Lisbon Fire Department
Standard Operating Guidelines and Policies
S.O.G.s
Administration
Compensation Schedules
Attendance
Motor Vehicle Driving
Health and Safety
Self Contained Breathing Apparatus
Incident Rehabilitation
Incident Command System
Blood Borne Pathogens
Structural Fires
Vehicle Fires
Vehicle Accidents and Extrication
Brush Fires
Hazardous Materials Incidents
Carbon Monoxide Alarms
Mutual Aid Response
Driver Operator Responsibilities
Live Fire Training In Structures
Hamilton High School Response
Templeton Middle School Response
Richmond Grade School Response
Emergency Medical Response
Waukesha County EMS Guidelines
1-1
1-2
1-3
1-4
2-1
2-2
2-3
2-4
2-5
3-1
3-2
3-3
3-4
3-5
3-6
3-7
3-8
3-9
3-10
3-11
3-12
4-1
4-2
Policies
Station Rules
Call Group Coverage Times
Controlled Substance Policy
Tampering with turnout gear
Internet and Email usage Policy
Exposure Plan
Probationary Testing
Unit Identification
Interfacility Operations
Emergency Response Standard
Drug and Alcohol Policy
Code of ethics
Dress Code
Priority Responses
1
2
3
4
5
6
7
8
9
10
11
12
13
14
LISBON FIRE DEPARTMENT
SOG 1-1
SUBJECT: Administration
EFFECTIVE DATE: 02/11/2011
PURPOSE:
This manual has been prepared to present Fire department personnel with the
various operational procedures and policies that govern the Fire department. The
goal is to define the operation; procedures of the Fire department as they interact
with the Town Ordinances, ILHR 30, and other department guidelines.
With regard to the emergency operations of the department, the term guideline
indicates that those procedures provide a basic framework for the
firefighter/officer in which to perform. Emergency guidelines can be altered for
unusual situations that may be encountered by the department. However, the
guidelines should be followed whenever possible.
It is the Fire Chief’s intention to amend, change and add to this guidebook from
time to time as new situations are encountered, or as need for the changing of an
existing policy becomes necessary. In this regard, your suggestions, ideas and
thoughts will be most helpful in maintaining a pleasant atmosphere in which we
can all be productive.
CREATION OF THE DEPARTMENT:
1.
The Lisbon Fire Department has been created by the Town Board to
protect the citizens of the Town. (Reference: Town Ordinance 5.01) The
Fire Department is governed in accordance with Chapter 34 of the Town
ordinances.
FINANCES, PROPERTY, EQUIPMENT:
1.
All property and equipment of the fire department are assets of the Town
of Lisbon.
2.
Finances will be provided by the Town of Lisbon for operation of the
department and the Town shall pay all invoices approved by the Fire Chief
and Town Board.
3.
All operating expenses and procedures of any equipment shall be
approved by the Fire Chief or written designee before ordering.
EMPLOYMENT APPLICATION AND ACCEPTANCE REGARDING PAID-ONCALL STATUS:
1.
All paid-on-call applicants will be subject to a hiring process provided by
the Board of Directors of the Lisbon Firefighters Inc. as sanctioned by the
Lisbon Fire and Police Commission. An application, with a copy of all
certificates and resume (if applicable) must be completed and turned into
the Fire Chief.
2.
A completed application and or resume shall be filed with the Fire Chief,
which then shall be reviewed. The interview process will be conducted by
the Board of Directors. Upon approval from the board, The Chief, or an
appointed designee, will then investigate the references, perform a
background check, and request the police department to check the
individual’s driving record.
3.
Employment shall be open to all persons who are residents of the town or
who reside within a reasonable response distance, (determined by the Fire
Chief), or persons working full-time in the town who’s employers allow
them to leave work. Non-residents can also be candidates for membership
based on individual case by case negotiated conditions of employment
accepted by the Chief and Board of Directors.
4.
All applicants for employment may be required to take a medical
examination based on national guidelines (NFPA 1582) and a drug/alcohol
test before employment will be considered. Periodic physicals may be
requested by the Fire Chief if deemed necessary including drug testing.
Random drug testing may also be conducted at the discretion of the
Department. The medical examination and drug/alcohol tests will be
conducted at the expense of the Town of Lisbon.
5.
The Town of Lisbon is an equal opportunity employer.
EMPLOYMENT APPLICATION AND ACCEPTANCE REGARDING CAREER
STATUS, FULL AND PART-TIME:
1.
Application for employment process is conducted by the Lisbon Police
and Fire Commission.
EMPLOYEES AND EMPLOYMENT:
Probationary Employee:
1.
A “Probationary Employee” shall be a minimum age of 18 and hold a
valid Wisconsin driver’s license with a good driving record.
2.
During the probationary period, the employee must attend department
trainings and meetings unless excused by an officer for a reasonable cause.
3.
The probationary employee must successfully complete two certification
courses. Complete required drive time training. Complete the orientation
class, and remain in good standing with the Department rules and
regulations. Probationary member shall maintain a satisfactory on-call
work history.
4.
A probationary employee cannot hold office.
5.
A probationary employee will be reviewed by the discretion of the Fire
Chief.
6.
When a probationary employee has successfully met the above criteria,
they shall be given a “Lisbon Fire Department Probationary Test”. Upon
passing this test, the probationary member will then obtain a “general
employee” status. General or full status member graduates shall become
sworn members by actions of Town officials.
General Employee:
1.
A “General Employee” shall be at least 18 years of age, have been on the
department for a minimum of one (1) year of continuous service and
successfully completed the probationary period, and hold a valid
Wisconsin driver’s license with a good driving record.
2.
The employee must attend department trainings and meetings unless
excused by an officer for a reasonable cause.
All Employees:
1.
Any employee may resign from the department by filing a written
resignation to the Fire Chief. Such resignation shall not relieve the
employee from returning all department issued equipment and uniforms.
The Town of Lisbon will hold their last check until all equipment is
returned. Failure to return all department property will result in the
individual being obligated to pay for all items not returned, at the market
replacement value.
2.
Any employee unfavorably terminated will agree not to use any
department insignia upon any personal equipment owned by him or
herself.
3.
Any employee may request a leave of absence by submitting a written
leave of absence to the Fire Chief. This period of leave may not exceed
one (1) year with six (6) month review. If the leave is due to illness or
injury, the request must be in writing accompanied with a doctor’s report
indicating the need for the leave.
Before returning to active duty from the illness or injury, the employee
must provide a written doctor’s order granting the employee to return to
active duty. In determining the ability to return to active duty, the doctor
must review the employee’s job description.
4.
Regarding any issues with disciplinary action or grievances, the individual
must file the complaint with the Chief. If a satisfactory conclusion is not
met, the following options are available. Town ordinances and State
statues apply.
-Paid on call members- may appeal to the board of directors.
-Career members and officers- may appeal to the Fire and Police
Commission.
DUTIES OF EMPLOYMENT:
1.
When possible, each probationary member or general employee shall
report immediately to the station for emergency calls, and get the
necessary apparatus to the scene of the emergency.
2.
No employee shall respond to an emergency scene in his or her private
vehicle, unless designated by the Fire Chief. The member will be equipped
with the proper PPE needed for that type of call.
3.
The employee will remain at the scene of any emergency to which he/she
responds until directed by command to depart. Absence from the scene or
at the station may only be granted by the Fire Chief, or the next highestranking officer in charge. All personnel shall return to the station after
every call to complete assignment.
4.
The employees who respond to the station for an emergency call, but do
not go out on the call, must stay at the station until all the apparatus
returns to the station in order to provide adequate coverage for other calls.
Roll call for attendance will not be taken until the Fire Chief, or the next
highest-ranking officer decides that the above duty has been completed,
including cleaning of apparatus and equipment, and are in proper
condition for future use.
8.
5.
Any general employee, in the absence of an officer, can assume command
and do everything within his/her power to handle the emergency incident
(Refer to SOG # 2-4, Incident Management System)
6.
Any employee or officer, who leaves a post of duty without being properly
relieved, who appears at any department call or function in an intoxicated
condition or under the influence of a controlled substance, or who fails to
maintain an acceptable attendance record, will be subject to legal
ramifications and disciplinary actions.
7.
All employees entrusted with possessions of the fire department shall be
responsible for keeping them in efficient working condition. The
employee shall report any unsatisfactory condition or needed repairs
immediately to the Fire Chief or officer.
Lisbon Fire Department Paid-on-Call Job Description
Position: Paid on Call FF/EMT
Employed by: Town of Lisbon, Lisbon Fire Department
Reports to: Lisbon Fire Department Chief, Staff Officers
Appointed by: Lisbon Fire Fighters Inc., Board of Directors (sanctioned by the Lisbon
Fire and Police Commission)
Position Summary
The Paid-on-call FF/EMT will be employed to primarily respond to emergency
calls during assigned hours and on assigned groups. Both fire and EMS response will be
required. Employee will be required to maintain a membership on the department and
will be held to the standards as set forth in all the rules, regulations, policies, and
protocols. Employee will be also required to carry a pager and will accept on-call duties
as agreed upon or assigned. The person will serve as an agent of the Town Fire
Department and will report to the group officers, captains, and Department Chiefs.
Responsibilities will include but not limited to; answering emergency calls EMS and fire
related, daily cleaning duties, communicating with the public, assisting department
officers as assigned, special assignments, public education, and general fire fighter duties.
Employee will be required to obtain training in fire fighting and or EMS and related
fields and specialties. The member will also be held accountable for maintaining
certifications, licensure and ongoing education as required for active status.
Duties and Responsibilities:
1. Respond to emergency calls, both fire and EMS, in Lisbon and mutual aid
requests in neighboring areas.
2. Be available for work during pre-determined hours set by the chief at the fire
station(s), and from home.
3. Play an active role in building a competent EMS/Fire service.
4. Participate in a positive manner creating an atmosphere confidence and
proficiency in the departments EMS/fire ranks.
5. To insure that proper EMS protocols are followed and procedures that are
called for are indeed enacted.
6. To insure that proper fire protocols are followed and procedures adopted to be
implemented.
7. Promote team work among the crew and personnel in their roles on the calls.
8. Provide additional information or learned techniques from acquired
experience to the departments EMS/Fire personnel.
9. Follow the standard operating guide lines of the Lisbon and Hartland Fire
Departments which apply to the position and perform in a professional
manner at all times.
10. Schedule available times for emergency response with the department’s
administration and respond with the rescue/fire groups per the program
guidelines.
11. Seek proper coverage for periods of absenteeism.
12. Participate in all Department trainings, and achieve required minimums.
13. Provide input in the evaluation of the Department programs in the proper
channels provided.
14. Report, through proper established channels any activity within the
Department or by individuals that undermine the mission and safety of the
Department and members.
The preceding responsibilities are intended to describe the general nature and
level of work being preformed. These statements are not intended to be construed as an
exhaustive list of all the responsibilities, duties, and services required. Other unforeseen
activities may also be included.
Required Knowledge, Skills and Abilities
The Paid-on-call FF/EMT position will be employed from an application process
directed by the board of directors of the Department. A probationary period will occur
for all members and will be in effect until basic requirements are met. Applicants must
be willing to carry a pager and physically capable to respond on EMS/Fire calls within
the Town of Lisbon and Village of Hartland. Possess knowledge of Lisbon and Hartland
ambulance procedures and state, local EMS protocols. Possess knowledge of fire
fighting equipment, Lisbon protocols, and response SOG’s. Member will commit to a
fire, medical, or combination career track upon acceptance.
EMS
Applicant will obtain a valid State of Wisconsin license for Emergency Medical
Technician, IV Technician, Intermediate-99 or EMT-Paramedic level. In lieu of this level
of Wisconsin Licensure a candidate may operate under their medical equivalent license
(i.e. nurse) of equal competencies and accepted by medical control. Candidate will
achieve one level of EMS and fire level I certification prior to being qualified to take the
Lisbon probationary test. If applicant is on an EMS path will obtain 2 levels of EMS
prior to test.
Fire
Must obtain state certified level fire fighter I and an EMS level of licensure prior
to being eligible to take the probationary test. If employee is on a fire only path, must
obtain two certifications prior to test. Members will successfully complete the
probationary period, obtain certifications, four hours of drive time on each vehicle,
complete EVOC training, and completed the probationary test to be eligible to run
emergent to calls.
Tools and Equipment Used
Use of, but not limited to, ambulance, defibrillators, IV-sets, immobilization
equipment, diagnostic devices, radios and other medical equipment. All firefighting
equipment, SCBA, personal protective equipment, firefighting apparatus, computers, and
all additional items required for training props.
Work Environment
While performing job duties, the paid-on-call FF/EMT will work in a variety of
environments. Work duties will be conducted in a variety of locations and environments.
Including all types of structures indoors, and outside in all types of weather. Including
working in the interior of an ambulance, operating a fire engine, utilizing all physical
positions such as standing, sitting, climbing, crawling, and any other positions as
required. Exposure to blood borne pathogens and other communicable diseases are
possible. Duties may include working in environments of structural fire emergencies,
outside fires, hazardous material incidents, and special rescue or other scenes.
Compensation and Benefits
The paid-on-call FF/EMT shall be compensated on an hourly basis, paid
quarterly, and based on a rate established by the fire chief and approved by the Town
board. Regular members will be placed in a Length of Service program.
The Town of Lisbon is an Equal Opportunity Employer. In compliance with the
Americans with Disabilities Act, Town/Village may provide reasonable
accommodations to qualifying individuals with disabilities and encourage both
prospective and current employees to discuss potential accommodations with the
employer.
CONDUCT OF EMPLOYEES:
1.
It shall be the duty of all employees to obey all rules, orders, and
instructions of their superior officers, policies of this document,
ordinances of the Town of Lisbon, laws of the State of Wisconsin and of
the United States of America.
2.
It shall be the responsibility of all employees to conduct themselves in an
exemplary manner, both on and off duty, and by so doing reflect credit
upon themselves and the Lisbon Fire Department.
3.
Violation of these rules of conduct and/or the ordinances and the laws of
the governing bodies shall subject the offender to the penalties as herein
provided.
