irregular rhythms)
ECA/EMT
INTERMEDIATE
PARAMEDIC
Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

O2 per high flow mask

Assist ventilation PRN

Place in Trendelenburg’s
position
(head down/feet up)

Transport
Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

O2 per high flow mask

Assist ventilation PRN

Place in Trendelenburg’s
position
(head down/feet up)

IV normal saline
If Systolic BP <90 mm Hg then
bolus of 250cc & repeat BP

Continue monitoring breath
sounds

Contact Medical Control
Repeat fluid bolus PRN

Transport
Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

O2 per high flow mask

Assist ventilation PRN

Place in Trendelenburg’s
position
(head down/feet up)

IV normal saline
If Systolic BP < 90 mm Hg then
bolus of 250cc & repeat BP

Continue monitoring breath
sounds

Contact Medical Control
Repeat fluid bolus PRN
If long transport time, request
Dopamine

Transport
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 107
The following cardiac guidelines are for ECA/EMT and Intermediate.
The Paramedic Guidelines begin on page
.
Apneic & Pulseless
ASSESSMENT
 Refer to Acute MI/Chest Pain Guideline
SPECIFIC ASSESSMENT
 Consider the possibility of a Trauma Code situation.
 Does the patient meet DNR criterion?
 Hypovolemia is first consideration in trauma, and drug therapy is of little value in that case.
 Check leads in two positions to confirm Asystole
ECA/EMT
INTERMEDIATE
Assess ABC’s

AED

CPR

Transport
Assess ABC’s

CPR

Intubate if possible

IV normal saline TKO

Transport
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 108
TACHYCARDIA – Unstable with Pulses
ASSESSMENT
 If Ventricular rate > 150/min. prepare for immediate Cardioversion.
 May give brief trial of medication based on the type of Dysrhythmia
 Immediate Cardioversion seldom needed for rates < 150/min.
ECA/EMT
INTERMEDIATE
Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

O2 high flow mask

Assist ventilation PRN

Transport
Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

O2 high flow mask

Assist ventilation PRN

Intubate PRN

IV normal saline TKO rate

Transport
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 109
TACHYCARDIA - Stable
STABLE BUT SYMPTOMATIC
ECA/EMT
INTERMEDIATE
Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

Transport
Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

Saline lock

Transport
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 110
VENTRICULAR FIBRILLATION/PULSELESS V. TACH (VF/VT)
ASSESSMENT
 Refer to Chest Pain Guideline
SPECIFIC ASSESSMENT
 Consider possibility of Trauma Code situation
 Check EKG leads & Patient Level of Consciousness
ECA/EMT
INTERMEDIATE
Assess ABC’s

Apply leads & follow AED
Protocol

CPR if pulse less

Transport
Assess ABC’s

Apply leads & follow AED
Protocol

CPR

Intubate if possible

IV normal saline TKO

Transport
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 111
CARDIAC EMERGENCIES
(PARAMEDIC LEVEL CARE)
TACHYCARDIA
(narrow & wide complex – with a pulse / non-arrest)
HISTORY










Estimated duration of the
tachycardia (if known).
ASHD
A-fib, tachydysrhythmias
(& previous treatment
for).
WPW.
Smoker.
Implanted defibrillator
(AICD).
Meds.
Previous MI’s.
Cardiovascular surgery.
Digitalis toxicity.
SIGNS & SYMPTOMS







Chest pain.
Shortness of breath
N/V.
Skin: diaphoresis,
cyanosis, pallor, flushed,
cool, clammy, etc.
Pulse regularity.
Weakness, syncope.
Orthostatic hypotension.
DIFFERENTIALS




Rate due to
compensation for
dehydration and/or
resp. distress.
Drug-induced
tachycardia.
Anxiety-induced
tachycardia.
Fever, sepsis.
PEARLS













The cardiac monitor & 02 kit must go in to the pt. on ALL calls with possible cardiac disorders (i.e.
altered LOC, chest pain, palpitations, shortness of breath, etc.)
Priority of treatment: Pain-Rate-Rhythm-BP.
Treat the patient – not the monitor.
Amiodarone contraindicated for patients taking Coumadin (see drug description)
Do NOT electrically cardiovert anyone on digitalis (Lanoxin, Digoxin) without consulting medical control
first.
An unstable pt. is one who is defined by a systolic BP <80, signs & symptoms of shock, and/or a
seriously depressed LOC.
Adenosine must be pushed as rapidly as possible followed with an immediate flush of saline. Use large
vein (if available).
Be prepared for a brief run (10 sec or greater) of asystole after giving Adenosine.
The effect of Adenosine may be short-lived in patients with WPW (Wolff-Parkinson-White syndrome)
and reoccurrence is common.
Symptomatic tachycardia does NOT equal unstable tachycardia. Assess the LOC, BP, & perfusion status
closely to determine stability.
If performing synchronized cardioversion – make sure sync control is turned on for EACH attempt.
Paced rhythms may resemble wide-complex tachycardia and spikes may be inconspicuous.
Always ask about allergies.
CONDITION
Narrow Complex (regular) SVT (HR > 150 bpm)
 Asymptomatic & Stable (systolic BP > 80,
weakness, no altered LOC).
ACTIONS




High flow 02.
Monitor ECG closely.
IV (saline lock).
Adenosine 6 mg rapid IVP. 12 mg may be
given 1-2 minutes after 1st dose if SVT
persists x 2. Not to exceed 18 mg.
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 112
TACHYCARDIA (continued)
(narrow & wide complex – with a pulse / non-arrest)

Unstable (systolic BP < 80, poor LOC,
dyspnea, chest pain, poor perfusion, etc.)
Narrow complex tachycardia -irregular with HR
> 150 (A-fib/flutter w/RVR)
 Asymptomatic & Stable (Systolic BP > 80, no
weakness or altered LOC).

Symptomatic or Unstable (Systolic BP < 80,
Altered LOC, weakness, chest pain, S&S of
poor perfusion).




High flow 02.
Monitor ECG closely.
IV (saline lock).
Consider sedation (Midazolam, Diazepam,
etc.)
 Synchronized cardiovert @ 100 J, 200J, 300 J,
360 J.











Wide-complex (Ventricular) Tachycardia
 Stable (systolic BP > 80, weakness, no altered
LOC).
High flow 02.
IV (saline lock).
Transport & monitor EKG closely
Consider administering medication to control
rate (Diltiazem or B-blocker)
Consult with Medical Control
High flow 02.
IV (saline lock)
Administer Diltiazem 5-10 mg IVP over 2
minutes.
Contact Medical Control
DO NOT cardiovert unless confirmed new
onset < 24 hours.
If confirmed new onset synchronize
cardiovert @ 50J, 100J, 200J, 300J, 360J







Unstable (systolic BP < 80, poor LOC,
dyspnea, chest pain, poor perfusion, etc.)






Torsades de pointes




HOTRAC Regional EMS Guidelines
Rev. 5.10
High flow 02.
Monitor ECG closely.
IV (saline lock).
Administer Lidocaine 1.0- 1.5 mg/kg
IVP or Amiodarone 150mg IV over 10
min.
Second dose of Lidocaine can be
administered at ½ dose not to exceed
3mg/kg.
Amiodarone may be repeated PRN at
150 mg over 10 min.
High flow 02.
Monitor ECG closely.
IV (saline lock).
Consider sedation
Synchronized cardiovert @ 100 J, 200J,
300 J, 360 J.
High flow 02.
Monitor ECG closely.
IV (saline lock).
Administer Magnesium 1 – 2 grams over
5 – 15 minutes.
Page 113
CARDIAC ARREST
V-FIB / PULSELESS V-TACH
HISTORY






Downtime.
Bystander CPR.
Implanted defibrillator
(AICD).
Meds.
Cardiovascular and/or other
significant medical history.
Substance abuse.
SIGNS & SYMPTOMS

Apnea, pulselessness.
DIFFERENTIALS










Hypoxemia.
Hypoglycemia
Hypovolemia.
Hypokalemia.
Hyperkalemia.
Hypothermia
Tension pneumothorax.
Cardiac Tamponade.
Trauma
Thrombosis
(pulmonary/coronary
embolism).
PEARLS








If CPR is being applied upon arrival – have continued until ECG ‘quick-look’ is available.
Half-dose Lidocaine on all pts. >70, BP <90, or with liver dysfunction (bolus & infusion).
Apply 02 at highest flow to BVM as early on as possible.
Flush IV line after each drug.
Avoid any interruption of CPR, except for pre intubation ventilation, defibrillation and rhythm check.
CPR should be performed for 2 minutes after each defibrillation without checking pulse or rhythm.
At any time the rhythm changes – go to the appropriate guideline.
At any time a pulse reoccurs – go to post-resuscitation guideline.
CONDITION
 Unconsciousness.
 Apnea.

No pulse.

V-Fib (or pulse less V-Tach)
ACTIONS
 Confirm
 Give 2 initial breaths with BVM (or other ventilation
device).
 If unknown down time or greater than 2-3 minutes,
begin CPR ( 30 compressions & 2 ventilations for 2
minutes).
 Quick-look to identify rhythm if monitor is available.

First Defib @ 360 J (monophasic) 200 J (biphasic).