4.
No plea of ignorance shall avail to relieve an employee from any of the
penalties as herein provided.
5.
A member shall not maliciously make any false report to create a
disturbance to bring discredit upon a fellow employee.
6.
It shall be considered a gross violation to engage in immoral or disorderly
acts, violate any criminal law, or commit a felony at any time or to appear
intoxicated or under the influence of drugs on duty (reference Drug and
Alcohol rule and policy).
7.
Conduct, not within the scope of these rules and regulations, shall be
governed by ordinary rules of good behavior as observed by law-abiding
citizens.
8.
Employees shall treat superior officers and subordinates with respect.
They shall be courteous and civil at all times in their relationships with
one another.
9.
No employee shall be party to any malicious gossip, report, or activity,
which would disrupt fire department morale or bring discredit to the
department or any other employee.
10.
In matters affecting the policies and practices of the department, no
employee shall give utterance, public speech, publication, or take similar
action directly or indirectly without first obtaining approval from the Fire
Chief.
11.
No employee may use department equipment for personal gain or uses not
authorized by the Fire Chief.
12.
No member shall represent himself or herself as a Lisbon Fire Department
employee to obtain information from outside agencies regarding results of
investigations or situations, unless prior approval from the Fire Chief is
secured
CHAIN OF COMMAND: On emergency scenes and during Fire
Department Operations.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
Chief
Assistant Chief
Deputy Chief
Captain
Captain
Lieutenant
Lieutenant
Lieutenant
Lieutenant
Lieutenant
Lieutenant
Lieutenant
Lieutenant
Lieutenant
TOBACCO USE POLICY:
1. No employee shall use tobacco, in any form, at the scene of an emergency or
in town owned vehicles. (Includes smokeless) No smoking is allowed in any
public buildings, including any part of any Lisbon Fire station.
2. Tobacco may be used at trainings, outdoors, when it is authorized by the Fire
Chief or the person in charge.
CHANGE OF ADDRESS AND PHONE NOTIFICATION:
1. In order to keep the roster current, any change of an address, phone number,
and e-mail will be forwarded to the Chief or his/her appointed designee.
UNIFORM POLICY:
1.
Employees shall wear full class “B” uniforms (see dress code policy) to all
business meetings, and fire department activities, according to the Lisbon
Fire Department Dress Code. Unless directed otherwise by the Fire Chief
or officer in charge.
CELL PHONES / PERSONAL PAGERS:
1.
During business meetings, all cell phones and personal pagers shall be
turned off or set to a vibrate mode to not disturb the meeting. No texting
will be permitted.
LISBON FIRE DEPARTMENT
POLICY 1-2
SUBJECT: Pay Rates and Time Records
EFFECTIVE DATE: 02/11/2011
PURPOSE:
To determine payroll calculations and create accurate record keeping.
OBJECTIVES:
To establish a standard of a fair and equal system of compensation.
STANDARDS:
Paid-on-Call Firefighter, EMT-Basic, EMT-Tech, EMT-Intermediate, EMTParamedic or Firefighter/EMT-B through P compensation, will be calculated
according to the following:
1.
Paid hourly while responding to emergency calls per set wage rates
established by the Lisbon municipal government. Members shall
in person sign the appropriate attendance forms designated for
each specific call.
2.
Paid hourly while attending training/business meetings per set
wage rates established by Lisbon municipal government.
Members shall in person sign appropriate attendance forms
designated for each specific training/meeting
3.
Bonus Stipend for extra duty. Each member shall turn in quarterly
appropriate forms documenting extra duty hours worked.
4.
All members are to be held to an honor system of honesty.
Full time, permanent part-time and part-time personnel regardless of rank
(excluding administrative positions) is compensated on an annual wage calculated
to an hourly rate that can earn comp time if over 54 hours are worked within a
Sunday to Sunday week period.
The Fire Chief and Lisbon Municipal
Government will determine all wages. All Employees shall submit time sheets in
a format adopted and approved by the Chief of the Department. The Chief or
designee will be responsible for reviewing for approval. Time sheets will be due
on the Monday morning or the first work day of the week prior to the Friday
payday and submitted to the Chief. Employee shall record time of arrival at the
station of assigned duty at beginning of tour of duty and record times leaving and
returning through out the day for all non-related work details. A ½ hour lunch
period is allotted for all hourly personnel of this category, lunch will be taken
from 12 noon to 12:30 or as close to this time frame as possible. This will also be
reflected on the time sheets.
Paid-on-Call Officers are annual salaried and composted at rates established by
the Lisbon Municipal government. Officers shall submit monthly time sheets
documenting duties on an approved time sheet format by the Chief.
PAY SCHEDULE:
Following is the schedule for dispersal of compensation.
Paid on Call Firefighters and EMT’s Quarterly;
1.
January 1st – March 31st paid in April
2.
April 1st – June 30th paid in July
3.
July 1st – September 30th paid in October
4.
October 1st – December 31st paid in January
Officers and part-time:
1.
Monthly
Full time, permanent part-time:
1.
Bi – weekly
LISBON FIRE DEPARTMENT
POLICY 1-3
SUBJECT: Standards For Attendance
EFFECTIVE DATE: 02/11/2011
PURPOSE:
To ensure proper attendance is met by all personnel.
OBJECTIVES:
All personnel must be thoroughly familiar with the fire and rescue
procedures practiced by this department. It is also essential that personnel
be experienced in working with each other under stressful conditions and
familiar with the skills of fellow members. In addition, the successful
organization relies on a teamwork approach to the unscheduled
responsibility of keeping equipment and apparatus ready for emergency
response.
STANDARDS:
1.
Each member is encouraged attend all the regularly scheduled training
sessions to stay proficient in their skills and the operations of the Lisbon
Fire Department. A 50% attendance per month for each calendar year is
required for all paid-on-call rank and file members. Note that in-house
classes to acquire or maintain certifications or Wisconsin Licensure may
require higher rates of attendance and will mandated. Officers will
maintain no less than 70% of trainings. All members will notify their
absences with their assigned officer. Absences due to regular primary
employment commitments will be accepted.
2.
Each member will respond to and attend all the EMS and Fire emergency
calls that occur when said employee is on call, or find a suitable
replacement, and shall attend fire emergency calls that occur when the
member is not working at regularly scheduled employment.
3.
Each member may perform at least 5 hours of additional duty per month.
Examples of additional duties include:
A.
B.
C.
Station clean up.
Apparatus repairs
Trips to vendors on official business.
D.
E.
F.
G.
H.
Outside education, (with a chief officer approval).
Participation in outside evolutions and drill.
Driving and operation of apparatus.
Special projects approved by a chief officer.
Other activities approved in advance by a chief officer.
Using the appropriate form, each member shall submit a short summary of his/her
additional duty at the monthly business meeting. Work in excess of the 5 hours is
not carried over to the next monthly period. A member’s attendance will
determine their quarterly payroll. (See policy 1-2)
If a member does not meet the minimum attendance requirements in any category,
the Chief will advise him/her. Excluding limiting circumstances, attendance
below the minimum requirement in any category for one additional quarter, after
being notified, will be grounds for dismissal action.
LISBON FIRE DEPARTMENT
SOG 1-4
SUBJECT: Motor Vehicle Driving
EFFECTIVE DATE: 02/11/2011
PURPOSE:
To provide a guideline for department personnel concerning the operation of
motor vehicles, either department or personal, when such employee is acting in an
official capacity for the Lisbon Fire department.
APPLICABLE STATE STATUTES - EMERGENCY VEHICLES:
1.
Wisconsin Statute 346.03, Applicability of rules of the road to authorized
emergency vehicles.
2.
Wisconsin Statute 346.63, operating under influence of intoxicant or other
drug.
3.
Town of Lisbon Municipal Code.
NOTE: A vehicle is an “emergency vehicle” only when BOTH visual
and audible warning devices are in operation.
DRIVERS/OPERATORS OF FIRE DEPARTMENT APPARATUS:
1.
Fire department vehicles will be operated by personnel who have
successfully completed an approved driver-training program, or by student
drivers who are under the supervision of a qualified driver. Members shall
have minimum of 4 documented hours of supervised time in all apparatus
before a member may operate any apparatus in a emergent situation,
unless authorized by the Fire Chief or officer in charge.
2.
Drivers of fire department vehicles shall be directly responsible for the
safe and prudent operations of the vehicles under all conditions. When the
driver is under the direct supervision of an officer, that officer shall also
assume responsibility for the actions of the driver.
3.
Drivers shall not move fire department vehicles until all persons on the
vehicle are seated and secured with seat belts in approved riding positions.
Exceptions: 1) loading of hose on apparatus, 2) personnel performing
emergency medical care in the patient compartment of the ambulances.
4.
During non-emergency travel, drivers of fire department vehicles shall
obey all traffic control signals and signs and all laws and rules of the
jurisdiction for the operation of motor vehicles.
5.
During emergency response, drivers of fire department vehicles shall bring
the vehicle to a complete stop under any of the following circumstances:
a.
b.
c.
d.
e.
f.
g.
h.
When directed by a law enforcement officer
Red traffic lights
Stop signs
Negative right-of-way intersections
Blind intersections
When the driver cannot account for all lanes of traffic in an
intersection
When other intersection hazards are present
When encountering a stopped school bus with flashing warning
lights.
USE OF PERSONAL VEHICLES:
1.
Employees are advised that personal vehicles used to respond to
emergencies are not covered by the insurance coverage. Employees are
also advised to consult with his/her insurance carrier to determine if
coverage is provided if such vehicle is used as an emergency vehicle.
GENERAL POLICIES:
1.
Probationary employees are not allowed the use of red lights and sirens for
personal vehicles. The Fire Chief may make an exception after the
employee has completed his/her required certification(s) and training.
2.
Employees are aware that an “emergency vehicle” is a “moving billboard”
advertising the department and how that vehicle is used and operated
reflects upon the entire department.
3.
Reckless driving and misuse of red lights and sirens will not be tolerated
and loss of privileges will result.
4.
Driving any department vehicle under the influence of an intoxicant or a
controlled substance may result in immediate termination.
NON-EMPLOYEES RIDING APPARATUS:
1. With the exception of ambulance patient conveyance, non-employees are not
allowed to drive, operate, and ride on department apparatus unless approved
by the Fire Chief.
LISBON FIRE DEPARTMENT
SOG 2-1
SUBJECT: Health & Safety
EFFECTIVE DATE: 02/11/2011
PURPOSE:
A primary goal of the Lisbon Fire department is to create the safest environment
possible for their employees. Based on available resources and realistic time
factors, the fire department will comply to the best of its ability to NFPA 1500,
NFPA 1582, and ILHR 30 health and safety standards.
PROBATIONARY EMPLOYEES
APPARATUS (SCBA) USE:
&
SELF-CONTAINED
BREATHING
Probationary employees are permitted to use an SCBA under the following
conditions:
1.
In the WI Firefighter I course;
2.
Under the supervision of a qualified instructor at fire department trainings.
After successful completion of the WI Firefighter I course and approval from the
fire chief, no restriction on SCBA use is in effect.
SELF-CONTAINED BREATHING APPARATUS (SCBA):
The use of SCBAs is mandatory during fire suppression/rescue operations
or where any atmosphere may be actually or suspected toxic in nature.
This includes, but is not limited to: structure fires (including overhaul),
vehicle fires, hazardous materials spills, and rescues where fires and/or
explosions may result. Water rescues are exempt from SCBA and
protective clothing requirements. At vehicle accidents, if the scene has
been deemed safe, SCBAs are not required. However, protective clothing
is required.
After a firefighter has consumed one (1) SCBA bottle of air, he/she shall
go to the designated rehabilitation area for rest. The firefighter may return
to duty after receiving approval from the Rehab Officer.
PERSONAL ALERT SAFETY SYSTEM (PASS):
One PASS device will be provided for each SCBA. PASS devices will be
utilized whenever SCBAs are used.
PASS devices will be checked during the routine inspection of SCBAs.
The 9-volt batteries that are used to power the device will be changed
every 12 months. Any malfunctions of the PASS device shall be reported
immediately.
PROTECTIVE CLOTHING:
When appointed to the department, each employee is issued protective
clothing. It is the responsibility of the employee to maintain his/her
clothing in proper working condition. If the clothing is damaged or
missing, it must be reported immediately to the officer in charge for repair
or replacement. Protective clothing shall not be abused or used for uses
not approved of, or for non-department uses. Protective clothing is
mandatory for all fire suppression/rescue operations. Modification of this
policy can be made by the officer in charge, based on known facts of the
situation.
All protective clothing should be donned prior to the apparatus leaving
quarters.
Each employee will be held accountable for properly utilizing personal
protective equipment.
All gear issued by the department may not be worn to, or in places where
alcoholic beverages are sold. Excluding fire department sponsored events.
For ems calls, refer to dress code for that has been established.
APPARATUS MANNING:
Apparatus manning will be limited to the number of seats that were
designated for passengers and are equipped with seat belts.
For emergency responses, apparatus should not leave the station unless the
apparatus has a full crew when possible. After a reasonable time expires,
the driver may respond with the apparatus if it appears that there are no
other personnel available.
APPARATUS SAFETY:
Any time the apparatus is backing, one employee will aid the driver in backing
the apparatus to prevent injury to persons or property (if someone is available).
The employee will position him/herself on the driver’s side so the driver has full
view of the person in his/her mirror. The spotter will be responsible for keeping
others a safe distance from the vehicle.
BEFORE a driver enters the cab to leave the fire station, he/she shall make sure
no cables or cords are attached and all compartment doors are closed.
ANY TIME a vehicle is in a tight position in close proximity to other objects, the
officer will assign a spotter that positions him/herself outside the vehicle to assist
the driver in safely moving the vehicle.
Upon arrival at the scene, no employee will dismount the apparatus until the
apparatus has been stopped, and the parking brake applied.
PERSONNEL ACCOUNTABILITY SYSTEM:
Each employee of the department is issued two (3) personnel accountability tags.
While enroute to the incident scene, personnel shall give both of their tags to the
person riding in the front passenger seat (officer seat). The officer, or acting
officer, will place one tag from each crewmember on the red Velcro swathe and
the other tag on the white Velcro swathe.
The apparatus driver/operator’s tags will be placed on the swathes upside down.
This will signify who is the driver/operator of the apparatus.
At the incident scene, the officer, or acting officer, will leave the red swath
(complete set of crew tags) in the apparatus and attach the white swathe (complete
set of crew tags) to their helmet. If needed, a designated person will collect the
red swathe from the apparatus and give to the Incident Commander. The Incident
Commander will then place the crew swathe(s) on the incident board in the
position slots of their duties.
Employees will remain in their crews, unless ordered otherwise.
Upon leaving the incident scene, each employee will retrieve his or her
accountability tag from the incident board.
FACIAL HAIR:
Firefighters are not permitted to have facial hair that will interfere with the seal of
the SCBA facepiece to their face. Employees must be clean - shaven to prevent
the possible failure of SCBAs to protect their respiratory system.
EVACUATION OF BUILDINGS:
Two types of evacuations will be used to remove all fire department personnel
from a structure or area:
Precautionary Evacuation: Used when conditions are deteriorating and the risk to
firefighters is great. Employees are instructed by radio and through company
officers to evacuate an area or building. Employees evacuating will take all
equipment and hose lines with them.
Upon evacuation, company officers will make immediate accounting of their
personnel and report to the Incident Commander. The incident board located at
the command post will be verified for personnel accountability.
Emergency Evacuation: This evacuation takes place when collapse has occurred
or intimate danger exists and represents a hazard to firefighting personnel.
Emergency evacuation occurs when three (3) long blasts of an air horn are made.
A pause will occur and the process will be repeated. Employees will also be
alerted by radio and through company officers.
Upon hearing this blast, all members will immediately leave the building or area,
leaving tools, equipment and hose lines behind. All company officers will make
an immediate accounting of their personnel and report to the Incident
Commander. The incident board located at the command post will be verified for
personnel accountability.
UNACCOUNTED PERSONNEL:
When it is discovered that there is one or more individuals missing, this shall be
reported to the Incident Commander immediately. The Incident Commander shall
refer to Mayday SOG.
FIREFIGHTER DEATH OR SERIOUS INJURY:
Upon death or serious injury of a firefighter, the following procedures shall be
used to document the facts and events surrounding their death or serious injury
(Be advised that the incident may result in one of the following forms):
1.
2.
3.
4.
Death at scene,
Dead on arrival at the hospital,
Alive upon arrival, but later dies,
Injuries or distress not detected at scene and member dies later,
possibly at home or at the fire station.
The Fire Chief, or the highest-ranking officer, shall be responsible to carry out the
following procedure:
Cause of Death:
In order for beneficiaries to receive funds from the Public Safety Officer’s
Benefits Programs, an autopsy may have to be requested where the cause of death
is not clearly a traumatic injury. In all cases of firefighter deaths, a toxicology
examination with a test for specific levels of carbon monoxide (CO) in the blood
expressed in an exact percent shall always be requested.
The firefighter admitted to the hospital shall have a blood test with specific tests
for CO expressed in exact percent levels. A blood sample shall also be taken and
the level of alcohol in the blood established in percent level.
If a firefighter becomes permanently and totally disabled or dies in the line of
duty, notify the P.S.O.B. office immediately and obtain direction in how to
proceed to process the claim correctly. Failure to follow PSOB guidelines may
result in non-payment of benefits.
Agencies to Notify:
1.
2.
3.
4.
5.
6.
Police department
State fire Marshall’s Office
Worker’s Compensation Board local office
Public Safety Officer’s Benefit Program (PSOB), Washington
D.C., by telephone during the next business day. Ask for the
Claims Examiner, at (202) 307-0635.
Notify all other insurance companies
Notify the National fire Academy and United States fire
Administration at the following numbers:
USFA - (301) 447-1272
NFA - (301) 447-1123 or
(301) 447-1000
Statements:
Statements should be gathered relating to the death or serious injury. If facts are
not known, then it should be clearly stated. Do not conjecture as to what
happened or interject personal opinions or emotions. The Lisbon Police
Department and/or Waukesha County Sheriff’s Department should gather all
statements.
Impoundment:
All equipment shall be impounded that was involved with the firefighter’s death
or serious injury. This may include, but is not limited to, protective clothing,
SCBA, radios, fire apparatus, all written records and communication tapes. This
should be done by the Lisbon Police Department and/or Waukesha County
Sheriffs Department.
RELEASING
/
INFORMATION:
ATTAINING
OF
EMERGENCY
INCIDENT
At no time shall any employee, except the fire chief or designated person, release
any information to the general public, or media concerning the fire department
itself, it’s operation, and/or information concerning any emergency incidents
which have occurred, or are under investigation. All requests for information
shall be referred to the Fire Chief.
At no time will an employee represent himself or herself as a member of the Lisbon Fire
Department to obtain information from outside agencies relating to the outcome of
incidents that occur in the Town of Lisbon, or other communities. Unless pre-approved
by the Fire Chief.
LISBON FIRE DEPARTMENT
SOG 2-2
SUBJECT: Self-Contained Breathing Apparatus
EFFECTIVE DATE: 02/11/2011
PURPOSE:
The purpose of this policy is to ensure the protection of all employees from
respiratory hazards, through proper use of self-contained breathing apparatus
(SCBA). SCBA shall be used only during activities designated for their use
according to the specifications established by the manufacturer.
SCOPE:
This policy contains minimum requirements of a fire service respiratory
protection program. The regulations of the Occupational Safety and Health Act
(OSHA) 1910.134 and American National Standards Institute (ANSI) require
written procedures governing the selection, use, and maintenance of protective
breathing apparatus (SCBA) be established.
DEFINITIONS:
Hazardous Atmosphere: Any atmosphere that is oxygen deficient (<19.5%) or
that contains a toxic or disease-producing containment. A hazardous atmosphere
might or might not be immediately dangerous to life and death.
Respiratory Hazard: An exposure to products of combustion, superheated
atmospheres, toxic gases, vapors, or dust, or potentially explosive or oxygendeficient atmospheres, or any condition that creates a hazard to the respiratory
system.
Self-Contained Breathing Apparatus (SCBA): A respirator worn by the user
that supplies a breathable atmosphere, that is either carried in or generated by the
apparatus, and that is independent of the ambient environment. At this time,
SCBA are the only respiratory equipment available to Lisbon Fire Department
personnel.
FACEPIECE FITTING:
A.
The facepiece seal capability of each member qualified to use SCBA shall
be verified by qualitative fit testing on an annual basis and whenever new
types of SCBA or facepieces are issued. Each new member shall be tested
before being permitted to use SCBA in a hazardous atmosphere. Only
members with a properly fitting facepiece shall be permitted by the fire
department to function in a hazardous atmosphere with SCBA.
B.
Members who have a beard or facial hair at any point where the SCBA
facepiece is designated to seal with the face, or hair that could interfere
with the operation of the unit, shall not be permitted to use respiratory
protection at emergency incidents or in hazardous or potentially hazardous
atmospheres. These restrictions shall apply regardless of the specific fit
test measurement that can be obtained under test conditions.
EMERGENCY SCENE USE:
A.
Respiratory protection shall be used by all employees who are exposed to
respiratory hazards or who might be exposed to such hazards without
warning. Employees who are operating in areas that might be subject to
these hazards where there is sufficient warning to don respiratory
protection equipment shall have respiratory protection equipment readily
available for use.
These hazards include overhaul situations, unless it is determined that the
area has been adequately ventilated to eliminate respiratory hazards. The
environment in question will be monitored during frequent intervals using
the CO gas monitor.
B.
Respiratory protection equipment shall be used by all members operating
in confined spaces, below ground level spaces, or where the possibility of
a contaminated or oxygen deficient atmosphere exists until, or unless, it
can be established by monitoring and continuous sampling that the
atmosphere is not contaminated or oxygen deficient.
One of the contaminants that can be readily measured is carbon monoxide
(CO). Respiratory protection equipment should not be removed where
tests reveal a concentration greater than 25 ppm of CO or where other
toxic contaminants are known or suspected to be present.
C.
Employees shall be monitored for indications of fatigue or other factors
that can result in unsafe conditions (see Emergency Incident
Rehabilitation guideline).
D.
Employees using SCBA shall operate in teams of two or more who shall
be able to communicate with each other through visual, audible, physical,
safety guide rope, or other means to coordinate their activities and who
shall be in close proximity to each other to provide assistance in case of an
emergency.
E. Where members are involved in operations that require the use of SCBA or
other respiratory protective equipment, at least one employee shall be
assigned to remain outside the area where respiratory protection is required.
This member shall be responsible for maintaining a constant awareness of the
number and identity of employees using a SCBA, their location and function,
and their time of entry. Employees with a SCBA shall be available for rescue.
TRAINING:
A.
The department’s training program shall evaluate the ability of employees
to:
1.
Identify the components of facepieces, regulators, harnesses, and
cylinders.
2.
Demonstrate the use of all types of SCBA utilized by the
department under conditions of obscured visibility.
3.
Demonstrate the emergency operations that are required when a
SCBA fails.
4.
Demonstrate emergency techniques using a SCBA to assist other
employees, conserve air, and show restrictions in use of the bypass
valve.
5.
Demonstrate the use of a SCBA in limited or confined spaces.
6.
Demonstrate the possible means of communications when wearing
a SCBA.
B.
Training shall be conducted under simulated stressful circumstances to
promote immediate response to emergency operations.
C.
Annual SCBA training shall be provided to each member required to use
breathing apparatus.
SCBA INSPECTION:
A.
Monthly inspection of respiratory protection equipment shall be conducted
and shall include a check of the entire unit for deteriorated components,
air-tightness of cylinders and valves, gauge comparison, reducing valve
and bypass valve operation, and a check of the regulator, exhalation valve,
and low-air alarm. The SCBA shall be cleaned and returned to service.
B.
Inspection of respiratory protection equipment shall be conducted by the
user before and after each use.
C.
Any deficiency found with a SCBA unit shall be tagged, indicating the
problem, and the unit shall be taken out of service until the unit can be
properly repaired.
SCBA MAINTENANCE:
Only qualified personnel shall conduct all maintenance and repairs on a SCBA in
accordance with manufacturer’s instructions.
SCBA CLEANING & SANITIZATION:
Firefighters shall clean and sanitize each SCBA facepiece after each use upon
their return to the fire station. The entire device shall be cleaned, and the
facepiece and breathing tube shall be sanitized.
RECHARGING AIR CYLINDERS:
A.
All breathing air cylinders will be refilled only from a compressor /
cascade system, which has been set up for this purpose.
B.
Air cylinders shall be filled only by personnel who have been trained on
the proper procedures and equipment.
C.
Personnel assigned to operate fill station equipment shall visually inspect
all cylinders before refilling.
Cylinders that do not meet the
manufacturer’s requirements due to defects or damage, or that have not
met hydrostatic test requirements, shall be left unfilled and removed from
service.
HYDROSTATIC TESTING:
A.
Every cylinder shall be hydrostatically tested within 60 days before the
latest hydrostatic test date has elapsed. All steel cylinders must be tested
every five- (5) years and all composite cylinders tested every three- (3)
years.
C.
Any cylinder that has been exposed to extreme conditions such as
dropping, excessive heat, or accident shall be hydrostatically tested before
being placed back in service.
LISBON FIRE DEPARTMENT
SOG 2-3
SUBJECT: Emergency Incident Rehabilitation
EFFECTIVE DATE: 02/11/2011
PURPOSE:
To ensure that the physical and mental condition of employees operating at the
scene of an emergency or a training exercise does not deteriorate to a point that
affects the safety of each employee or that jeopardizes the safety and integrity of
the operation.
SCOPE:
This procedure shall apply to all emergency operations and training exercises
where strenuous physical activity or exposure to heat or cold exists.
RESPONSIBILITIES:
a. Incident Commander.
The Incident Commander shall consider the circumstances of each
incident and make adequate provisions early in the incident for the rest
and rehabilitation for all employees operating at the scene. These
provisions shall include medical evaluation, treatment and monitoring,
food and fluid replenishment, mental rest, and relief from extreme climatic
conditions and the other environmental parameters of the incident. The
rehabilitation shall include the provision of Emergency Medical Services
(EMS) at the Basic Life Support (BLS) level or higher. If needed, the
Incident Commander or his/her appointed designee can activate the Lisbon
Fire Department Auxiliary, according to the activation information located
in the apparatus.
b. Supervisors.
All supervisors shall maintain an awareness of the condition of each
employee operating within their span of control and ensure that adequate
steps are taken to provide for each employee’s safety and health. The
command structure shall be utilized to request relief and the reassignment
of fatigued crews.
c. Personnel.
During periods of hot weather, employees shall be encouraged to drink
water and activity beverages throughout the workday. During any
emergency incident or training evolution, all employees shall advise their
supervisor when they believe that their level of fatigue or exposure to heat
or cold is approaching a level that could affect themselves, their crew, or
the operation in which they are involved. Employees shall also remain
aware of the health and safety of other members of their crew.
ESTABLISHMENT OF REHABILITATION SECTOR:
a. Responsibility.
The Incident Commander will establish a Rehabilitation Sector or Group
when conditions indicate that rest and rehabilitation is needed for
personnel operating at an incident scene or training evolution. An
employee will be placed in charge of the sector/group and shall be known
as the Rehab Officer.
b. Location.
The Incident Commander will normally designate the location for the
Rehabilitation Area. If a specific location has not been designated, the
Rehab Officer shall select an appropriate location based on the site
characteristics and designations below.
c. Site Characteristics.
1.
It should be in a location that will provide physical rest by
allowing the body to recuperate from the demands and hazards of
the emergency operation or training evolution.
2.
It should be far enough away from the scene that employees may
safely remove their turnout gear and SCBA, and be afforded
mental rest from the stress and pressure of the emergency
operation or training evolution.
3.
It should provide suitable protection from the prevailing
environmental conditions. During hot weather, it should be in a
cool, shaded area. During cold weather, it should be in a warm,
dry area.
4.