Continue CPR

Place ET or other airway device & confirm for
correct placement.

IV (saline or saline lock).

Epi 1mg IVP (repeat Q3-5 min)

If no IV is available Epi x 2 via ET

Second Defib @ 360 joules (mono) 300 (biphasic)

Continue CPR x 2 minutes

Administer Lidocaine 1mg/kg IVP (repeat Q5


HOTRAC Regional EMS Guidelines
Rev. 5.10
min to a max of 3mg/kg) or 300 mg
Amiodarone IVP.
All further Defib @ 360 joule
Continue CPR x2 minutes between drugs and
defibrillations.
Page 114
ASYSTOLE
HISTORY






Downtime.
Bystander CPR.
Implanted defibrillator
SIGNS & SYMPTOMS

Apnea, pulselessness.
(AICD).
Meds.
Cardiovascular and/or
other significant medical
history.
Substance abuse.












DIFFERENTIALS
Hypoxemia.
Hypovolemia.
Hypokalemia.
Hyperkalemia.
Hypothermia.
Toxins
Tension
pneumothorax.
Tamponade.
Thrombosis (coronary
or pulmonary
embolism).
Thrombosis (MI).
Trauma
Acidosis
PEARLS







The cardiac monitor & 02 kit must go in to the pt. on ALL calls with possible cardiac disorders
(i.e. altered LOC, chest pain, palpitations, shortness of breath, etc.).
If CPR is being applied upon arrival – have continued until ECG ‘quick-look’ is available.
If downtime >20 min – consider DNR (refer to DNR guideline). This must be well
documented.
Apply 02 at highest flow to BVM as early on as possible.
Flush IV line after each drug.
At any time the rhythm changes – go to the appropriate guideline.
At any time a pulse reoccurs – go to post-resuscitation guideline.
CONDITION
 Unconsciousness.
 Apnea.

No pulse.

Asystole
ACTIONS
 Confirm.
 Give 2 initial breaths with BVM (or other
ventilation device).
 Quick-look to identify rhythm (CPR until
monitor/defibrillator attached).
 Check in 2 leads.
 CPR (w/BVM/OPA).
 ET (Monitor pulse Ox & Capnography)
 IV access.



Epinephrine 1mg IVP Q3-5 min (2
mg/20 ml ET if IV not available).
Atropine 1mg IVP Q5 min (to max of
3.0mg).
Monitor rhythm for changes.
CONTACT MEDICAL CONTROL
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 115
PULSELESS ELECTRICAL ACTIVITY
HISTORY






Downtime.
Bystander CPR.
Implanted defibrillator
SIGNS & SYMPTOMS

Apnea, pulselessness.
(AICD).
Meds.
Cardiovascular and/or
other significant medical
history.
Substance abuse.











DIFFERENTIALS
Hypoxemia.
Hypovolemia.
Hypokalemia.
Hyperkalemia.
Hypothermia.
Hypoglycemia.
Toxicology.
Tension
pneumothorax.
Tamponade.
Thrombosis
(pulmonary
embolism).
Thrombosis (MI).
PEARLS







The cardiac monitor & 02 kit must go in to the pt. on ALL calls with possible cardiac disorders
(i.e. altered LOC, chest pain, palpitations, shortness of breath, etc.).
If CPR is being applied upon arrival – have continued until ECG ‘quick-look’ is available.
If downtime >20 min – consider DNR (refer to DNR guideline). This must be well
documented.
Apply 02 at highest flow to BVM as early on as possible.
Flush IV line after each drug with no less than 20cc NS.
At any time the rhythm changes – go to the appropriate guideline.
At any time a pulse reoccurs – go to post-resuscitation guideline.
CONDITION
 Unconsciousness.
 Apnea.

No pulse.

PEA.
ACTIONS
 Confirm.
 Give 2 initial breaths with BVM (or other
ventilation device).
 Quick-look to identify rhythm (CPR until
monitor/defibrillator attached).
 CPR (w/BVM/OPA).
 ET (Monitor Pulse Ox & Capnography)
 IV access.
 Fluid challenge with 250cc-500cc NS



Epinephrine 1 mg IVP Q 3-5 min (2
mg/20 ml ETP if IV not available).
Atropine 1 mg IVP Q 5 min (to max of 3
mg) IF HR <60.
Monitor rhythm for changes.
CONTACT MEDICAL CONTROL
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 116
POST-RESUSCITATION
(guideline for resuscitated cardiac arrest)
PEARLS




Half-dose Lidocaine on all pts. >70, BP <90, or with liver dysfunction (bolus & infusion).
Use caution in the immediate post-resuscitation period (1st 15-min post-arrest) by avoiding
medications (or electrical therapy) for SVT, bradycardia, or hypotension without first allowing
these things to correct themselves – however, they may need to be corrected if prolonged –
contact Medical Control when unsure.
Do NOT hyperventilate resuscitated pts. (ventilate adults at 12-15 min & with normal tidal
volume). DO apply high flow 02.
Restraints should be considered to prevent self-extubation by the pt.
CONDITION
 Pulse returned.


Ventricular ectopy (10 or more PVC’s/min
after 15 min post-arrest). If unstable or runs of
V-Tach
Intubated pt. (struggling with tube).
ACTIONS
 High flow 02.
 Assess for return of spontaneous
respirations & provide if needed (do NOT
hyperventilate).
 Assess blood pressure.
 Lidocaine 0.5mg/kg IV may repeat
up to 3mg/kg




Hypotension.

For active gag reflex, Do NOT extubate.
Attempt to get pt. to tolerate tube. If
needed, and BP is stable, administer
Promethazine 12.5mg slow IVP to
minimize gag reflex (6.25mg in
elderly/small pts.)
Or, if sedation is indicated, you may
deliver 1.0mg Versed IVP.
250ml saline fluid challenge (if breath
sounds are clear).
Consider Trendelenburg’s position.
CONTACT MEDICAL CONTROL

Hypotension refractory to fluids (after 15 min
post-arrest).
HOTRAC Regional EMS Guidelines
Rev. 5.10

Dopamine infusion @ 5mcg/kg/min
(14-18 gtt/min).
Page 117
RESPIRATORY DISTRESS MEDICAL
General Considerations
ASSESSMENT
 History of Asthma, COPD, Heart Failure, Pulmonary Edema, Pneumonia
 Medications, including Theophylline preparations, inhalers, digitalis
 Events leading to distress...allergic exposure, chest pain, elevated BP
SPECIFIC ASSESSMENT
 Level of Consciousness
 Airway obstruction
 Cyanosis
 Respiratory rate and depth of ventilation
 Neck vein distention or not
 Consider trauma
MANAGEMENT WITH O2 AND AIRWAY ADJUNCTS

ECA/EMT
INTERMEDIATE
PARAMEDIC
Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

O2 per high flow mask

Assist ventilation PRN

Transport, sitting if necessary
for comfort
Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

O2 per high flow mask

Assist ventilation PRN

Intubate PRN

Contact Medical Control

Transport, sitting if necessary
for comfort
Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

O2 per high flow mask

Assist ventilation PRN

Intubate PRN

Contact Medical Control

Monitor & treat any
Dysrhythmia per protocols

Transport, sitting if necessary
for comfort
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 118
RESPIRATORY DISTRESS MEDICAL
Asthma & COPD
SEVERE WHEEZING & DYSPNEA OR DECREASED RESPIRATORY EFFORT

ECA/EMT
INTERMEDIATE
PARAMEDIC
Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

High flow O2 & assist
ventilation PRN

Monitor level of consciousness
and respiratory rate

*Albuterol if wheezing is
severe or not moving air well.

Transport, sitting if necessary
for comfort
*May NOT be performed by ECA
Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

High flow O2 & assist
ventilation PRN

Monitor level of consciousness
and respiratory rate

Saline lock

Albuterol if wheezing is severe
or not moving air well.