It should enable employees to be free of exhaust fumes from
apparatus, vehicles, or equipment (including those involved in the
Rehabilitation Sector/Group operations).
5.
It should be large enough to accommodate multiple crews, based
on the size of the incident.
6.
It should be easily accessible by EMS units.
7.
It should allow prompt reentry back into the emergency operation
upon completion of recuperation.
d. Site Designations.
1.
A nearby garage, building lobby, or other structure.
2.
A school bus or municipal bus.
3.
Fire apparatus, ambulance, or other emergency vehicles at the
scene or called to the scene.
4.
An open area in which a rehab area can be created using tarps,
fans, etc.
e. Resources.
The Rehab Officer shall secure all necessary resources required to
adequately staff and supply the Rehabilitation Area. The supplies should
include the items listed below:
1.
Fluids - water, activity beverage, oral electrolyte solutions and ice.
2.
Food - soups, broth, or stew served in hot/cold cups.
3.
Medical - blood pressure cuffs, stethoscopes, oxygen
administration devices, cardiac monitors, intravenous solutions and
thermometers.
4.
Other - awnings, fans, tarps, smoke ejectors, heaters, dry clothing,
extra equipment, floodlights, blankets and towels, traffic cones,
and fire line tape (to identify the entrance and exit of the
Rehabilitation Area).
GUIDELINES:
a. Rehabilitation Sector/Group Establishment.
Staff officers during the initial planning stages of an emergency response
should consider rehabilitation. However, the climatic or environmental
conditions of the emergency scene should not be the sole justification for
establishing a Rehabilitation Area. Any activity/incident that is large, long
in duration, and/or labor intensive will rapidly deplete the energy and
strength of personnel and therefore merits consideration for rehabilitation.
Climatic or environmental conditions that indicate the need to establish a
Rehabilitation Area are a stress index above 90F or wind-chill index
below 10F.
b. Hydration.
A critical factor in the prevention of heat injury is the maintenance of
water and electrolytes. Water must be replaced during exercise periods
and at emergency incidents. During heat stress, the employee should
consume at least one quart of water per hour. The rehydration solution
should be 50/50 mixture of water and a commercially prepared activity
beverage and administered at about 40F. Rehydration is important even in
cold weather operations where, despite the outside temperature, heat stress
may occur during firefighting or other strenuous activity when protective
equipment is worn. Alcohol and caffeine beverages should be avoided
before and during heat stress because both interfere with the body’s water
conservation mechanisms. Carbonated beverages should also be avoided.
c. Nourishment.
The department shall provide food at the scene of an extended incident
when units are engaged for three or more hours. A cup of soup, broth, or
stew is highly recommended because it is digested much faster than
sandwiches and fast-food products. In addition, foods such as apples,
oranges, and bananas provide supplemental forms of energy replacement.
Fatty and/or salty foods should be avoided.
d. Rest.
The “one air bottle rule”, or 45 minutes of worktime, is recommended as
an acceptable level prior to mandatory rehabilitation. Employees shall
rehydrate (at least eight ounces) while SCBA cylinders are being changed.
Firefighters having worked for one full 45-minute rate bottle, or 45
minutes, shall be immediately placed in the Rehabilitation Area for rest
and evaluation. In all cases, the objective evaluation of an employee’s
fatigue level shall be the criteria for rehab time. Rest shall not be less than
ten minutes and may exceed an hour as determined by the Rehab Officer.
Fresh crews, or crews released from the Rehabilitation Sector/Group, shall
be available in the Staging Area to ensure that fatigued employees are not
required to return to duty before they are rested, evaluated, and released by
the Rehab Officer.
e. Recovery.
Employees in the Rehabilitation Area should maintain a high level of
hydration. Employees should not be moved from a hot environment
directly into an air-conditioned area because the body’s cooling system
could shut down in response to the external cooling. An air-conditioned
environment is acceptable after a cool-down period at ambient
temperature with sufficient air movement. Certain drugs impair the
body’s ability to sweat and extreme caution must be exercised if the
employee has taken antihistamines, such as Actifed or Benadryl, or has
taken diuretics or stimulants.
f. Medical Evaluation.
(1) Emergency Medical Services (EMS) - EMS should be provided and
staffed by the most highly trained and qualified EMS personnel on the
scene (at a minimum of BLS level). They shall evaluate vital signs,
examine employees, and make proper disposition (return to duty,
continued rehabilitation, or medical treatment and transport to medical
facility). Continued rehabilitation should consist of additional monitoring
of vital signs, providing rest, and providing fluids for rehydration.
Medical treatment for employees, whose signs and/or symptoms indicate
potential problems, should be provided in accordance with local medical
control procedures. EMS personnel shall be assertive in an effort to find
potential medical problems early.
(2) Heart Rate and Temperature - The heart rate should be measured for
30 seconds as early as possible in the rest period. If an employee’s heart
rate exceeds 110 beats per minute, an oral temperature should be taken. If
the employee’s temperature exceeds 100.6F, he/she should not be
permitted to wear protective equipment. If it is below 100.6F and the
heart rate remains above 110 beats per minute, rehabilitation time should
be increased. If the heart rate is less than 110 beats per minute, the chance
of heat stress is negligible.
(3) Documentation - All medical evaluations shall be recorded on standard
forms along with the employee’s name and complaints and must be
signed, dated and timed by the Rehab Officer or his/her designee.
g. Accountability.
Employees assigned to the Rehabilitation Sector/Group shall enter and exit the
Rehabilitation Area as a crew. The Rehab Officer or his/her designee shall
document the crew designation, number of crewmembers and the times of entry to
and exit from the Rehabilitation Area. Crews shall not leave the Rehabilitation
Area until authorized to do so by the Rehab Officer.
LISBON FIRE DEPARTMENT
SOG 2-4
SUBJECT: Incident Management System
EFFECTIVE DATE: 02/11/2011
PURPOSE:
The purpose of this standard is to define and describe the essential elements of an
incident management system (IMS).
The purpose of an IMS is to provide structure and coordination to the
management of emergency incident operations in order to provide for the safety
and health of fire department personnel and other persons involved in those
activities.
SCOPE:
These requirements shall be applicable to organizations providing rescue, fire
suppression, emergency medical care, special operations, and other emergency
services.
IMPLEMENTATION:
The IMS shall be utilized at all emergency incidents. The IMS also shall be
applied to drills, exercises, and other situations that involve hazards similar to
those encountered at actual emergency incidents and to simulated incidents that
are conducted for training and familiarization purposes.
COMMUNICATIONS:
1.
Standard terminology shall be established to transmit information,
including strategic modes of operation, situation reports, and emergency
notifications of imminent hazards.
2.
All apparatus going enroute and arriving on scene will be conducted on
County Fire, Once on scene, all fire ground communications will be on a
channel designated by the Incident Commander.
3.
All water supply operations will be conducted on a channel designated by
the Incident Commander or the Water Officer.
INCIDENT COMMANDER:
1.
At an emergency incident, the incident commander shall be responsible
for the overall management of the incident and the safety of all personnel
involved at the scene. As incidents escalate in size and complexity, the
incident commander shall divide the incident into tactical-level
management units and assign an incident safety officer to assess the
incident for hazards or potential hazards.
2.
At an emergency incident, the incident commander shall establish an
organization with sufficient supervisory personnel to control the position
and function of all personnel operating at the scene and to ensure that
safety requirements are satisfied.
3.
At an emergency incident, the incident commander shall have the
responsibility for the following:
a.
Arrive on-scene before assuming command.
b.
Assume and confirm command of an incident and take an effective
command position.
c.
Perform situation evaluation that includes risk assessment.
d.
Initiate, maintain, and control incident communications.
e.
Develop an overall strategy and an incident action plan, and assign
companies and personnel consistent with the standard operating
guidelines.
f.
Develop an effective incident organization by managing resources,
maintaining an effective span of control, and maintaining direct
supervision over the entire incident, and designate supervisors in
charge of specific areas or functions.
g.
Review, evaluate, and revise the incident action plan as required.
h.
Continue, transfer, and terminate command.
i.
On incidents under the command authority of the fire department,
provide for liaison and coordination with all other cooperating
agencies.
j.
On incidents where other agencies have jurisdiction, implement a
plan that designates one incident commander or that provides for
unified command.
SAFETY OFFICER:
1.
The safety officer shall report directly to the incident commander.
2.
Safety officer(s) shall have the authority to immediately correct situations
that create an imminent hazard to personnel.
OPERATIONS OFFICER:
1.
The operations officer shall report directly to the incident commander.
2.
The operations officer shall be assigned to operations functions that
support the overall strategic plan, as directed by the incident commander,
and shall work toward the accomplishment of tactical objectives.
3.
The operations officer shall be accountable for all resources assigned
under his/her span of control. The safety and health of all personnel shall
be primary considerations.
STAGING OFFICER:
1.
The staging officer shall report directly to the incident commander.
2.
The staging officer is responsible for managing reserves of personnel and
other resources at or near the scene of the incident.
WATER SUPPLY OFFICER:
1.
The water supply officer shall report directly to the incident commander.
2.
The water supply officer is responsible for the water capacity and
availability required to combat the fire or potential for fire. Water
capacity and availability includes tanker operations and/or municipal
water systems.
SECTOR OFFICER (S):
1.
The operations officer establishes the sector officer(s) once the span of
control becomes unmanageable.
2.
The sector officer(s) report directly to the operations officer.
3.
The sector officer shall be accountable for all resources assigned under
his/her span of control.
4.
The sector officer(s) shall provide progress reports and any deviations to
established plans on a regular basis to the operations officer.
5.
The sector officer(s) shall be alert to recognize conditions and actions that
create a hazard within their span of control. The sector officer(s) shall
have the authority and responsibility to take immediate action to correct
imminent hazards and to advise the appropriate supervisor regarding these
actions.
LISBON FIRE DEPARTMENT
SOG 3-1
SUBJECT: Structure Fires
EFFECTIVE DATE: 02/11/2011
PURPOSE:
This guideline has been developed to provide the Lisbon Fire Department
personnel with a set of guidelines to be followed in the event of a structure
fire or a structure related fire alarm.
APPARATUS RESPONSE:
Apparatus should respond in the following order:
1. Engine 2662
2. Engine 2663
3. Tender 2695
4. Tender 2691
5. Tender 2693
6. Engine 2661
7. Ambulance 2653/2652
8. Utility vehicle 2688
The first 2 qualified firefighters arriving at the station may respond with
2662/2663 to the scene to establish a size up, assume command, set up equipment
for assignments needed to extinguish the fire.
At times, some of the above apparatus may be responding simultaneously.
APPARATUS POSITIONING:
1 – 2 Family Dwellings:
Positioning of the apparatus is the responsibility of the driver/operator.
The driver should position the apparatus for optimum efficiency. When
positioning the engine at a dwelling fire, the driver should proceed just
past the fire building. (If the driveway is longer than 100ft, the engine will
have to use the driveway for entrance.) This is done for two reasons:
1.
It allows the officer to view three sides of the fire building (sides
A, B, and D);
2.
It leaves side A (front) of the fire building available for the second
engine, or the aerial company.
The ladder engine or aerial truck should be positioned in the front of the
building so they may perform their duties.
Placement of the engine just past the fire building or placement of the ladder,
engine or aerial in front of the building may not always be possible. Conditions
such as location of the fire, access to the property, wind direction, and exterior
exposures may cause the driver to deviate from positioning the apparatus
As specified above, apparatus placement must always be positioned for the safety of
personnel and equipment.
The first unit on the scene shall establish command. Command shall relay a brief
size-up to other responding units. Command at this time, will estimate needed
water supply. (Mutual Aid)
Larger Commercial & Industrial:
Positioning of the apparatus is the responsibility of the driver/operator. The driver
should position the apparatus for optimum efficiency. All apparatus are to hold at
their staging designations and remain uncommitted until ordered to proceed by
command.
The first unit on the scene shall establish command. Command shall relay a brief
size-up to other responding units. Command shall form a fire/smoke investigation
team of the crew of the first engine company. The crew will investigate any findings
inside the building and report these findings back to Command.
FIRST ARRIVING ENGINE OPERATIONS:
The first arriving engine shall respond directly to the fire building. The engine crew shall
advance at least one 1-1/2 inch, or greater, handline to attack the fire from the unburned
side.
If the Incident Commander declares the fire shall be fought as an exterior attack, he/she
may order the first arriving engine to utilize the deck gun, or other means of suppression.
As soon as possible, a second handline shall be placed as a backup line to the initial
handline.
Under no circumstances shall a crew enter a burning building without a backup crew and
second handline in place.
SECOND ARRIVING ENGINE OPERATIONS:
The second arriving engine shall assist the first engine crew in securing the water supply
line. If the first engine did not lay a supply line, then the second engine shall be instructed
by the Incident Commander on what is needed. (forward, reverse or hand lay)
After the water source has been secured, the personnel from the second engine shall be used to
supplement the crew from the first arriving engine. A back-up line should be
implemented as soon as possible. The back-up line should follow the initial attack line for
support using the same entry point.
WATER SUPPLY ENGINE:
If an underground tank or drafting operations from a natural water source is required, an
engine shall be placed at the water source to fill tanker trucks. If hydrants are used as a water
source for tanker trucks, this engine may not be needed. The Sussex Fire Department will be
automatically toned out for securing a water source, whether a hydrant or draft.
EMS:
The Incident Commander shall request for the ambulance crew(s) to stand-by at the fire scene.
The crew shall be ready to provide EMS care to any victims from the fire, including
firefighters. In addition, the crew shall be available to respond to an EMS emergency in the
Town.
A second ambulance may be requested to establish a rehabilitation area for weary firefighters
(refer to Emergency Incident Rehabilitation guideline).
RESCUE:
Life safety is of the utmost concern. The rescue of trapped or endangered persons is essential
and should be carried out immediately. All options should be examined to ensure that rescue
is accomplished.
VENTILATION:
Ventilation is an important function that must be performed at every fire. Ventilation should
be carried out because of the following advantages:
1.
2.
3.
4.
5.