Transport, sitting if necessary
for comfort
Note: If very long transport
time and unable to contact
Medical Control, repeat
Albuterol PRN if pulse < 140
HOTRAC Regional EMS Guidelines
Rev. 5.10
Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

High flow O2 & assist
ventilation PRN

Monitor level of consciousness
and respiratory rate

Saline lock

Cardiac monitor & contact
Medical Control if Dysrhythmia

Albuterol if wheezing is severe
or not moving air well.
May repeat x1 (up to 3 times)

Contact Medical Control for
additional medication
administration

Transport, sitting if necessary
for comfort
Page 119
RESPIRATORY DISTRESS MEDICAL
Pulmonary Edema
ASSESSMENT
 Note rales, neck vein distention, Dyspnea, frothy or blood-tinged sputum
ECA/EMT
Follow General Respiratory
Distress Protocol

Monitor BP q 5 minutes

If patient not allergic or history
of active ulcer disease,
4 chewable baby aspirin or
equivalent even in absence
of active chest pain

Transport, sitting if necessary
for comfort
HOTRAC Regional EMS Guidelines
Rev. 5.10
SEVERE DYSPNEA WITH MOIST RALES

INTERMEDIATE
Follow General Respiratory
Distress Protocol

Monitor BP q 5 minutes

If patient not allergic or history
of active ulcer disease,
4 chewable baby aspirin or
equivalent even in absence
of active chest pain

Saline lock

Transport, sitting if necessary
for comfort
PARAMEDIC
Follow General Respiratory
Distress Protocol

Monitor BP q 5 minutes

If patient not allergic or history
of active ulcer disease,
4 chewable baby aspirin or
equivalent even in absence
of active chest pain

Saline lock

Cardiac monitor & manage
any Dysrhythmia

If BP  100 Systolic, 2 NTG
0.4 mg & repeat BP

If still Dyspneic & BP ≥ 110
Systolic, repeat 2 NTG 0.4 mg
x 2 PRN

Contact Medical Control
If transport time > 15 min. and
still dyspneic, Furosemide 1
mg/Kg. May start Dopamine
drip; dosage per medical
control

Transport, sitting if necessary
for comfort
Page 120
RESPIRATORY DISTRESS MEDICAL
Suspected Epiglottitis
ASSESSMENT
 Toxic appearing child/adult with sore throat and respiratory distress
SPECIFIC ASSESSMENT
 Usually in children from 2 to 5 years old but can occur at any age
 Febrile, very toxic appearing children with respiratory distress and drooling
 Head usually held forward in "tripod” position
 Can also occur in adults at any age
 Croup in children also presents similarly, usually in child age 6 mo. to 3 yr.
ECA/EMT
INTERMEDIATE
PARAMEDIC
Follow General Respiratory
Distress Protocol

Use extreme caution and try to
keep child quiet. May ask
mother to hold child and hold
O2 near child's nose & mouth

Use Bag-Valve-Mask with tight
seal if airway starts to close

Contact Medical Control

Transport
Follow General Respiratory
Distress Protocol

Use extreme caution and try to
keep child quiet. May ask
mother to hold child and hold
O2 near child's nose & mouth

Use Bag-Valve-Mask with tight
seal if airway starts to close.
Do not attempt intubation

Contact Medical Control

No IV in children

Transport
Follow General Respiratory
Distress Protocol

Use extreme caution and try to
keep child quiet. May ask
mother to hold child and hold
O2 near child's nose & mouth

Use Bag-Valve-Mask with tight
seal if airway starts to close.
Do not attempt intubation

Contact Medical Control

No IV in children

Transport
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 121
VENTILATOR PROTOCOL
(for Auto Vent 2000/3000 Portable Ventilators)
Policy: The Auto vent Portable Ventilator is to be used for facility-to-facility transports of patient requiring constant
ventilator support. They may be used for scene-to-hospital transports, especially when there is a prolonged scene time, a
cardiac arrest, or prolonged scene-to-hospital time.
I.
SET-UP
a. Connect:
1. 6 ft 02 tubing (green) to source gas inlet and O2 source
2. Dual white 3 ft hose assembly to patient outlet
3. Assemble basic or PEEP parts
b. Turn on 02 source (50 PSI)
c. Set RATE (per Respiratory Therapist) or 10-12 if scene response
d. Set TIDAL VOLUME (per Respiratory Therapist) or 10cc/kg if scene response
e. Set dial to child or adult (auto vent 3000 only)
f. Adjust volume and rate as needed (from pulse ox and capnography readings) and document all adjustments and
their effect.
g. Assure that the green visual indicator located on top of the patient valve assembly appears during each
ventilation.
II. PATIENT APPLICATION
a. Check all alarms and settings, and run ventilator for several cycles to confirm that everything is functional.
b. If the high pressure alarm sounds, check unit for kinked tube or obstruction.
III. USE OF THE VENTILATOR
a. Prior to making a ventilator transport, be sure that the unit has an ample supply of oxygen. Be prepared to change
02 tanks en route if needed.
b. If the machine malfunctions and it cannot be easily remedied, remove it and provide ventilations via a bag-valvemask.
IV. STORAGE
a. After use, discard and replace all disposable parts.
b. Surface clean entire unit and connections (refer to manufacturer’s manual for detailed cleaning instructions).
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 122
TASER REMOVAL GUIDELINE
STEPS:
1. Before touching any patient who has been subdued using a Taser, insure that the police officer has
disconnected the wires from the handheld unit.
2. Identify the location of the probes on the patient’s body.
3. Determine from the law enforcement officer, the patient’s condition from the time of Taser discharge,
until EMS arrival.
4. Assess vital signs including ECG monitoring and pulse oximeters.
5. If patient’s age greater than 35, perform 12-lead ECG.
6. Obtain patient’s history including; tetanus, cardiac history and mind altering stimulants such as
Phencyclidine (PCP) or Cocaine.
7. All of the above findings should be documented on the patient care report and transport the patient if
appropriate.
8. Extracted probes are evidence and should be given to law enforcement officers.
Removal of Probe(s) by EMS Provider:
1. Place one hand on the area where the probe is embedded and stabilize the skin surrounding the
puncture site.
2. Place second hand firmly around the probe.
3. In one fluid motion, pull the probe straight out from the puncture site.
4. Repeat procedure for second probe.
5. Cleanse puncture sites and bandage as appropriate.
6. Suggest patient be evaluated within 48 hours by MD.
7. If no tetanus within 5 years, advise patient to obtain tetanus within 48 hours.
Contraindications:


When a probe is embedded in a potentially vulnerable region (i.e. face, neck, groin or female breast)
do not remove.
If potential for complications exist, contact on-line medical control or transport to appropriate hospital.
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 123
SNAKEBITE
ASSESSMENT
 Identify Snake if possible.
 Note localized swelling, erythema and circulation/ pulses
 Bite wound: Location, number of fang marks
 Signs of envenomation: Edema, vomiting, hypotension, paresthesias
ECA/EMT
INTERMEDIATE
PARAMEDIC
Remove patient from area of
snake

Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

Remove any rings or jewelry
because of swelling

Immobilize bitten part lower
than heart

Do not place ice on affected
part or attempt incision or
suction

Transport
Remove patient from area of
snake

Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

Remove any rings or jewelry
because of swelling

Immobilize bitten part lower
than heart

Do not place ice on affected
part or attempt incision or
suction

Saline lock

Transport
Remove patient from area of
snake

Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

Remove any rings or jewelry
because of swelling

Immobilize bitten part lower
than heart

Do not place ice on affected
part or attempt incision or
suction

Saline lock

Cardiac monitor if symptoms
or cardiac history

Transport
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 124
POISONING & OVERDOSE
ASSESSMENT
 Note type of poisoning. If possible bring sample of poison, or container, to hospital
 If substance is identified in the field, call hospital as early as possible with information
 Try to determine amount, time of exposure, concentration of poison
 Note skin condition, pupils, salivation, odor of breath
 Medical history, medications, any injury associated with the poisoning?
Take precautions examining any patients with possible contact poisoning. Decontamination of patient should include
protective garments for rescuer and removal of the patient from contact with the poison, followed by cleansing of the
body or affected body parts with water.
ECA/EMT
INTERMEDIATE
PARAMEDIC
Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

Contact Medical Control

Transport
Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

Contact Medical Control

Saline lock

Transport
Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

Contact Medical Control

Saline lock

Cardiac monitor

If suspected opiate ingestion,
Naloxone 2 mg IV

Contact Medical Control
May request Diphenhydramine
25 IV if dystonic reaction

Contact Medical Control
If organophosphate poisoning
and has salivation, lacrimation,
vomiting, then request
Atropine, 1 mg IV & repeat
PRN in 5 minutes.

If known Tricyclic overdose
contact Medical Control for 1
amp Sodium Bicarbonate slow
IV

Transport
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 125
INTOXICATION AND BEHAVIORAL EMERGENCIES
ASSESSMENT
 SCENE SAFETY SHOULD ALWAYS BE OBSERVED.
 Intoxication assessment in field consists mostly of clinical evaluation.
 Odor of alcohol
 If possible with patient's behavior evaluate per Poisoning & Overdose Guideline
 If not able to apply monitor or start saline lock etc., due to inability of patient to cooperate then document the
circumstances and proceed to transport
ECA/EMT
INTERMEDIATE
PARAMEDIC
Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

C-Spine Precautions if
indicated

Psych support

Restrain PRN according to
restraints policy

May do finger stick and
perform Dextrostix

If Dextrostix  50 give Instant
Glucose if patient can protect
airway

Transport
Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

C-Spine Precautions if
indicated

Psych support

Restrain PRN according to
restraints policy

Perform Dextrostix

Saline lock

If Dextrostix  50, start IV of
Normal saline & give D50, 25
gm IV. If no IV access, Instant
Glucose if patient can protect
airway

Transport
Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

C-Spine Precautions if
indicated

Psych support

Restrain PRN according to
restraints policy

Perform Dextrostix

Saline lock

If Dextrostix  50, start IV of
Normal saline & give D50, 25
gm IV. If no IV access, Instant
Glucose if patient can protect
airway If not Glucagon 1 mg
IM

Transport
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 126
HYPERTHERMIA
Heat Exhaustion
ASSESSMENT
 Does patient have fever? Is he sweating or not, was he exercising prior to onset
 Environmental factors: temperature, humidity
 Predisposing factors, age, medications, alcohol, exercise
 Altered level of consciousness?
 Hypovolemic?
SPECIFIC ASSESSMENT
 Patient may not have a fever. Warm, sometimes diaphoretic with headache, nausea, weakness. Usually
somewhat Hypovolemic. *No very high fever and *no alteration in state of consciousness
ECA/EMT
INTERMEDIATE
PARAMEDIC
Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

Remove from warm
environment & loosen clothing

Sponge with cool water if
available

Small amounts of clear liquids
PO is OK if not nauseated

Transport
Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

Remove from warm
environment & loosen clothing

Sponge with cool water if
available

Small amounts of clear liquids
PO is OK if not nauseated

IV Normal saline 250 cc Bolus
then reassess and may rebolus

Transport
Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

Remove from warm
environment & loosen clothing

Sponge with cool water if
available

Small amounts of clear liquids
PO is OK if not nauseated

IV Normal saline 250 cc Bolus
then reassess and may rebolus

Cardiac monitor

Transport
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 127
HYPERTHERMIA
Heat Stroke
SPECIFIC ASSESSMENT
 Patients with Heat Stroke will have high fever and appear quite ill. They are hot & dry and almost always have
some altered level of consciousness.
ECA/EMT
INTERMEDIATE
PARAMEDIC
Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

Remove patient from hot
environment and loosen
clothing

Aggressively cool patient with
ice packs, wet towels, if
available

Small amounts of clear liquids
PO is OK if not nauseated

Transport
Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

Remove patient from hot
environment and loosen
clothing

Aggressively cool patient with
ice packs, wet towels, if
available

Small amounts of clear liquids
PO is OK if not nauseated

IV Normal saline 250 cc bolus
then re-assess and may rebolus

Transport
Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

Remove patient from hot
environment and loosen
clothing

Aggressively cool patient with
ice packs, wet towels, if
available

Small amounts of clear liquids
PO is OK if not nauseated

IV Normal saline 250 cc bolus
then re-assess and may rebolus

Cardiac monitor

If seizure activity, then
Diazepam 5 mg IV

Transport
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 128
HYPOTHERMIA
SPECIFIC ASSESSMENT
 Air & water temperature and length of exposure are risk factors. Was patient wet or dry?
 Level of consciousness
 Vital Signs. If present, but very depressed, do not start CPR
 History including medications, alcohol, trauma
ECA/EMT
INTERMEDIATE
PARAMEDIC
Move patient to warm area &
remove wet clothing. Wrap in
blankets.

Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

High flow O2 if possible

If core temperature > 90°F OK
to use blankets. Warm
blankets OK.

If core temp  90°F, use
blankets, but no external heat
to be applied. Do not use
airway adjuncts unless CPR.

CPR PRN after 1 min. of
evaluation to determine
pulselessness. Pt will require
CPR until re-warmed.

Transport
Move patient to warm area &
remove wet clothing. Wrap in
blankets.

Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

High flow O2 if possible

If core temperature > 90°F OK
to use blankets. Warm
blankets OK.

If core temp  90°F, use
blankets, but no external heat
to be applied. Do not use
airway adjuncts unless CPR.

CPR PRN after 1 min. of
evaluation to determine
pulselessness. Pt will require
CPR until re-warmed.

IV Normal saline, 250 cc bolus
then re-assess and may rebolus. Warm the solution if
possible.

Transport
Move patient to warm area &
remove wet clothing. Wrap in
blankets.

Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

High flow O2 if possible

If core temperature > 90°F OK
to use blankets. Warm
blankets OK.

If core temp  90°F, use
blankets, but no external heat
to be applied. Do not use
airway adjuncts unless CPR.

CPR PRN after 1 min. of
evaluation to determine
pulselessness. Pt will require
CPR until re-warmed.

IV Normal saline, 250 cc bolus
then re-assess and may rebolus. Warm the solution if
possible.

Cardiac monitor. Note that if
V. Fib then defibrillation not
effective until re-warmed. Any
cardiac drugs will have
delayed effects.

Transport
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 129
OBSTETRICS
Normal Delivery & General Considerations
****note triage tags with
all assessment
information.
ASSESSMENT
 Due date & previous pregnancies
 Medical History, allergies, bleeding disorders
 Previous complications such as C-sections, difficult deliveries

It patient is a multiple trauma victim, then becomes a Level III unless other factors make her a higher trauma
level
SPECIFIC ASSESSMENT
 Interval between pains. Are membranes ruptured? Bleeding? Urge to Push?
 Face or extremities edematous or headache present or elevated BP? (Possible pre-eclampsia)
 Perineum inspection: Any bleeding or fluid? Crowning?
 If infant delivered, evaluate with APGAR score at 1 minute and 5 minutes with score of 0-2 for each category.
 APGAR: Color, Heart Rate, Respirations, Reflexes, Muscle Tone
 If multiple births, must provide which baby came first
ECA/EMT
INTERMEDIATE
PARAMEDIC
If not crowning or actively
pushing transport on left side

Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

High flow O2

If crowning: sterile technique &
control speed of delivery.
Suction nose & mouth. Gently
dry baby. Resuscitate baby
PRN. Prepare for delivery of
placenta. Clamp cord 8" and
10" from baby & cut cord
between clamps

Transport

Keep mother & baby together.
Place triage tag on both
mother and baby & note
mother’s number on baby’s tag
and baby’s number on
mother’s tag
If not crowning or actively
pushing transport on left side

Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

High flow O2

If crowning: sterile technique &
control speed of delivery.
Suction nose & mouth. Gently
dry baby. Resuscitate baby
PRN. Prepare for delivery of
placenta. Clamp cord 8" and
10" from baby & cut cord
between clamps

Saline lock

Transport

Keep mother & baby together.
Place triage tag on both
mother and baby & note
mother’s number on baby’s tag
and baby’s number on
mother’s tag
If not crowning or actively
pushing transport on left side

Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

High flow O2

If crowning: sterile technique &
control speed of delivery.
Suction nose & mouth. Gently
dry baby. Resuscitate baby
PRN. Prepare for delivery of
placenta. Clamp cord 8" and
10" from baby & cut cord
between clamps

Saline lock

Monitor, if cardiac history

Transport

Keep mother & baby together.
Place triage tag on both
mother and baby & note
mother’s number on baby’s tag
and baby’s number on
mother’s tag
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 130
OBSTETRICS
Prolapsed Cord
ASSESSMENT
 Loop of cord will be protruding from vagina prior to delivery of baby, usually with fetal distress
ECA/EMT
INTERMEDIATE
PARAMEDIC
Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

High flow O2

Put mother in Knee-Chest
Position

Glove & place 3 fingers into
vagina and support head off cord

Sterile, moist saline dressing on
cord during transport

Transport
Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

High flow O2

Put mother in Knee-Chest
Position

Glove & place 3 fingers into
vagina and support head off cord

Sterile, moist saline dressing on
cord during transport

Saline lock, but do not delay
transport

Transport
Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

High flow O2

Put mother in Knee-Chest
Position

Glove & place 3 fingers into
vagina and support head off cord

Sterile, moist saline dressing on
cord during transport

Saline lock, but do not delay
transport

Transport
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 131
OBSTETRICS
Nuchal Cord
ASSESSMENT
 Baby will deliver with loop of cord around his neck, may be cyanotic. Usually some tension on cord
ECA/EMT
INTERMEDIATE
PARAMEDIC
Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

High flow O2

Attempt to slip cord over
infant's head with gloved hand

If attempt unsuccessful, clamp
cord x2 and cut between
clamps

Keep infant's head dry & warm
& suction nose & mouth if
procedure lasts over 60
seconds

Follow Normal Delivery
Protocol

Transport
mother & baby together
Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

High flow O2

Attempt to slip cord over
infant's head with gloved hand

If attempt unsuccessful, clamp
cord x2 and cut between
clamps

Keep infant's head dry & warm
& suction nose & mouth if
procedure lasts over 60
seconds

Follow Normal Delivery
Protocol

Saline lock but do not delay
transport

Transport
mother & baby together
Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

High flow O2

Attempt to slip cord over
infant's head with gloved hand

If attempt unsuccessful, clamp
cord x2 and cut between
clamps

Keep infant's head dry & warm
& suction nose & mouth if
procedure lasts over 60
seconds

Follow Normal Delivery
Protocol

Saline lock but do not delay
transport

Transport
mother & baby together
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 132
OBSTETRICS
Breech Presentation
ASSESSMENT
 Buttocks will be presenting part. Usually body rotates so that face is down. No extreme force should be used to
affect baby position. If Limb presentation, field delivery is not possible & should not be attempted. Rapid
transport in that case.
ECA/EMT
INTERMEDIATE
PARAMEDIC
Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

High flow O2

If buttocks presenting, prepare
for delivery. If short transport
time, better to transport rapidly

Keep infants abdomen toward
floor

Use gloved fingers to feel
around neck for cord and try to
slip off from around the neck

Slip gloved fingers along
infant's nose to establish air
passage

Keep infant's body warm &
proceed as in Normal Delivery
Protocol

Transport
mother & baby together
Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

High flow O2

If buttocks presenting, prepare
for delivery. If short transport
time, better to transport rapidly

Keep infants abdomen toward
floor

Use gloved fingers to feel
around neck for cord and try to
slip off from around the neck