Reduces potential for flashover;
Reduces potential for backdraft;
Improves firefighter visibility;
Reduces the toxicity of the atmosphere inside of the room or area; and
Reduces fire damage.
Fires that occur in living or sleeping quarters can be ventilated by removing windows from the
exterior of the building with pike poles or ladders.
Fire that extends to attics must be controlled quickly. Ventilation of the roof is essential.
Venting of the roof should be performed directly over, or as safely close as possible to the
fire.
When roof ventilation is performed, it shall be performed with a minimum number of two
firefighters in full protective equipment, including SCBA and a charged hose line of 1 ½ or
greater. Once ventilation is complete, command shall be notified
UTILITY CONTROL:
Control of the utilities shall always be performed by the appropriate agency with the
exception of natural gas. Natural gas can be shut off at the meter by locating the shut-off
valve. This valve is normally located on the left side of the meter at or near grade level. One
firefighter should be assigned this task.
SALVAGE - OVERHAUL:
Ceilings and walls that have been exposed to fire should be pulled to verify that the fire has
been extinguished. Care should be taken not to cause unnecessary damage. Salvage shall
begin as soon as the fire or personnel permits. Salvage covers and runners should be used as
soon as possible to prevent any further damage to property.
FIRE INVESTIGATION:
The Incident Commander shall conduct an investigation to determine the cause
and origin of the fire. If the fire appears to be suspicious in nature, he/she shall activate
the fire investigation team and inform the law enforcement agency of jurisdiction.
LISBON FIRE DEPARTMENT
SOG 3-2
SUBJECT: Vehicle Fires
EFFECTIVE DATE: 02/11/2011
PURPOSE:
This guideline has been developed to provide the Lisbon Fire Department personnel with
a set of guidelines to be followed for the extinguishment of vehicle fires. This procedure
applies to automobiles, light duty trucks, medium trucks, tractor-trailers, campers, buses,
construction equipment, motorcycles and other on and off road vehicles. This guideline
does not apply to vehicles involved in hazardous materials or to vehicle fires inside of
structures.
(See Hazardous Materials and Structure Fire SOG’s)
SIZE-UP:
Upon arrival at the scene, the officer in charge shall size-up the situation, informing the
other units responding to continue or return to the station.
Special Attention shall be made to identify any and all placards and/or labels that may
provide essential information to the Incident Commander for the safety of all persons
involved.
The engine shall, if possible, position uphill and upwind from the vehicle(s) affected.
The engine shall be positioned approximately 100 feet from the vehicle. When possible,
pull beyond the vehicle, and pull hose back to fire.
APPARATUS RESPONSE:
All apparatus shall respond in the following order:
1.
Engine 2662
2.
3.
4.
Engine 2663
Tender 2695/2693
Ambulance 2653/2652
Note: 2681 should be used for anything off road
RESCUE:
Vehicles shall be searched for the presence of persons with special attention to small
children or infants. Any persons found shall be removed to a safe location and
emergency medical attention started, if necessary.
FIRE CONTROL:
Fire control shall be made with an offensive attack using a 1-1/2 inch handline or larger.
Additional lines shall be used as required for the control of the fire or protection of
exposures.
Batteries need to be disconnected, and other possible ignition sources eliminated to
prevent the ignition of flammable vapors or chemicals. Cut the negative cable in two
places. (minimum of 5 inches).
OVERHAUL:
Caution shall be taken during overhaul procedures so that the origin and cause of the fire
may be determined. Overhaul shall be preformed so that a rekindle of the fire will not
occur. This will also include clean up of the road, if necessary.
SAFETY:
Caution should be taken during all operations near driver and passenger air bag inflation
areas. Crews should presume air bags might activate even though the battery has been
disconnected.
All persons shall be in full protective clothing including self-contained breathing
apparatus.
Caution shall always be exercised because of the possibility of hazardous materials.
FIRE INVESTIGATION:
The Incident Commander shall conduct an investigation to determine the cause and origin
of the fire. If the fire appears to be suspicious in nature, he/she shall activate the fire
investigation team and inform the law enforcement agency of jurisdiction.
LISBON FIRE DEPARTMENT
SOG 3-3
SUBJECT: Vehicle Accidents
EFFECTIVE DATE: 2/11/2011
PURPOSE:
This is to establish the guidelines for the personnel of the Lisbon Fire Department while
responding to automobile accidents with or without extrication.
SAFETY:
1) First priority is the safety of rescue personnel. Members on scene of incident must
wear personnel protective equipment (turnout coat, pants, boots, gloves, and
helmet). This includes all personnel operating on the scene.
2) Second priority is the safety of patient and all bystanders on the scene.
PROCEDURES:
RESPONSE
1) Upon receiving alarm, response to scene is designated by priority given by
dispatch. For an alpha response the first ambulance will respond emergent and all
other units non emergent. Bravo response will have both ambulances emergent
and first engine emergent. For any accident with higher priority than bravo
response all vehicles will respond emergent. (Unless otherwise directed)
2) First out unit for all accidents will be an ambulance. Second unit out will be
an engine. Third unit out will be a second ambulance. (Unless otherwise
directed by an officer)
3) Use caution upon approaching location of incident.
ON SCENE
1) Initial size up of incident.
a. Number of vehicles involved.
b. Types of vehicles (trucks, cars, vans, bus, etc.)
c. Hazards approaching and around vehicles (wires down, leaning poles,
2)
3)
4)
5)
6)
7)
8)
9)
leaking fluids, smoke, etc.).
d. Location of vehicles (in or out of traffic, rollover or on side)
Apparatus should be positioned to shield fire department personnel from
approaching traffic, also to best approach affected vehicles for extrication. The
recommended placement for apparatus would be the ambulance to the front of
the accident and the engine blocking/shielding all emergency personnel at the
scene.
Incident command shall be enacted by first arriving unit. All incoming units shall
contact command on the operating frequency (tac 1 for most incidents) for an
assignment.
Determine scene safety and complete initial size up (enough resources, haz-mat,
etc). First arriving unit on scene will complete an inner and outer circle, marking
the area with traffic cones. While the circles are being performed the interior
medic should stage at the front of the vehicle and establish contact with the
patient(s).
Stabilization of vehicle or vehicles shall be performed before any rescue
personnel enter or work on vehicle.
Once the vehicle is stabilized and the circles have been completed, the Incident
Commander shall direct the interior medic to gain access into the vehicle to begin
patient care.
Access shall be gained to battery compartment if the Incident Commander deems
necessary.
a. An extinguisher (preferably ABC Dry Chem.) or hose line of a minimum
1 ¾ diameter shall be in place before attempting to disconnect battery.
b. Negative terminal is disconnected, taking out a 5 inch section.
Patient assessment (# of patients, # of ambulances, etc)
Oil dry shall be used on leaking fluids. (anti-freeze, oils, gasoline, etc.)
PATIENT EXTRICATION:
1) Upon determination extrication will be needed, the incident commander will
designate a person to act as the extrication leader.
2) The extrication leader will be responsible for the tactics implemented for the
extrication process.
3) Only personnel that have been trained on the use of the extrication equipment
should be operating it during the process.
4) Safety glasses are the preferred eye protection to be used in addition to PPE.
THE EXTRICATION TEAM
As with all operations, extrication is a team effort. The extrication team consists
of three main teams:
 The Extrication Team - Is responsible for the extrication of the victim.
 The Hose Team - In the event that extrication operations are required, the
incident commander shall appoint a crew member to pull a charged handline
of 1 ¾ size.

 The EMS Team - Patient care must begin as soon as possible. The EMS
team is responsible for not only caring for the patient, but protecting the
patient during extrication procedures. All medical treatment and procedures
shall be in accordance with the Waukesha County EMS guidelines and the
Lisbon Fire Department medical guidelines.
TERMINATION OF COMMAND
Termination of command will be done when all patients are in EMS care and all vehicles
involved in the incident are no longer a hazard to public safety and all apparatus are
available for the next call.
LISBON FIRE DEPARTMENT
SOG 3-4
SUBJECT: Grass/Brush fires
EFFECTIVE DATE: 02/11/2011
PURPOSE:
This guideline has been developed to provide the Lisbon Fire Department
personnel with a set of guidelines to be followed in the response to grass/brush
fire incidents.
APPARATUS RESPONSE:
Apparatus should respond in the following order:
1.
2.
3.
4.
5.
6.
Grass Rig 2681
Engine 2662/2663
Utility vehicles 2688 and 2689. (call 2688 and 2689 in service
together)
Engine 2661
Ambulance 2652
Tender 2695 (if requested by Incident Command)
Only units 2681 and 2689 shall leave the roadways or other hard surface areas
unless approved by the officer-in-charge. When pulling 2689 with 2688, do not
use overdrive selection on shift indicator.
SAFETY:
1.
Personnel shall not ride on the back of any apparatus while extinguishing
grass/brush fires.
2.
All personnel extinguishing grass/brush fires shall wear all protective
clothing appropriate to the task they are performing.
3.
Grass/brush fires shall be extinguished from up wind and from the burned
to the unburned side whenever possible.
FIRE INVESTIGATION:
The Incident Commander shall conduct an investigation to determine the cause and origin
of the fire. If the fire appears to be suspicious in nature, he/she shall activate the fire
investigation team and inform the law enforcement agency of jurisdiction.
LISBON FIRE DEPARTMENT
SOG 3-5
SUBJECT: Hazardous Material Incidents
EFFECTIVE DATE: 02/11/2011
PURPOSE:
This guideline has been developed to provide the Lisbon Fire Department
personnel with a set of guidelines to be followed in the response to hazardous
material incidents.
Hazardous material incidents encompass a wide variety of potential situations,
including fires, spills, transportation accidents, chemical reactions, flammability,
radiological hazards, corrosives, explosives, health hazards and combination of
factors. This guideline provides a general framework for responding to hazardous
material incidents.
APPARATUS RESPONSE:
1.
2.
Engine 2662/2663
Other units requested by Incident Command
FIRST ARRIVING UNIT:
The first arriving officer responding on the first unit will establish command and
begin a size-up. The first unit must consciously avoid committing itself to a
dangerous situation. When approaching, slow down or stop to assess any visible
activity taking place. Evaluate effects of wind, topography and location of the
situation.
Command shall advise ALL OTHER UNITS to stage until instructed to take
specific action. Units must stage in a safe location; taking in account wind, spill
flow, explosion potential and similar factors in any situation.
SIZE-UP:
The objective of the size-up is to identify the nature and severity of the immediate
problem and gather sufficient information to formulate a valid action plan (FROM
A SAFE DISTANCE). A hazardous materials incident requires a more cautious
and deliberate size-up than most fire incidents.
Avoid commitment of companies and personnel to potentially hazardous
locations. Proceed with caution in evaluating risks before formulating a plan and
keep uncommitted companies at a safe distance.
Identify a hazardous area based on potential danger, taking into account materials
involved, time of day, wind and weather conditions, location of the incident and
degree of risk to unprotected personnel. Take immediate action to evacuate
and/or rescue persons in critical danger, if possible, providing for safety of
rescuers.
The major problem in most cases is to identify the type of materials involved in a
situation and the hazards presented before formulating a plan of action. Look for
labels, markers, and shipping papers, refer to pre-fire plans, and ask personnel at
the scene (business management, responsible party, truck drivers, dispatch
center). Utilize reference materials carried on the apparatus and have the dispatch
center contact other sources for assistance in sizing up the problem (Chemtrec,
manufacturers of materials, etc.).
ACTION PLAN:
A.
Establish and identify an initial command post.
B.
Advise dispatch center of type of materials involved, if possible.
C.
Request City of Waukesha Haz-mat teams (for level A or B).
D.
Establish an evacuation procedure of affected people, if procedure
can be performed safely. Keep in radio contact with all evacuation
units.
E.
Request additional assistance:
1.
2.
Law enforcement agencies.
Waukesha County Emergency Management Office, 5487580 or through Sheriff’s Department, 548-7117 pager 449.
3.
Wisconsin Department of Emergency Government,
1-800-943-0043.
4.
Wisconsin Department of Natural Resources.
5.
Chemtrec, 1-800-424-9300.
LISBON FIRE DEPARTMENT
SOG 3-6
SUBJECT: Carbon Monoxide Alarms
EFFECTIVE DATE: 02/11/2011
_______________________________________________________________________
PURPOSE:
This guideline was developed to provide the Lisbon Fire Department personnel
with a set of guidelines to be followed in response to carbon monoxide (CO)
alarm activation incidents.
INTRODUCTION:
Carbon monoxide is an odorless, tasteless, colorless gas that is deadly. It is a byproduct of a fuel burning process. Many appliances such as furnaces, kitchen
stoves, hot water heaters, automobiles, etc. can produce carbon monoxide. When
a faulty or unusual condition exists, CO may be vented into areas where people
are present.
CO poisoning may be difficult to diagnose. Its symptoms are similar to the flu,
which may include headache, nausea, fatigue, and dizzy spells.
The Occupational Safety and Health Administration (OSHA) has established a
maximum safest working level for CO at 35 parts per million (PPM) over an 8hour period in the general workplace. The US Environmental Protection Agency
has established that residential levels are not to exceed 9 PPM over an 8-hour
average.
APPARATUS RESPONSE:
Apparatus shall respond in the following order:
1. Engine 2662/2663
2. Ambulance 2653/2652
3. Engine 2662/2663
SIZE-UP:
The first arriving unit shall initiate the Incident Command system. Once
Command has been established, the IC or a designee shall interview the caller to
determine if EMS is needed.
Emergency medical personnel shall check the caller or any occupant complaining
of, or showing, signs/symptoms of CO poisoning.
INVESTIGATION:
1.
No one is to enter the building until a CO level reading is taken inside the
door. The Carbon Monoxide Incident Checklist shall be taken in the
building and completed by the investigating crew. In the event there is a
downed patient in the residence, the crew will don SCBA’s
immediately, enter the residence and remove that person to safety.
Under no circumstances will anyone enter the residence unless on
SCBA or a CO reading has been taken.
2.
An SCBA shall be worn by anyone inside the building if a reading of 25
PPM is obtained at any time throughout the investigation. A minimum of
2 firefighters wearing full protective clothing including SCBA and
carrying a portable radio will investigate.