Slip gloved fingers along
infant's nose to establish air
passage

Keep infant's body warm &
proceed as in Normal Delivery
Protocol

Saline lock if personnel
available so no delay in
transport

Transport
mother & baby together
Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

High flow O2

If buttocks presenting, prepare
for delivery. If short transport
time, better to transport rapidly

Keep infants abdomen toward
floor

Use gloved fingers to feel
around neck for cord and try to
slip off from around the neck

Slip gloved fingers along
infant's nose to establish air
passage

Keep infant's body warm &
proceed as in Normal Delivery
Protocol

Saline lock if personnel
available so no delay in
transport

Transport
mother & baby together
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 133
PEDIATRIC NEWBORN RESUSCITATION
ASSESSMENT
 Note if Meconium staining. Note APGAR score at 1 minute and 5 minutes. Evaluate respiration effort
 In route, be sure and keep baby warm and dry. Note any congenital abnormalities
 If color blue or dusky, provide O2 & continue to re-evaluate in route
ECA/EMT
INTERMEDIATE
PARAMEDIC
Position infant & gently suction
mouth & then nose

Suction trachea if Meconium
stained fluid

Provide tactile stimulation

If spontaneous respirations,
Note heart rate. If below 100
ventilate with BVM 100% O2
for 10 seconds

If rate does not increase then
continue ventilation and start
compressions if rate < 80

If rate < 60 start CPR

Transport
Position infant & gently suction
mouth & then nose

Suction trachea if Meconium
stained fluid

Provide tactile stimulation

If spontaneous respirations,
Note heart rate. If below 100
ventilate with BVM 100% O2
for 10 seconds

If rate does not increase then
continue ventilation and start
compressions if rate < 80

If rate < 60 start CPR

Intubate if possible

Attempt IV Normal saline TKO
in route, no more than 2
attempts

Transport
Position infant & gently suction
mouth & then nose

Suction trachea if Meconium
stained fluid

Provide tactile stimulation

If spontaneous respirations,
Note heart rate. If below 100
ventilate with BVM 100% O2
for 10 seconds

If rate does not increase then
continue ventilation and start
compressions if rate < 80

If rate < 60 start CPR

Intubate if possible

Attempt IV Normal saline TKO
in route, no more than 2
attempts

Epinephrine 0.1cc/kg 0f
1:10,000 or ET 0.1cc/kg of
1:1000

Transport
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 134
OBSTETRICS/GYNECOLOGY
Vaginal Bleeding
SPECIFIC ASSESSMENT
 Consider Trauma
 History of last menstrual period, number of months gestation if pregnant
 Try to estimate amount of blood loss
 If tissue present, save tissue
 Fever?
 Vital signs
ECA/EMT
INTERMEDIATE
PARAMEDIC
Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

High flow O2

If patient is post partum,
fundus massage

Assess fetal status if pregnant

Transport on left side if > 6
months pregnant
Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

High flow O2

If patient is post partum,
fundus massage

Assess fetal status if pregnant

Saline lock

If BP < 100 Systolic bolus with
250 cc Normal saline. Repeat
BP. May repeat bolus if BP <
100 Systolic.

Contact Medical Control

Transport on left side if > 6
months pregnant
Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

High flow O2

If patient is post partum,
fundus massage

Assess fetal status if pregnant

Saline lock

If BP < 100 Systolic bolus with
250 cc Normal saline. Repeat
BP. May repeat bolus if BP <
100 Systolic.

Contact Medical Control

Transport on left side if > 6
months pregnant
Note: If patient not known to be
pregnant, or post menopause,
then may need to go to
hypotension protocol or to
abdominal pain protocol.
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 135
TRAUMA
General Procedures (Follow for Category 1 & 2 Classification)
ASSESSMENT
 Note mechanism of injury and damage to vehicle if MVA
 If penetrating trauma, note type of weapon, number of wounds, and location of wounds
 Revised Trauma Score to be completed on all major trauma incidents
 All Category 1 trauma patients are to be treated as "load & go"
 All Category 1 & 2 trauma patients are to be transported directly to Hillcrest Baptist Medical Center.
SPECIFIC ASSESSMENT
 Level of consciousness and Glasgow Coma Score if applicable
 ABC's secured and C-spine protected
 Secondary Survey to be completed rapidly. Do not delay transport.
 Note pulses, sensation and movement of all extremities
ECA/EMT
INTERMEDIATE
PARAMEDIC
Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

Immobilize C-Spine PRN

Control airway; high low O2

Follow Spinal Motion
Restriction Guidelines &
Transport

CPR PRN

Control hemorrhage

Apply splints & dressings as
needed. Do not delay
transport in unstable or
hypotensive patients
Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

Immobilize C-Spine PRN

Control airway; high flow O 2

Follow Spinal Motion
Restriction Guidelines &
Transport

CPR PRN

Control hemorrhage

IV Normal saline large bore
cath & 2nd IV if BP < 90 sys.
Bolus with 250 ml. Do not
delay transport to start the IV

Contact Medical Control

If BP still < 90 systolic. Rebolus with 250 ml

Apply splints & dressings as
needed.
Check ABC’s

Assess oxygenation; use
supplemental O2 as indicated

Immobilize C-Spine PRN

Control airway; high flow O 2

Follow Spinal Motion
Restriction Guidelines &
Transport

CPR PRN

Control hemorrhage

IV Normal saline large bore
cath & 2nd IV if BP < 90 sys.
Bolus with 250 ml. Do not
delay transport to start the IV

Contact Medical Control

If BP still < 90 systolic. Rebolus with 250 ml

Monitor if cardiac history or
patient has chest pain

Apply splints & dressings as
needed.
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 136
CLASSIFICATION OF TRAUMA PATIENTS for PRE-HOSPITAL
Patients in TSA-M are classified according to severity of injury in order to determine the medical resources which
may be required. EMS personnel will triage and transport trauma patients in TSA-M according to the following
guidelines:
Category 1. Trauma Patients with the most severe injuries are classified as Category 1 patients.
Patients with the following problems are included in this category and will require the medical resources
available at a TSA-M Level II Trauma Facility. When EMS personnel are unable to establish on-line
medical control, these patients should be transported directly to Hillcrest Baptist Medical Center (or
another appropriate Level I or Level II Trauma facility) unless the patient’s condition requires
resuscitation and stabilization at the nearest appropriate acute care facility.







Gun Shot Wound to head, neck or torso
Respiratory Compromise/obstruction
GCS less than 8
O2 sat less than 85%
Adult Patients with a SBP less than 90
Child less than one year with SBP less than 70 or heart rate less than 100 or more than 190
Child 1-9 years with SBP less than 70 + 2 x age in years or heart rate less than 80 or more than 150
Category 2. Trauma Patients with the serious injuries are classified as Category 2 patients.
Patients with the following problems are included in this category and will require the medical resources
available at a TSA-M Level II Trauma Facility. When EMS personnel are unable to establish on-line
medical control, these patients should be transported directly to Hillcrest Baptist Medical Center (or
another appropriate Level I or Level II Trauma facility) unless the patient’s condition requires
resuscitation and stabilization at the nearest appropriate acute care facility.











Penetrating injuries to head, neck, and torso (non-GSW)
Suspected Amputation proximal to the wrist or ankle
Suspected Two or more proximal long bone fractures (Femur, Humerus)
O2 sat less than 90%
Suspected Pelvic fractures
Burns more than or equal to 20% BSA or more than 10% if under 6 years old
Temperature less than or equal to 95◦F
GCS less than 13
Adult SBP 90-100
Heart rate more than 140
Patients with traumatic paralysis
Category 3. Category 3 trauma patients are those with injuries not classified as Category 1 or Category
2. When EMS personnel are unable to establish on-line medical control, these patients should be
transported directly to the nearest appropriate TSA-M trauma facility for physician evaluation. Level IV
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 137
Trauma Facilities after stabilization should make the decision whether to transfer to the Level II Trauma
Facility if the patient has any mechanism listed or any finding listed below.
Mechanism of Injury








Motor Vehicle Collision
- With ejection
- High speed more than 40 mph
- Unrestrained more than 20 mph
- Death in same car
- Extrication more than 20 minutes
- Rollover
MCC/ATV/Bike/Large animal
- Separation of rider
- Crash speed more than 20 mph
Falls (greater than 10 feet or 2 x child’s height if under 6 years old)
Assault/child abuse
Auto/Pedestrian
Burns (partial or full thickness)
Hanging/Immersion
Crush injury (not hands or feet)
Findings






Head
- Suspected skull fracture
- Documented LOC less than 5 minutes
Neurologic
- GCS less than 14
- Focal deficit
- Traumatic paresis
Musculoskeletal
- Suspected Open fracture (humerus, femur, tibia)
- Suspected Femur fracture
- Suspected Spine fracture
- Suspected Pelvic fracture
- Pulseless extremity
Abdomen
- Severe abdominal pain
- Seat belt “abrasions”
Burns
- Inhalation injury
- More than or equal to 5% or less than 20% BSA
Chest
- O2 sat less than 92%
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 138
-
Suspected Multiple (more than 2) rib fractures
Sub Q air
Suspected Pneumothorax/Hemothorax
Significant neck and/or chest “abrasions”
Category 4. Category 4 trauma patients are those with injuries not classified as Category 1, 2, or 3.
When EMS personnel are unable to establish on-line medical control, these patients should be
transported directly to the nearest TSA-M acute care facility for physician evaluation.






GCS less than 15
Falls (less than 10 feet or less than 2 x child’s height if under 6 years old)
Snakebites
Injured diabetic patients taking insulin
Injured pregnant patients not classified as 1, 2, or 3
Toxic substance at scene in contact with the patient
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 139
TRAUMA
Head Injury & Spinal Trauma
SPECIFIC ASSESSMENT
 Mechanism of Injury
 Vital signs...consider spinal trauma in patient with hypotension but warm & flushed
 Any motor deficit? Level of sensory deficit if any present
 Note priapism if present
ECA/EMT
INTERMEDIATE
PARAMEDIC
Follow General Trauma
Protocol

Transport with frequent reevaluation. Be prepared for
vomiting.
Follow General Trauma
Protocol

Intubate if decreased
respiratory effort or PRN to
protect airway.

Transport with frequent reevaluation. Be prepared for
vomiting.
Follow General Trauma
Protocol

Contact Medical Control
May premedicate with
Lidocaine 100mg IV prior to
intubation.

Intubate if decreased
respiratory effort or PRN to
protect airway.

Transport with frequent reevaluation. Be prepared for
vomiting.
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 140
TRAUMA
Respiratory Distress with Chest Injury
ASSESSMENT
 Mechanism of injury
 Note crepitus on affected side, decreased breath sounds, flair chest movement
 Note any tracheal deviation, venous distention
ECA/EMT
INTERMEDIATE
PARAMEDIC
Follow General Trauma
Protocol

If paradoxical movement Splint
area and ventilate with BVM

If sucking chest wound:
cover with 3-sided dressing &
palpate for crepitus

Recheck lung sounds
frequently
Follow General Trauma
Protocol

If paradoxical movement Splint
area and ventilate with BVM

If sucking chest wound:
cover with 3-sided dressing &
palpate for crepitus

Recheck lung sounds
frequently
Follow General Trauma
Protocol

If paradoxical movement Splint
area and ventilate with BVM

If sucking chest wound:
cover with 3-sided dressing &
palpate for crepitus

Recheck lung sounds
frequently

Needle Thoracostomy if
ordered by Medical Control
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 141
TRAUMA
Abdominal Trauma
SPECIFIC ASSESSMENT
 Note any evidence of evisceration
 Note rigidity, bruising, abrasions, swelling, and pulsations
 Note number, location, size, and depth of wounds
 Note pelvic stability
 Important if bloody emesis or hematuria.
ECA/EMT
INTERMEDIATE
PARAMEDIC
Follow General Trauma
Protocol

If implementing Spinal Motion
Restriction, Patient may keep
knees bent if comfortable

If open wound or evisceration:
Cover area with moist, sterile
dressing
Follow General Trauma
Protocol

If implementing Spinal Motion
Restriction, Patient may keep
knees bent if comfortable

If open wound or evisceration:
Cover area with moist, sterile
dressing
Follow General Trauma
Protocol

If implementing Spinal Motion
Restriction, Patient may keep
knees bent if comfortable

If open wound or evisceration:
Cover area with moist, sterile
dressing
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 142
TRAUMA
Amputated Parts
ECA/EMT
INTERMEDIATE
PARAMEDIC
Follow General Trauma
Protocol

Cover stump with moist sterile
gauze & elevate

Control hemorrhage

If severed part can be quickly
located: wrap in moist sterile
gauze, place in water tight
container and place container
in ice (Do not freeze)

If severed part cannot be
quickly located, delegate
search for part
Follow General Trauma
Protocol

Cover stump with moist sterile
gauze & elevate

Control hemorrhage

If severed part can be quickly
located: wrap in moist sterile
gauze, place in water tight
container and place container
in ice (Do not freeze)

If severed part cannot be
quickly located, delegate
search for part
Follow General Trauma
Protocol

Cover stump with moist sterile
gauze & elevate

Control hemorrhage

If severed part can be quickly
located: wrap in moist sterile
gauze, place in water tight
container and place container
in ice (Do not freeze)

If severed part cannot be
quickly located, delegate
search for part
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 143
TRAUMA
Isolated Fractures, Dislocations, & Sprains
SPECIFIC ASSESSMENT
 Note localized swelling, discoloration, deformity, lacerations, and exposed bones
 Check for loss of motion or function
 Note guarding, pain, instability, pulses, sensation, movement
ECA/EMT
INTERMEDIATE
PARAMEDIC
ABC's & follow Spinal Motion
Restriction Guidelines

Check motor, sensory,
circulation

Splint areas of tenderness or
deformity in accordance with
Musculoskeletal Motion
Restriction procedure

Recheck pulses, if absent try
gentle traction. Do not attempt
if open fracture with bone
exposed. If unsuccessful,
apply splint & note time

Elevate extremity and apply
cold packs to distal extremities

Transport
ABC's & follow Spinal Motion
Restriction Guidelines

Check motor, sensory,
circulation

Splint areas of tenderness or
deformity in accordance with
Musculoskeletal Motion
Restriction procedure

Recheck pulses, if absent try
gentle traction. Do not attempt
if open fracture with bone
exposed. If unsuccessful,
apply splint & note time

Elevate extremity and apply
cold packs to distal extremities

Transport
ABC's & follow Spinal Motion
Restriction Guidelines

Morphine up to 5 mg IV if
severe pain and no respiratory
depression or hypotension

Check motor, sensory,
circulation

Splint areas of tenderness or
deformity in accordance with
Musculoskeletal Motion
Restriction procedure

Recheck pulses, if absent try
gentle traction. Do not attempt
if open fracture with bone
exposed. If unsuccessful,
apply splint & note time

Elevate extremity and apply
cold packs to distal extremities

Contact Medical Control
May request repeated
Morphine if patient still in pain

Transport
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 144
TRAUMA
Burns
SPECIFIC ASSESSMENT
 Type of burn (thermal, electrical, chemical)
 Explosion or toxic fumes involved? (trauma and respiratory complications)
 Entrance and/or exit wounds for electrical burns
 Estimate depth and per cent body area of burns
 Watch for possibility of rescuer contamination (chemical burns)
ECA/EMT
INTERMEDIATE
PARAMEDIC
Remove patient from source

Decontamination PRN

Follow General Trauma
Protocol

If burns >10% body area,
cover with dry, sterile dressing
Remove patient from source

Decontamination PRN

Follow General Trauma
Protocol

If respiratory burn with soot or
charring of mouth/nose,
consider intubation

If burns >10% body area,
cover with dry, sterile dressing
Remove patient from source

Decontamination PRN

Follow General Trauma
Protocol

If respiratory burn with soot or
charring of mouth/nose,
consider intubation

If burns >10% body area,
cover with dry, sterile dressing

Contact Medical Control
Morphine up to 5 mg IV if
severe pain and no respiratory
depression or hypotension.
May repeat with concurrence
of medical control until pain is
controlled
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 145
TRAUMA
Near Drowning
ASSESSMENT
 Important factors are water temperature, length of time submerged, water contamination.
 Bring sample of water if contaminated
 Note depth of water (Possible trauma from diving injury)
 Lung sounds and neurologic status important
 Is SCUBA diving a factor?
HYPOTHERMIA IS FREQUENT ACCOMPANIMENT OF NEAR DROWNING.
ALWAYS TRANSPORT: PULMONARY EDEMA CAN BE DELAYED FOR SEVERAL HOURS
ECA/EMT
INTERMEDIATE
PARAMEDIC
Protect C-Spine while
removing patient from water
on backboard

Follow General Trauma
Protocol

Suction PRN. Vomiting is
common
Protect C-Spine while
removing patient from water
on backboard

Follow General Trauma
Protocol

Suction PRN. Vomiting is
common
Protect C-Spine while
removing patient from water
on backboard