3.
If the circumstances in No. 2 exist, a backup crew (minimum of 2
firefighters) must be on the scene prior to further interior operations.
4.
Once the crew has entered the building, the on scene CO detector shall be
checked (if one is present). Determining the cause of the alarm, i.e. true
alarm, low battery indication, poor location of device, etc. (Consult
owner’s manual of particular detector if available).
5.
Wisconsin Electric Gas Operation shall be notified if any of the following
conditions exist:
a.
A meter reading above 9 PPM for CO and the presence of natural
gas-burning appliances.
b.
Anyone has reported symptoms of CO poisoning and natural gasburning appliances are present.
c.
A CO alarm has reached an alarm state and natural gas-burning
appliances are present.
d.
The natural gas supply has been turned off.
6. If fossil fuel-burning appliances other than natural gas are present, a heating
contractor with the appropriate expertise should be requested to respond and
provide assistance in the investigation.
7. A completed Carbon Monoxide Notice of Findings report form should be left
at any building where the presence of CO is suspected.
8. The findings should be explained to the occupants.
8. A CO release form must be signed by the owner or occupant, attesting to their
understanding of the findings and the contents of the release.
LISBON FIRE DEPARTMENT
SOG 3-7
SUBJECT: Mutual Aid Response
EFFECTIVE DATE: 02/11/2011
PURPOSE:
This guideline has been developed to provide the Lisbon Fire Department
personnel with a set of guidelines to be followed for mutual aid responses.
APPARATUS RESPONSE:
The following apparatus is to respond per the following requests with a full crew
aboard.
Ambulance – minimum of 2 EMT’s and a driver. (One of the EMT’s must be a
paramedic)
Engine – minimum of 3 certified firefighters and 1 certified driver/operator
Tender – minimum of 1 certified tanker driver
Grass Rig – minimum of 3 certified firefighters
2688/2689 – minimum of 2 certified firefighters
EMS:
1.
Ambulance 2653/2652
Engine Company:
1.
Engine 2662/2663
Tenders:
1.
2.
3.
2695
2693
2691
Extrication:
1.
Engine 2662
Grass/Brush:
1.
2.
Grass/brush 2681
2688 & 2689
No other apparatus or manpower shall respond unless authorized to do so by the
Fire Chief, or the next highest-ranking officer.
Automatic Mutual Aid
Sussex Fire Department –
1.
2662/2663 (with a full crew. If there are additional box alarms,
follow the MABAS protocol.)
Merton Fire Department:
1.
2.
3.
2663/2662 (for water supply. A minimum of 2 Firefighters.)
2691
2693
CREW ASSIGNMENTS:
Whenever possible, the responding apparatus shall be manned by the most
qualified personnel trained for the apparatus responding.
Whenever possible, an officer should respond with the crew and apparatus.
Unless re-assigned by the Incident Commander, the responding crew shall remain
intact as a crew.
Upon arrival, the officer of the responding crew shall report to the staging area. If
a staging area has not been implemented, the officer of the responding crew shall
report to the Incident Commander, or his/her designee, for an assignment.
Upon arrival, the crew shall give to the Incident Commander, or his/her designee, the
crew’s accountability tags.
LISBON FIRE DEPARTMENT
SOG 3-8
SUBJECT: Driver/Operator Responsibilities
EFFECTIVE DATE: 02/11/2011
PURPOSE:
The purpose of this guideline is to ensure the readiness of all fire apparatus of the
Lisbon Fire Department. And to comply with the best of its ability, to
NFPA 1002.
OBJECTIVES:
For the Driver/Operator of any fire apparatus to perform inspections and
servicing functions on the specified systems and components listed on the
“Back in Service Checklist”, according to fire department and
manufacturer’s specifications, so that the operational status of the vehicle
is verified.
1.
Perform back in service checks according to the “Back in Service
Checklist” form.
2.
It is the responsibility of the officer in charge or the senior person, to
ensure that these checklists are completed, and spot check the apparatus to ensure
quality.
Document or rectify any problems noted. If there is a problem that cannot be
taken care of at that time, a work order report must be filled out and all
information will be written down pertaining to the problem. If the problem entails
that the apparatus be taken out of service, an “Out of Service” tag will be attached
to the steering wheel and the keys removed (where applicable). It will be the
responsibility of the driver/operator to make sure that the correct personnel are
notified of the situation. All work orders will be put into the proper bin on the
dispatch desk.
LISBON FIRE DEPARTMENT
SOG 3-9
SUBJECT: Live Fire Training in Structures
EFFECTIVE DATE: 02/11/2011
________________________________________________________________________
Purpose:
This procedure establishes guidelines for training of fire suppression personnel
engaged in structural firefighting operations under live fire conditions as set forth
in NFPA 1403. This procedure focuses on training for coordinated interior fire
suppression operations with a minimum exposure to risk for the participants. The
evolutions conducted within these guidelines shall be managed by means of a
documented incident management system. The line of authority shall be made
clear to all participants in order that both expected and unforeseen situations will
be managed with the most efficiency possible and that reasonable margins of
safety will be provided.
1.
Minimum Training
a.
In order to ensure safe operations during a live fire training exercise, all
participating members shall meet the requirements of NFPA 1001, or have
completed the Firefighter Level I Certification program or be in the
process of completing it.
Note: All participants shall have completed SCBA familiarization.
b.
2.
Participants from other departments must meet the same criteria above,
provide documentation of same, or will not be allowed to take part in the
exercise.
Structures
a.
Members must keep in mind that acquired structures were never designed
or intended for burn applications and through lack of maintenance or
disrepair may lack even the fundamental elements of fire resistance. For
that reason strict safety practices shall be applied at all times when doing
live fire training evolutions.
b.
Any building that is considered for a structural fire training exercise shall
be properly prepared for the live fire training evolution.
This is to include the proper permits that may include the following:
1. demolishing permit
2. burn permit
3. fire department waiver (which relieves the responsibility off
the fire department if the owner tries to collect insurance
money etc.)
c.
The property owner must be the only individual to sign the permits and
prior to the burn, the owner must show proof of ownership, cancellation
of insurance or a signed statement of nonexistence of insurance.
d.
In preparation for live fire training, an inspection of the structure shall be
made to determine that the floors, walls, stairs and other structural
components are capable of withstanding the weight of contents,
participants and accumulated water that will result from the exercise. Any
hazards potentially dangerous to participants such as floor openings,
missing stair treads and rails and other such hazards shall be repaired or
made inaccessible.
Note: Particular attention should be made in that all walls/ceilings shall
be intact, utilities shall be disconnected, adequate ventilation openings
shall be made in the roof, any excessive debris is removed and any
hazards of insect hives, toxic weeds are disposed of accordingly.
Note: Any structures containing forms of asbestos shall not be used by the
Lisbon Fire Department for live fire training unless the owner has the
asbestos removed by an approved contractor and has the proper
paperwork documenting same from the contractor that performed the
work..
e.
Any exposures that might be damaged by the live fire training shall be
properly protected or removed if applicable.
f.
Property adjacent to the structure that could be affected by the smoke shall
be identified and the owner/caretaker informed about the date and time of
the fire training exercise.
3.
g.
Appropriate safeguards shall be taken when the structure is in the vicinity
of streets/highways to protect motorists. These may include road closures
or traffic rerouting which may warrant assistance from the Lisbon Police
Department and/or one of the local police agencies.
h.
A fire line utilizing barrier tape shall be roped off completely around the
structure to keep the general public at a safe distance. The Safety Officer
shall define this area.
Water Supply
a.
The water supply for any individual live fire training evolution shall be
assessed based on the extent of the evolutions, size and construction of the
building and contents to be involved, method of attack to be used,
protection of exposures and reserves for potential unexpected problems.
b.
The minimum water supply and delivery for the live fire training
evolutions shall meet the criteria identified in NFPA 1142.
Note: The minimum water supply required for any single structure,
without exposure hazards, shall not be less than 2000 gallons.
The minimum water supply required for any single structure with exposure
hazards shall not be less than 3000 gallons.
A minimum reserve of additional water in the amount of 50% of the fire
flow demand shall be available to handle exposure protection or
unforeseen situations
c.
Separate sources shall be utilized for supply of attack lines and backup
lines in order to prelude the loss of both water supply sources at the same
time.
Note: Two separate pumpers shall be utilized, one for attack and one for
backup as stated above. It will be the policy of the Lisbon Fire Department
to deploy two folding tanks capable of holding a minimum of 2000 gallons
of water each (one for attack apparatus, the other for backup apparatus).
4.
Apparatus Staging/Parking
5.
6.
7.
a.
Adequate areas for staging, operating and parking of fire apparatus that
will be used in the live fire training evolution shall be designated.
Consideration for emergency medical services shall be included in the
process.
b.
An area shall be designated to park apparatus and vehicles that are not part
of the evolution so as to not interfere with fire ground operations. This
area shall be designated for prompt response of apparatus that will be
handling true emergencies.
c.
Any personnel that respond in their own vehicle (pv) shall park in an area
that is not to interfere with operating or staging areas and will be
designated by the Incident Commander.
Pre-burn Briefing Session(s)
a.
Prior to conducting an actual live fire training evolution in the structure, a
pre-burn briefing session shall be conducted for all participants.
b.
All aspects of every evolution to be conducted shall be discussed and
assignments shall be made for all crews participating in the training
sessions.
c.
A plan shall be prepared for the structure and shall be utilized in the
briefing sessions. All interior rooms, hallways and exterior openings shall
be indicated on the plan.
d.
Prior to conducting any live fire training in the structure, all participants
shall have a knowledge and familiarity with the layout of the building in
order to facilitate necessary evacuation of the building.
e.
Prior to conducting any live fire training in the structure, all participants of
the evolution shall be required to have a walk-through of the structure.
Spectator Safety
a.
All spectators shall be restricted to an area outside the fire line or the
operations area established by the Safety Officer.
d.
Visitors allowed to observe operations and allowed within the operations
area perimeter shall be escorted at all times and shall be equipped with and
properly wear protective equipment.
Fuel Materials
a.
The fuels that are utilized in live fire training evolutions shall have known
burning characteristics of such a nature to be as controllable as possible.
Unidentified materials, such as debris found in or around the structure,
which may burn in unanticipated ways, react violently or create
environmental or health hazards, shall not be used at all.
b.
Class “A” materials shall be used in only the amounts necessary to create
the size fire desired.
Note: There are some exceptions, which include, pressure treated wood,
rubber and plastic materials. These materials shall not be used.
c.
The use of flammable or combustible liquids shall be prohibited for use in
live fire training evolutions.
d.
The officer/instructor in charge of operations shall assess the selected fire
room environment for factors that will affect the growth, development and
spread of fire.
e.
The officer/instructor in charge of operations shall also monitor fuel
loading, including furnishings, wall and floor coverings and ceiling
materials.
Note: The training exercise shall be immediately stopped if the
officer/instructor determines a potential hazard. The exercise shall
continue only when the appropriate actions have been taken to reduce the
hazard.
8.
Safety
a.
A Safety Officer shall be appointed for all live fire training evolutions.
The Safety Officer is unable to participate in the training exercise.
b.
The Safety Officer shall have the authority, regardless of rank, to
intervene and control any aspect of the operations when, in their judgment,
a potential or real danger, accident or unsafe condition exists.
c.
The Safety Officer’s responsibilities may include but not limited to the
following:
1) prevention of unsafe acts
2) elimination of unsafe conditions
d.
The Safety Officer shall provide for the safety of everyone at the training
exercise, this includes visitors and spectators.
Note: The Safety Officer shall not be assigned other duties that interfere
with safety responsibilities.
e.
Sufficient back up lines shall be provided to ensure adequate protection
for personnel on the attack lines during live fire training exercises.
f.
The number of attack lines and back up lines shall be determined prior to
each exercise by the officer/instructor in charge.
Note: Each hose line shall be capable of delivering a minimum of 95
g.p.m.
g.
The officer/instructor in charge shall assign the following:
1) an officer/senior firefighter to each functional crew, which
shall not exceed 5 personnel
2) an officer/senior firefighter to each “back-up line”
3) sufficient additional personnel to “back-up lines” to
provide mobility
4) an additional officer/instructor for each additional
functional assignment
h.
If the Safety Officer deems it necessary, additional safety personnel shall
be placed within the structure to react to any unplanned, threatening
situation or condition.
i.
A method of fire ground communications shall be established, preferably
by radio, to allow coordination among the incident commander, the
interior and exterior sectors, the Safety Officer and any other functional
assignment operating at the exercise.
Note: Should the need arise for an evacuation of the building; all
personnel will adhere to the Lisbon Fire Department SOG on emergency
evacuations. (see SOG 2-1)
j.
Emergency medical services shall be available on site to handle any
injuries.
Note: If anyone is injured, a copy of the run sheet will be obtained and
kept with a copy of the Lisbon Fire Department training form and placed
in the individual’s personal file.
k.
One person shall be designated as the “ignition officer” to control the
materials being burned. Keep in mind that this position may be altered due
to the rehab of personnel on the training exercise.
Note: This person shall be an officer/instructor.
A charged hose line shall accompany the ignition officer when igniting
any fire.
This person shall wear full protective equipment including SCBA and
PASS device.
l.
A thorough search of the structure shall be conducted to ensure no
unauthorized personnel or objects are in the building prior to ignition.
m.
It will be the decision of the Incident Command in coordination with the
Safety Officer when to ignite any training fires. The Safety Officer shall
supervise the ignition officer when the fire is ignited.
Note: No more than one fire shall be permitted within the structure at any
given time.
n.
9.
No person(s) shall be placed inside the building to play the role of a
victim.
Protective Clothing
a.
Each participant that is partaking in the training exercise shall be equipped
with full protective equipment including SCBA and PASS device.
b.
All participants shall be inspected by the Safety Officer prior to entry into
a live fire training evolution to ensure that all protective equipment is
being worn properly and is in serviceable condition.
c.
All protective gear shall meet the requirements of the NFPA standard
applicable for that particular year of manufacture.
d.