Follow General Trauma
Protocol

Suction PRN. Vomiting is
common
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 146
EMS Guidelines
APPENDIX
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 147
S A M P L E ------- EMS Patient Refusal Checklist
Name
Age/DOB
Date
Nature of Call
Run #
ASSESSMENT OF PATIENT (Complete each item, check appropriate response)
1. Oriented to:
Person, Place, Time?
Yes
No
Age?
Yes
No
Birthday?
Yes
No
President?
Yes
No
Count backwards?
Yes
No
Recall of three items?
Yes
No
2. Altered level of consciousness?
No
Yes
3. Suspected head injury?
No
Yes
4. Alcohol / drug ingestion? (Exam or History)
No
Yes
5. Age 18 or over?
Yes
No
MEDICAL CONTROL (Contact if patient is unable to make legal informed consent.)
Contacted by:
Phone
Radio
Time
Unable to contact: (Explain)
Possible
Possible
Spoke With
Orders:
 Indicated treatment and/or transport may be refused by patient
 Use reasonable force and/or restraints to provide indicated treatment
 Use reasonable force and/or restraints to transport
 Other:
PATIENT ADVISED (Complete each item, check appropriate response)
Yes No Medical treatment / evaluation
needed
Yes No Ambulance transport needed
Yes No Further harm could result
without medical treatment /
evaluation
Yes No Transport by means other than
ambulance could be hazardous
in light of patient’s present
illness or injury
Yes No Patient provided with refusal
advice sheet
Yes No Patient accepted refusal advice
sheet
Yes No Patient informed, if appropriate,
that there is a potential threat to
life/limb
HOTRAC Regional EMS Guidelines
Rev. 5.10
Yes
Yes
No
No
Yes
No
Yes
Yes
No
No
Agency:
Officer:
Yes No
Refused all EMS Services
Refused transport, accepted field
treatment
Refused field treatment, accepted
transport
Released in care or custody of self
Released in custody of law
enforcement agency
Released in care or custody of
relative or friend
Name:
Relationship:
Page 148
S A M P L E ---- Refusal of Care Information Sheet
Please read and keep this form!
The Emergency Medical Service has given this form to you because you have refused treatment and/or transport. Your
health and safety are our primary concern. Even though you have decided not to accept our advice, please remember the
following:
1.
2.
3.
4.
5.
6.
The evaluation and/or treatment provided to you by EMS are not a substitute for medical evaluation and treatment by a doctor. We advise you to
get medical evaluation and treatment.
Your condition may not seem as bad to you as it actually is. Without treatment, your condition or problem could become worse. If you are
planning to get medical treatment, a decision to refuse treatment or transport by the EMS may result in a delay that could make your condition or
problem worse.
Medical evaluation and/or treatment may be obtained by calling your doctor, if you have one, or by going to any hospital emergency department in
this area, all of which are staffed 24 hours a day by emergency physicians. You may be seen at these departments without an appointment.
If you change your mind or your condition becomes worse and you decide to accept treatment and transport by EMS, please do not hesitate to call
us back. We will do our best to help you.
Don't wait! When medical treatment is needed, it's usually better to get it right away.
If the box at the left has been checked, it means that your problem or condition has been discussed with an emergency physician by radio or
telephone and the advice given to you by EMS has been issued or approved by the emergency physician.
I have received a copy of this information sheet.
I assume all risks and consequences of my decision and hereby release Provider and their agents or employees from any
liability arising from this decision.
Patient Signature _______________________________________Date_______________________
La NEGATIVA DE HOJA de INFORMACION de CUIDADO
Lea por favor y mantenga esta forma!
La Emergencia el Servicio Médico le ha dado esta forma a usted porque usted ha rehusado el tratamiento y/o el transporte.
Su salud y la seguridad son nuestro primario concierno. Aunque usted ha decidido no aceptar nuestro consejo, recuerda
por favor lo Siguiente:
1.
2.
3.
4.
5.
6.
La evaluación y/o el tratamiento proporcionados a usted por EMS no son un substituto para la evaluación y el tratamiento médicos por un doctor.
Nosotros lo avisamos a obtener la evaluación y el tratamiento médicos.
Su condición no puede parecer como mala a usted como es verdaderamente. Sin el tratamiento, su condición o el problema podrían llegar a ser
peores. Si usted planea para obtener el tratamiento médico, una decisión de rehusar el tratamiento o el transporte por el EMS pueden tener como
resultado una demora que podría hacer su condición o el problema peores.
La evaluación y/o el tratamiento médicos pueden ser obtenidos llamando a su doctor, si usted tiene uno, o yendo a cualquier departamento de la
emergencia del hospital en esta área, todos los cuales son proveídos 24 horas un día por médicos de emergencia. Usted puede ser visto en estos
departamentos sin una cita.
Si usted cambia de opinión o su condición llega a ser peor y usted decide aceptar el tratamiento y el transporte por EMS, por favor no vacilan en
llamarnos apoyamos. Haremos nuestro ayudarlo mejor.
¡No espere! Cuándo tratamiento médico se necesita, generalmente mejor lo deberá obtener inmediatamente.
Si la caja en la izquierda se ha verificado, significa que su problema o la condición han sido discutidos con un médico de la emergencia por radio o
teléfono y por el consejo dado a usted por EMS ha sido publicado o ha sido aprobado por el médico de la emergencia.
He recibido una copia de esta hoja de información.
Asumo que todo se arriesga y las consecuencias de mi decisión y por la presente libera Provider y sus
agentes o los empleados de cualquier responsabilidad que surge de esta decisión.
La Firma paciente____________________________________La fecha: _______________________
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 149
S A M P L E ---- Pre-Hospital Thrombolytic Screen
Date___________________
Patient Name________________________________________
Age__________
Weight__________
Time since onset of chest pain in Hours____________________
Medications Now:_____________________________________
___________________________________________________
___________________________________________________
___________________________________________________
Allergy to Medication?_________________________________
History:
Recent CVA/Stroke
Pregnant?
Recent surgery (3 months)
Recent Injury or wound?
History of clotting disorder?
High Blood Pressure?
History of Cancer?
Peptic ulcer or GI bleeding?
Suspected Aortic Dissection
Allergy to TPA or Streptokinase?
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
Additional History or Pertinent Information or Comments:
___________________________________________________
___________________________________________________
EMT:_______________________________________________
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 150
Pediatric & Neonatal Assessment
ASSESSMENT
1. LOC may be difficult to evaluate. Need to know baseline from the parent
2. Airway evaluation: note obstructions, stridor, drooling, head in sniff position
3. Breathing evaluation: note retractions, nasal flaring, use of accessory muscles
Begin Newborn resuscitation with airway management and ET intubation if APGAR < 8
APGAR SCORE, NEWBORN
Sign
0
1
2
Heart Rate
Absent
<100
>100
Respirations
Absent
Slow/Irregular
Good, Crying
Muscle Tone
Limp
Some Flexion
Active Motion
Reflex Irritability
No Response
Grimace
Color
Blue or Pale
Acrocyanosis
Cough or Sneeze
Completely Pink
PEDIATRIC VITAL SIGNS
Age
Heart Rate
Respiratory Rate
Newborn
85-205 (Mean 140)
30-60 (Mean 30+)
3 mo.-2 yr.
100-190 (Mean 130)
26-34 (Mean 27)
2 yr.-10 yr.
80-140 (Mean 80)
20-30 (Mean 24)
>10 yr.
60-100 (Mean 75)
15-24 (Mean 20)
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 151
Example of a Standard Delegation Order (SDO)
(Attachment 8 of HOT Area Chempack SOG)
Standard Delegation Order for
Administration of CHEMPACK Pharmaceuticals
PURPOSE:
To provide for immediate response in treating patients with nerve agent exposures.
AUTHORITY:
Texas Administrative Code, Title 25 Health Services
DEFINITIONS:
CHEMPACK: The voluntary participation project for the forward placement of sustainable repositories of nerve
agent antidotes in numerous locations throughout the United States for quick response to a nerve agent event such as
a terrorist attack. CHEMPACK is a component of the federal Strategic National Stockpile Program (SNS) operated
by the Centers for Disease Control and Prevention (CDC).
Nerve Agents: Extremely toxic organophosphate type chemicals, including GA (tabun), GB
(sarin), GD (soman), GF (cyclosarin), and VX, which attack the nervous system and interfere with chemicals that
control nerves, muscles, and glands. They are odorless and invisible and can be inhaled, absorbed through the skin,
or swallowed.
POLICY:
1) In the event of a nerve agent release, a CHEMPACK container (s) will be deployed from strategically
located positions within the Heart of Texas Area.
2) Once deployed, CHEMPACK pharmaceuticals are administered under standing delegation orders that apply
to the agency administering the pharmaceuticals during the incident. Documentation of pharmaceuticals
administered should also follow standard protocols set forth by the agency administering the
pharmaceuticals.
3) All Providers will ensure personal safety by assuring adequate decontamination of victims and using
appropriate personal protective equipment (PPE). Medical procedures within the Exclusion Zone (Hot
Zone/contaminated area) will only be performed by personnel who have specific training to allow them to
function in that area.
FOR:
Administration of CHEMPACK Pharmaceuticals
EFFECTIVE DATE:
Through
AUTHORIZING PHYSICIAN:
SIGNATURE:
,M.D.
DATE:________________
(Authorizing Physician)
SIGNATURE:_________________________________________DATE:________________
Name of Entity: ______________________________________________________________
Address of Entity: _____________________________________________________________
Phone Number of Entity: _______________________________________________________
HOTRAC Regional EMS Guidelines
Rev. 5.10
Page 152
Antidote Administration Recommendations
for CHEMPACK Medications
(Attachment 9 of HOT Area Chempack SOG)
Subject:
Nerve Agent / Organophosphate Antidote Administration Recommendations
Purpose:
Provide medical guidance to physicians providing delegated authority for any local jurisdiction receiving the
CHEMPACK. The treatments outlined within this document are considered the standards for administration of
these medications and are based on best practice recommendations from the United States Army Medical
Research Institute for Chemical Defense.
Authority:
This document does not constitute or represent any authorization for distribution or administration of any
medication or medical procedure. It is the responsibility of the local medical authority to determine and
authorize the appropriate application, dosing, and management for patients exposed to nerve agents /
organophosphates.
Definitions:
The nerve agents – Tabun (GA), Sarin (GB), Soman (GD), GF, and VX – are considered primary agents of threat
because of their high toxicity and effectiveness through multiple routes of entry. Routes of exposure include
the gastrointestinal tract, eyes, respiratory tract, and skin. Nerve agents are chemically similar to
organophosphate pesticides, but are intended to be much more potent.
Organophosphates – insecticides/pesticides – pose equal threat through both common use (accessibility) and
ease of accidental exposure through the multiple routes of exposure, as described above.
The main principles of therapy for nerve agent poisoning are early treatment, assisted ventilation, bronchial
suction, muscarinic cholinergic blockade (atropine), enzyme reactivation (pralidoxime chloride), anticonvulsants
(diazepam), and bronchodilation (albuterol/atrovent – not included in the CHEMPACK).
Medications are delivered in various forms including Auto-injectors (automatic, spring activated syringes
containing a predetermined medication) for expedient intramuscular (IM) administration and multi-dose vials for
less expedient administration intramuscularly (IM) or intravenously (IV).
The terms, “Nerve Agent Antidote Kit”, “NAAK” and “Mark I" are used interchangeably and contain adult dosing
of atropine and pralidoxime (2-PAM).
The terms “pralidoxime chloride” and “2-PAM” are used interchangeably.
Indications:
The most effective care that patients can receive is that care given within the first few minutes following their
exposure to nerve agent or organophosphate pesticide.
The CHEMPACK can be used by medical personnel as additional antidote in the case of exposure to nerve agent
or organophosphate pesticide.
Reference:
U.S. Army Medical Research Institute of Chemical Defense (2000) Medical Management of Chemical Casualties
Handbook. Third Ed. Chemical Casualty Care Division: Aberdeen Proving Grounds.
Procedure:
HOTRAC Regional Trauma System Plan
Revised May 2010
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Page
Upon recognition that nerve agent or organophosphate pesticide exposure has occurred and symptoms of
exposure are present, personnel should administer antidotes using the following weight based recommended
guidelines.
HOTRAC Regional Trauma System Plan
Revised May 2010
154
Page
A. Patients >90 lbs.
B.
Mild Exposure for Patients >90 lbs. – Pinpoint Pupils (Dim Vision)
No antidote administration
Advise patient to monitor for progression of other obvious signs and symptoms
C.
Moderate Exposure for Patients >90 lbs. – Pinpoint Pupils (Dim of Vision), Nasal Discharge, Mild
SOB, Nausea or Vomiting, or Tremors
2mg Atropine IM or IV and 600mg Pralidoxime Chloride IM or IV
Atropine 2mg IM (Syringe or AtroPen auto-injector) or IV (Syringe), immediately followed by
Pralidoxime Chloride 600mg IM (Syringe or ComboPen auto injector) or IV (Syringe)
Pinpoint pupils (dim vision) may be persistent after life-threatening conditions have been resolved.
D.
Severe Exposure for Patients >90 lbs. – Severe SOB, Apneic, Unconscious, or Convulsions
6mg Atropine IM or IV, 1800mg Pralidoxime Chloride IM or IV, and 10mg Diazepam IM or IV
EITHER:
Atropine 6mg IM or IV (Syringe), immediately followed by
Pralidoxime Chloride 1800mg IM or IV (Syringe)
OR 3 NAAKs:
Atropine 2mg IM by AtroPen auto-injector, immediately followed by
Pralidoxime Chloride 600mg IM by ComboPen auto injector, immediately followed by;
Atropine 2mg IM by AtroPen auto-injector, immediately followed by
Pralidoxime Chloride 600mg IM by ComboPen auto injector, immediately followed by;
Atropine 2mg IM by AtroPen auto-injector, immediately followed by
Pralidoxime Chloride 600mg IM by ComboPen auto injector
AND:
Diazepam 2-10mg IM (Syringe or 10mg auto injector) or IV (Syringe)
Repeat Atropine 2mg IM (Syringe or AtroPen auto-injector) or IV (Syringe) PRN until SOB relieved and
drying of secretions.
Repeat Prolidoxime Chloride is not necessary until approximately 1 hour after initial dosing. The same
dosing regimen is appropriate. Re-dosing should not occur until atropinization has occurred.
Repeat Diazepam 2-10mg IM (Syringe or 10mg auto-injector) or IV (Syringe) PRN until convulsions cease.
Seizures in the absence of other muscarinic and/or nicotinic effects of nerve agents / organophosphates
require further investigation for cause.
Monitor patient for return of signs and symptoms. Always assure the safety of the medical team and the
patient by consideration of routes of exposures and potential for missed agent / substance in
decontamination.
Pinpoint pupils (dim vision) may be persistent after life-threatening conditions have been resolved.
Patients ≥40 and ≤90 lbs.
E.
Mild Exposure for Patients ≥40 and ≤90 lbs. – Pinpoint Pupils (Dim Vision)
No antidote administration.
Advise patient to monitor for progression of obvious signs & symptoms
F.
Moderate Exposure for Patients ≥40 and ≤90 lbs. – Pinpoint Pupils (Dim of Vision), Nasal
Discharge, Mild SOB, Nausea or Vomiting, or Tremors
Dose with 1mg Atropine IM or IV
Atropine 1mg IM (Syringe or 1mg AtroPen auto-injector) or 1mg IV (Syringe)
Pinpoint pupils (dim vision) may be persistent after life-threatening conditions have been resolved.
HOTRAC Regional Trauma System Plan
Revised May 2010
155
Page
Patients ≥40 and ≤90 lbs. (Continued)
G.
Severe Exposure for Patients ≥40 and ≤90 lbs. – Severe SOB, Apneic, Unconscious, or
Convulsions
Dose with 3mg Atropine IM or IV and 2-10mg Diazepam IM or IV
EITHER:
Atropine 3mg IM or IV (Syringe)
OR 3 Atropen 1mg IM Injections:
Atropine 1mg IM by AtroPen auto-injector, immediately followed by
Atropine 1mg IM by AtroPen auto-injector, immediately followed by
Atropine 1mg IM by AtroPen auto-injector
AND:
Diazepam 2-10mg IM (Syringe or 10mg auto injector) or IV (Syringe)
Pralidoxime Chloride is not recommended in pediatric patients.
Repeat Atropine 2mg IM (Syringe or AtroPen auto-injector) or IV (Syringe) PRN until SOB relieved and
drying of secretions.
Repeat Diazepam 2-10mg IM (Syringe or 10mg auto-injector) or IV (Syringe) PRN until convulsions cease.
Seizures in the absence of other muscarinic and/or nicotinic effects of nerve agents / organophosphates
require further investigation for cause.
Monitor patient for return of signs and symptoms. Always assure the safety of the medical team and the
patient by consideration of routes of exposures and potential for missed agent / substance in
decontamination.
Pinpoint pupils (dim vision) may be persistent after life-threatening conditions have been resolved.
H. Patients <40 lbs.
I.
Mild Exposure for Patients <40 lbs. – Pinpoint Pupils (Dim Vision)
No antidote administration
Advise patient to monitor for progression of other obvious signs and symptoms
J.
Moderate Exposure for Patients <40 lbs. – Pinpoint Pupils (Dim of Vision), Nasal Discharge, Mild
SOB, Nausea or Vomiting, or Tremors
Dose with 0.5mg Atropine IM or IV
Atropine 2mg IM (1 AtroPen auto-injector)
Pinpoint pupils (dim vision) may be persistent after other symptoms have been resolved.
K.
Severe Exposure for Patients <40 lbs. – Severe SOB, Apneic, Unconscious, or Convulsions
Dose with 1.5mg Atropine IM or IV and 2-10mg Diazepam IM or IV
EITHER:
Atropine 1.5mg IM or IV (Syringe)
OR 3 Atropen 0.5mg IM injections:
Atropine 0.5mg IM by AtroPen auto-injector, immediately followed by
Atropine 0.5mg IM by AtroPen auto-injector, immediately followed by
Atropine 0.5mg IM by AtroPen auto-injector
AND:
Diazepam 0.5-10mg IM (Syringe or 10mg auto injector) or IV (Syringe)
Pralidoxime Chloride is not recommended in pediatric patients.
Auto-injectors are not recommended for patients under 15 lbs.
HOTRAC Regional Trauma System Plan
Revised May 2010
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Page
L. Patients <40 lbs. (Continued)
Repeat Atropine 0.5mg IM (Syringe or AtroPen auto-injector) or IV (Syringe) PRN until SOB relieved and
drying of secretions.
Repeat Diazepam 0.5-10mg IM (Syringe or 10mg auto-injector) or IV (Syringe) PRN until convulsions
cease. Seizures in the absence of other muscarinic and/or nicotinic effects of nerve agents /
organophosphates require further investigation for cause.
Monitor patient for return of signs and symptoms. Always assure the safety of the medical team and the
patient by consideration of routes of exposures and potential for missed agent / substance in
decontamination.
Pinpoint pupils (dim vision) may be persistent after life-threatening conditions have been resolved.
In children with cholinergic poisoning, a loading dose of pralidoxime (20-40 mg/kg IV over 30-60 min) followed by
an infusion of 10-20 mg/kg/h is often recommended (Goldfrank's Toxicologic Emergencies 8th ed 2006, p. 1515).
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