All participants at the exercise will follow Lisbon Fire Department SOG
(see SOG 2-1) on wearing of air mask and will wear SCBA when
operating below ground level at all times.
10.
Instructors
a.
Instructors shall be at least Instructor Level I to deliver structural
firefighting training.
b.
The ratio of FF’s to officer shall not exceed 5 to 1.
c.
Other factors such as extreme temperatures (summer), large groups and
long duration exercises shall be taken into consideration and additional
instructors shall be designated as deemed necessary to ensure proper levels
of safety.
d.
The officer in charge shall try to comply with NFPA 1403 and this
guideline to the best of his/her ability.
e.
Prior to ignition of any fire, officers shall ensure that all protective
equipment is being worn.
Note: PAS tags will be grouped by teams and kept at the command post
on the accountability board.
f.
11.
Officers shall make a head count when entering and after exiting the
structure during an actual attack evolution. They shall closely monitor and
supervise all assigned personnel during the live fire training evolution.
Accountability will be notified which crews are assigned to what
evolution.
Reports and Records
a.
The following records and reports (documentation) shall be maintained on
all live fire training evolutions in accordance with NFPA 1403, which will
include the following:
1. an accounting of the activities conducted
2. a listing of instructors present and their assignments
3. a listing of all participants
4. documentation of any unusual conditions encountered
5. any injuries incurred
6. any changes in the structure
7. the condition of the premises and adjacent are at the
conclusion of the training exercise
b. A post training critique session, complete with documentation, shall be conducted to
evaluate student performance and to reinforce the learning experiences of all participants.
At this time, an over all evaluation of the exercise should be done so that any problems
encountered can be corrected to prevent them from happening again.
LISBON FIRE DEPARTMENT
SOG 3-10
SUBJECT: Hamilton High School
EFFECTIVE DATE: 02/11/2011
PURPOSE:
This guideline has been developed to provide the Lisbon and Sussex Fire
Department personnel, with a pre-plan of action to be followed in the event of a
structure fire or a structure related fire alarm at Hamilton High School.
APPARATUS RESPONSE: Sussex Fire Department.
Apparatus should respond in the following order:
1.
Engine (water source)
2.
Engine
3.
Ladder Truck
4.
Rescue/Equipment
5.
Ambulance
Lisbon Fire Department, refer to SOG # 3-1 for apparatus response.
APPARATUS POSITIONING:
Lisbon Fire Department:
Positioning of the apparatus is the responsibility of the driver/operator. The
driver should position the apparatus for optimum efficiency. When positioning
the engine(s) at Hamilton High School, the driver(s) should follow the positioning
sequence described below;
1.
2.
2662: Parking lot of south side.
2663: East side of building.
3.
2661: South side of building.
Conditions such as location of the fire, access to the property, wind direction, and exterior exposures may cause the officer
to deviate from positioning the apparatus as specified above. Apparatus placement must always be positioned for the
safety of personnel and equipment.
The first unit on the scene shall establish command. Command shall relay a brief
size-up to other responding units. Command shall form a fire/smoke investigation
team of the crew of the first engine company. Personnel will utilize the Knox
Box key to gain access into the building if doors are locked. The crew will
investigate any findings inside the building and report any
findings to Command. Command will then dispatch equipment and personnel
needed for that situation.
Sussex Fire Department:
Sussex shall stage all of their equipment responding to the high school in the
south entrance driveway, and should await further direction from Incident
Command.
LISBON FIRE DEPARTMENT
SOG 3-11
SUBJECT: Templeton Middle School
EFFECTIVE DATE: 02/11/2011
PURPOSE:
This guideline has been developed to provide the Lisbon Fire Department and
Sussex Fire Department personnel with a pre – plan of action to be followed in
the event of a structure fire or related fire alarm at Templeton Middle School.
APPARATUS RESPONSE: Sussex Fire Department.
Apparatus should respond in the following order:
1. Engine (water source)
2. Engine
3. Ladder Truck
4. Rescue/Equipment Truck
5. Ambulance
Lisbon Fire Department, refer to SOG # 3-1 for apparatus response.
APPARATUS POSITIONING:
Lisbon Fire Department:
Positioning of the apparatus is the responsibility of the driver/operator. The
driver should position the apparatus for optimum efficiency. When
positioning the engine(s) at Templeton Middle School, the driver(s) should
follow the positioning sequence described below;
1. 2662: Parking lot of south side.
2. 2663: with 2662
3. 2661: East Side of building.
2663 will stage with 2662. If needed, 2663 will connect a 5-inch supply to 2662 and then
proceed with a reverse lay to Silver Spring, staying on the west side of the driveway. If
needed, Sussex will then continue the reverse lay to the hydrant by the industrial park.
Conditions such as location of the fire, access to the property, wind direction and exterior
exposures may cause the officer to deviate from positioning the apparatus as specified
above. Apparatus placement must always be positioned for personnel and equipment.
The first unit on the scene shall establish Incident Command. Command shall relay a
brief size-up to the other responding units. Command shall form a fire/smoke
investigation of the crew of the first engine company. The crew will investigate any
findings inside the building and report any findings to command. Command will then
dispatch equipment and personnel needed for that situation.
Sussex Fire Department:
Sussex shall stage at the entrance to Templeton Middle School on Hwy. VV, and
await further direction from Incident Command.
LISBON FIRE DEPARTMENT
SOG 4-1
SUBJECT: Medical Emergency
EFFECTIVE DATE: 02/11/2011
PURPOSE:
This guideline has been developed to provide the Lisbon Fire Department
personnel with a set of guidelines to be followed in the event of a medical
or rescue emergency of one patient.
OBJECTIVES:
To ensure that the members of the Lisbon Fire Department respond to a
medical emergency with the proper personnel and apparatus, and to
control number of personnel and apparatus at the scene. In addition, to
provide adequate personnel and apparatus for another emergency.
APPARATUS RESPONSE:
Apparatus should respond in the following order;
1. 2653
2. 2652
3. 2688-2681 (Dependant on which station)
First out ambulance may respond with one or two EMT’s if other qualified
personnel are responding to the scene. This information may be derived from
radio, cellular, telephone communications, or pre-established criteria. If one EMT
is waiting with an ambulance and they hear a officer or another qualified person
go enroute, or if they see a second EMT pulling into the station, they are then
required to call enroute. They will then wait for any other personnel that are
pulling into the station.
After first ambulance is enroute, and more personnel arrive, they should
respond with 2688 or 2681. If only one person is in 2688 or 2681, and you know
that there are other people on your group responding, please wait for them and
then respond. If a few minutes has passed, or the officer in charge requests, you
may respond. Once 2688 or 2681 is enroute and additional personnel arrive at the
station, and there are ample personnel already enroute, either stand bye at the
station for another call, or contact the officer in charge for direction.
PERSONNEL:
A minimum of one (1) EMT-P will be required for all emergency medical calls.
Two (2) EMT-P’s is preferred.
MEDICAL RELEASES:
A Lisbon Fire Department medical release will be used if a patient refuses any
medical services, or if after attaining a complete set of vital signs, the patient
refuses transport. If the vital signs are unstable, and every attempt to convince the
patient to be transported fails, and they are alert and oriented, a release must be
signed, and all information documented on a state run report.
Lisbon Fire Department
Station Policy,
Rules and Regulations
Issued 2/26/08
PURPOSE
The Lisbon Fire Department in order to maintain a safe, affable, clean, healthy,
and professional atmosphere for the department’s staff; and to assure station integrity and
preservation is here-by issuing the following policy. This set of regulations are here by
established to guarantee an on-duty crew will be ready to respond to an emergency in the
Town with the appropriate tools and mind set. All references to the word “station” in this
document apply to both Good Hope Company and Richmond Company.
Every member of the Town of Lisbon Fire Department is expected to operate in a
highly self-disciplined manner and is responsible to regulate his/her own conduct in a
positive, productive and mature way. Failure to do so will result in disciplinary action
ranging from counseling to dismissal.
PERSONNEL EXPECTATIONS
All members shall:
1. Follow Department SOG manuals, rules & regulations and written directives.
2. Always conduct themselves in a manner that creates good order inside the
department.
3. Keep themselves informed as to the expected responsibilities in station care,
duties, and assignments as it pertains to their stay at the station.
4. Keep themselves in readiness to perform their duty while at the station, and not
absent themselves from duty or place of assignment without specific permission
of their superior officer.
5. Exercise precautionary measures to avoid unnecessary injury to themselves and
others while in the performance of their duty, or stay at the station.
6. Notify on-call officer of any sudden illness or injury in which would result in
leaving the station or ending your scheduled shift.
7. Be concerned and protective of each member’s welfare.
8. Be considerate in each member’s rights, and their personal belongings.
9. Be courteous and respectful in interacting with all other department members.
10. Show courtesy, respect and obedience to superior officers and those performing
the duties of a higher rank.
11. When assigned to a higher rank, accept the responsibility for performance of the
duties of that position.
12. Be courteous and respectful in dealings with the public visiting the station.
13. Observe the work/recreational/quiet hours as set by the department.
14. Obey the law.
15. Be careful of department equipment and property. Exercise due caution to avoid
unnecessary damage to and/or loss of Fire Department property.
16. Promptly notify their immediate supervisor of all matters coming to their attention
directly, which significantly affects the interest and welfare of the Fire
Department, equipment, and its assets.
17. Familiarize themselves with all equipment they may be required to use in the
performance of their duty.
18. Participate in and obtain confirmation of attendance for all Department provided
orientations of station equipment and its correct uses, including exercise
apparatus, before stay at station.
Members shall not:
1. Engage in any activity that is detrimental to the department.
2. Fight.
3. Engage in any rough-housing, wrestling, or any other inappropriate personal
contact.
4. Steal.
5. Use alcoholic beverages, debilitating drugs, or any substance which could impair
their physical or mental capabilities while on duty and or at the station.
6. Have in possession while at the station any alcoholic beverages or illegal
substances.
7. Engage in any sexual activity on or off duty at the station, in any Town owned
vehicles, or on any paid department time.
8. Engage in any sexually suggestive or offensive type of conduct.
9. Engage in any form of sexual harassment.
10. Members shall not loan, rent, sell, give away or appropriate for their own use any
Fire Department property without permission or authority. This includes, but not
limited to, use of copiers, paper, tools, and promotional items.
11. Members shall not change or alter the arrangement of firefighting equipment or
apparatus without approval.
12. Members shall not participate in or retain any knowledge of illegal activity on
Town property.
13. Tamper with any other member’s items at any time.
GENERAL RULES
1. No persons other than members of the Fire Department shall be permitted to ride on
the fire apparatus except when authorized to do so by the Fire Chief.
2. Members may participate in organized meals. It being in the interest of the employees
for the morale of the Department and for the harmonious working relationship
between firefighters. This will be a no cost item to the Fire Department as there shall
be no contribution to this fund. It shall be the responsibility of each member to
contribute their fair share for the daily meals while on duty.
3. Members who are on disability leave or who suffer from an ailment that precludes
them from active firefighting duties may be placed on light duty upon
recommendation of a physician and authorization of the Fire Chief. The authorizing
physician shall present a letter to the Fire Department indicating the light duty
capabilities of the employee. All light duty assignments will be performed at disabled
accessible areas of the station.
4. Only Town of Lisbon employees may utilize exercise equipment located at any Fire
Department station.
5. At 22:00 the fire station will comply to a quiet time status, doors closed, lights
dimmed, bay lights out, yard lights out, no loitering in parking lot, quiet time upstairs,
and it is expected that no one group or persons will negatively affect any other
member from resting/sleeping.
6. All personnel before going off duty shall remove their firefighting turn out gear from
the apparatus and place it in its proper location.
7. All Fire Department phones portable, vehicular and stationary shall be used
exclusively for Fire Department business. All other calls are to be made on the private
phones.
8. Snow shoveling - On duty personnel are responsible for assuring appropriate paths are
cleaned at all sidewalks and approaches to overhead doors. Safe walkways shall be
maintained for visitors and other personnel.
9. Lockers are to be kept closed at all times. When a member is off duty, the lockers
shall be locked. A key shall remain in the possession of the occupant plus a spare key
with the Fire Chief and/or Station Officer. Lockers shall be kept in a clean and orderly
fashion at all times.
10. Members shall strictly adhere to the Town’s/Department’s internet/computer use
policies.
11. Staff dorms are available to the on-call FF/EMTs on a first come first serve basis.
Richmond Co. does house an officer bunk, which will be reserved for such. The
rooms shall be occupied at each station as assigned by the group officer. Remaining
rooms may be occupied by other Lisbon staff, or a ride-along that is pre-approved by
the Chief of the Department. Non-on-call members will be supplemental personnel to
the on-call group and will not interfere with the on-call members, but lend assistance
as requested. All overnight residents will be responsible to fill out the log in each
bunk room, before and after the stay. Each member is responsible for providing and
for proper maintenance (laundering, etc.) of their own bedding. Mattress covers will
be supplied by the Department, but shall be left in a clean condition for next occupant.
12. Lockers: While members are staying at the station they may have use of a locker in the
appropriate locker room. The lockers shall be emptied after each stay if the number of
lockers available drop below an acceptable level. Members shall keep their locker
neat and orderly. Locker doors shall normally be kept closed. Locks keep on the
lockers shall be clearly marked with the owner’s name. All items are to be removed at
the end of each shift if the demand for lockers exceeds the amount available.
13. Housekeeping will be every member’s responsibility and all will accept details
assigned to them.
14. No boots or turn-out gear on carpeting at any time.
15. Refrain from food and drink in training room. Absolutely, need to clean any spills
immediately after each episode, on all carpeted surfaces.
16. The washer and dryer at station shall only be used for specific items. The
washer/dryer policies will be addressed in a different document.
17. Kitchen will be cleaned after each and every meal, with dishes place away in cabinets.
No dishes shall be left in dishwasher overnight. Refrigerator items will be removed
after each shift, unless appropriately marked that anyone can consume. There will be
one specific cabinet space assigned to each of the 6 groups, where dry items could be
stored. Condiments shared in refrigerator will be supplied from a kitty created by
members participating in meals.
18. Outdoor cooking will be kept orderly and the site clean, free of all cigarette butts, and
debris.
19. Air conditioning/heat will be turned off at any point in which the majority of members
present would prefer open windows. An officer will be notified of the status of the air
conditioning system.
VISITORS
Family members and friends may visit on duty personnel as long as the visits do
not interfere with training or other vital department activities. Visits shall be kept short,
and limited to one person per member or more if immediate family. (i.e. spouse,
children). The officer in charge shall be informed of all visitors. Visitors shall be
accompanied at all times by members, while in the station.
Visitors will not be permitted in the fire station after 22:00 hours unless
authorized by the Fire Chief. At other times, visitors will remain in the area of the
apparatus floor unless accompanied by Department members. Sitting in or on
Department vehicles will not be permitted unless accompanied by a Department
member.
At no time will any visitors be allowed in the common hall way accessing any
dorm rooms.
SMOKING
Smoking shall be prohibited on all apparatus and at emergency scenes. No
smoking will be allowed at any public appearances within close proximity of any
Department equipment. No smoking is permitted at any time in Town vehicles, or Town
buildings that are heated or air conditioned. Smoking at outside trainings will be allowed
at the times the instructor indicates, away from the focus of the training.
PETS
Pets at the station will be kept only in the apparatus bay, or outside on a chain.
Owners will provide a cage for confinement in the bay during calls. Owners will be held
responsible for the pet and will clean-up all pet droppings on the property. Any
complaints will be investigated and handled on an individual basis.
PERSONAL VEHICLES
Members may work on personal vehicles at the station while on unpaid duty. The tasks
performed shall be consistent with the type of example activities listed:
1)
2)
3)
4)
5)
6)
Wash, wax, cleaning interior of vehicles, using individual’s own supplies.
Minor mechanical work.
Lubrication, oil changes, and coolant system flushing with proper disposal of
waste by member doing the work.
Tire rotation.
Keys must remain with the vehicle. The vehicle shall be properly supported and
the work area shall be properly cleaned after each use.
Department tools shall be cleaned and returned to proper locations.
ADULT MATERIAL
Adult materials shall not be allowed at the station.
A Fire Department is an emergency agency and it is impossible to formulate Rules,
Regulations and Procedures that will provide a guide or solution to every question or
problem. It is expected, however, that these Rules, Regulations and Procedures of the
Town of Lisbon Fire Department will be sufficiently definitive and comprehensive to
guide the responsibilities, obligations and duties of the officers and members of the
Town of Lisbon Fire Department.
These Rules and Regulations are not designed or intended to limit the obligation of any
members in the exercising of their judgment or their initiative in taking the action a
reasonable person would take in extraordinary situations. Many actions, by necessity,
must be left to the loyalty, integrity and discretion of the members.
The degree which the individual member demonstrates these qualities in the application
of the discharge of their duty, and to that degree alone, will the Department measure up
to the high standard required of the Fire Service, and the Town of Lisbon Fire
Department.
Douglas J. Brahm
Lisbon Fire Chief
8-01-04
Lisbon Fire Department Policy
Regarding on call times
The on call times for groups will start at 18:00 and expire at
06:00 on weekdays (Monday through Fridays). There will also
be an expected 15 minute overlap of groups at the change time.
Therefore the on call group will respond until 06:15. This is to
assure coverage when member’s clocks may read differently. On
weekend call the start time for Saturday will be 08:00 and end at
08:00 on Sunday. Sunday call time will start at 08:00 and end at
06:15 Monday morning.
Douglas J. Brahm
Lisbon Fire Chief
LISBON FIRE DEPARTMENT
Controlled Substance policy
Revised 12-06-2010
PURPOSE: Certain medications carried by the Lisbon Fire Department are
considered Scheduled II medications under the Controlled Drugs and Substances Act
of 1970. In accordance with state and federal laws, these medications need to be
regulated by keeping a complete and accurate record of all stocks on hand.
Monitoring of these medications shall be done through the Lisbon Fire Department
Controlled Drug Record, found on each ambulance.
ACTIONS: All controlled substances shall undergo daily monitoring and be
documented on the approved form.
RESPONSIBILITIES:
1. With the exception of a minimal amount of controlled drugs stored on the
jump bag, all controlled pharmaceuticals shall be kept in a locked box.
2. All controlled pharmaceuticals transported either to and/or from the hospital
or between either stations, shall be done in a portable locked box. An
inventory log shall accompany this lock box at all times.
3. A daily inventory shall occur.
4. A log shall be kept on each ambulance containing controlled substances.
5. Drugs shall be dispensed according to medical control protocols or under the
direction of the online medical control physician.
6. Amounts used and wasted shall be recorded, along with patient’s name, date,
route, and time of administration.
7. Discrepancies shall be reported to a Lisbon Fire Department manager and
properly documented immediately upon discovery.
8. Discrepancies shall be investigated by the Fire Chief or his designee.
9. The keys for the lock box shall be stored in a smaller combination-type locked
vessel.
I. Daily inventory
a. Daily inventory shall be taken of the following medications:
i. Morphine Sulfate
ii. Hydromorphone (Dilaudid)
iii. Valium (Diazepam)
iv. Versed (Midazolam)
v. Fentanyl Citrate
vi. Geodon (Ziprasidone Hydrochloride)
OG 6.07 - 2
b. The daily inventory shall utilize the sealed tags with numbers. The
controlled substance bin shall have two tags, and the lock box shall have
one tag.
c. Daily “Sealed” Audit
i. A daily “sealed” audit can be completed by one ALS member or
officer. (If two approved members; an ALS member or officer and
a second ALS member or officer; are available for the daily
“sealed” audit, utilize both signatures)
ii. The ALS person, or officer, shall place their initials, print name,
and sign the User Log (right side of sheet).
iii. The ALS person, or officer, shall document the date and the time
the controlled substances were checked.
iv. The ALS person, or officer, checking the daily inventory shall
write “SEALED” across the drug inventory boxes for that day and
also place his/her initials in the Initials #1 box.
v. The ALS person, or officer, checking the daily inventory shall
mark “AUDIT” in the patient name/comment section of the log
sheet.
vi. The ALS person, or officer, then shall document the lock box seal
number and the controlled substance bin seal numbers in the
corresponding boxes located on the log.
vii. If a discrepancy is found between the daily “sealed” audit and the
previous audit, refer to the Re-Stock/Discrepancy section.
II. New Log Procedures
a. These procedures shall be followed when starting a new log following the
previously completed log.
i. The ALS person starting the log shall be accompanied by a second
ALS person, or officer and both members shall perform the task of
starting and verifying the new log.
ii. Both members shall mark their initials, print name, and sign in the
User Log section of the form.
iii. First line of new log (Carry-over of counts from previous log):
1. Date and time shall be completed.
2. The counts of each medication shall be filled in from the
counts located on the previous log.
3. Initials #1 and Initials #2 shall be completed by both
members.
4. Seal numbers from previous sheet shall be documented.
iv. Second line of new log (Re-Count/Re-Seal Audit shall be
performed):
1. Date and time shall be completed.
2. The lock box and controlled substance bin shall be opened
and the actual count of each medication is to be
documented in their corresponding boxes.
OG 6.07 - 3
3. The expiration date on each medication shall be checked.
If a medication is expired, see section on Use and Re-Stock
Procedures.
4. Initials #1 and Initials #2 shall be completed by both
members.
5. The lock box and controlled substance bin shall then be resealed
with new tags and the new lock box seal and
controlled substance bin numbers are to be documented.
v. The actual count of medication (second line), shall correspond with
the carried over from previous sheet numbers (first line).
1. If there is a discrepancy between these two lines, refer to
the Re-stock Breakage/Discrepancy section below.
III. Use and Re-Stock procedures
a. ALL actions related to usage shall be entered on a separate line.
b. Every time a seal is broken, all medications shall be counted and
documented prior to re-sealing the bin and lock box by an ALS person and
officer, or 2nd ALS person.
c. The expiration date of each medication shall be checked.
d. List the date, time administered, and amount used in the “used” column.
e. Enter the patient name in the log with the amounts used / wasted.
f. The amount of medication used and subtracted, shall be documented in red
ink.
g. The ALS person administering the medication is responsible for initialing
his/her name for each medication, and print name in the name column.
h. All wasted medications shall be witnessed by a second ALS person, or
officer, who shall then initial his/her name next to ALS person
administering the medication.
i. If an instance of only one ALS member is present and not a second
ALS member or officer is present, the most senior member shall
initial as the second person verifying wasting and documenting.
i. Expired medications shall be wasted by one ALS person and an officer or
2nd ALS person.
j. Before re-sealing, a separate line shall be completed for an audit of the
actual total amounts of controlled substances.
k. The User Log section of the form shall be filled in by each member
completing task.
IV. Re-stock Breakage / Discrepancy
a. An officer or EMS Captain shall be notified as soon as possible.
b. Identify in the “use” column, the number of medications which were
broken or inconsistent.
c. Write Breakage or Discrepancy in the patient name/comment section.
d. The ALS person shall initial, print, and sign their name. A Second ALS
person, or officer, shall also initial, print, and sign their name as witness.
e. Document the incident on a “Controlled Substance Incident” form and
submit to the EMS Captain AND Fire Chief with both names of the ALS
person and witness.
OG 6.07 - 4
f. Re-stocking controlled substances shall be done by an ALS person and an
officer, or 2nd ALS person. Re-Stocking, or adding medications, shall be
done in RED ink. Both personnel shall initial, print, and sign their name.
g. Before re-sealing, a separate line shall be completed for an audit of the
actual total amounts of controlled substances.
h. If re-stocking requires the transportation of controlled substances from
CMH and/or between either station, refer to the Transporting section.
V. Transporting
a. All controlled substances transported from CMH and/or between either
station; must be done in a portable locked box.
b. An inventory log shall accompany this box at all times.
c. Two signatures shall be required to either stock or take medications out of
the portable locked box.
d. Any additions or subtractions of inventory from the locked box shall be
done in RED ink.
e. From CMH to LFD
i. An ALS member shall be designated to acquire the controlled
substance order from CMH.
ii. The ALS member and a CMH Inpatient Pharmacy employee shall
verify and document the controlled substances being placed in the
lock box.
iii. One line shall be designated for the addition of controlled
substances; done in red ink.
iv. A second line shall be designated for an audit of the actual count
contained within the box.
v. The expiration date of each medication shall be checked.
vi. Date and time shall be documented.
vii. Initials #1 and Initials #2 shall be completed by both members.
viii. The User Log section of the form shall filled in by each member
completing task.
f. Between Apparatus
i. The ALS member and an officer, or 2nd ALS member shall both be
present for the exchange to occur.
ii. If necessary, the ambulance needing and/or supplying medications
to the other ambulance shall be driven to the necessary station for
the exchange to occur.
iii. If daily audit is not complete, a daily audit must be completed prior
to exchange of medication.
iv. On each ambulance log pertaining to exchange:
1. One line shall be designated for the addition and/or
subtraction of controlled substances; done in RED ink.
2. A second line shall be designated for an audit of the actual
count contained within the box.
3. The expiration date of each medication shall be checked.
4. Date and time shall be completed.
OG 6.07 - 5
5. Initials #1 and Initials #2 shall be completed by both
members.
6. The User Log section of the form shall filled in by each
member completing task.
7. All necessary bins and boxes shall be re-sealed and tag
numbers shall be documented.
VI. Completed forms
a. The log start and end date along with the counts to be carried over shall be
completed before submission of the form.
b. Completed forms shall be submitted to the EMS captain for verification of
proper documentation.
c. The EMS captain shall verify completeness with the Assistant Chief or
Fire Chief, or their designee.
d. The EMS captain and/or the Assistant Chief, Fire Chief, or designee, shall
document and sign verifying their review of submitted forms.
e. The EMS captain is responsible for maintaining completed logs.
f. A third party audit shall be completed every six months.
g. All logs are to be kept for a minimum of 7 years.
OG 6.07 - 6
LISBON FIRE DEPARTMENT
Controlled Substance Incident
Explanation / Resolution
Date
Time
Unit
Person making report
Other people involved
Nature of report Discrepancy Breakage Contamination Other (circle one)
Statement of events:
____________________________________ ___________
Signature Date
____________________________________ ____________
Witness Date
____________________________________ ____________
Reviewed By Date
08-01-04
Lisbon Fire Department Policy
Regarding the tampering or misappropriation of gear
The tampering or misappropriation of any members gear or personal belongings will not
be tolerated. If any such act is committed the perpetrators and or any parties aware of
said act will be subject to disciplinary action up to and including termination of
employment.
Douglas J. Brahm
Lisbon Fire Chief
Internet and Email Usage Policy
Lisbon Fire Department
INTERNET & EMAIL USE
1. Electronic Mail Security Policy
Electronic messages generated on or handled by electronic communications systems are
the property of the Lisbon Fire Department and are not the private property of any users
of the electronic communications services.
The Lisbon Fire Department’s communications systems shall be used for authorized
Town business only. Users are forbidden to intentionally use electronic communications
systems for unauthorized, non-Town related charitable endeavors, religious or political
causes, private business activities, personal activities, amusement/entertainment
purposes, or other non job-related communications.
2. Offensive Messages
The Lisbon Fire Department prohibits the display or transmission of sexually explicit
images, offensive or disruptive messages and cartoons, gender-specific comments, as
well as the use of ethnic slurs, racial epithets, any comment that offensively addresses
someone's age, sexual orientation, religious or political beliefs, national origin, disability,
or anything that may be construed as harassment.
3. User Accountability
Employees are expected to not divulge their individual passwords. To prevent
unauthorized parties from obtaining access to electronic communications, users shall
choose passwords which are difficult to guess. Passwords to avoid are family member
names or pet names, or obvious work-related words.
4. Employee Responsibilities
Except as otherwise specifically provided, employees may not intercept, disclose, or
assist in intercepting or disclosing electronic communications that are not sent to them or
they are not the intended recipient. The Lisbon Fire Department is responsible for
servicing and protecting the electronic communications networks. To accomplish this, it
occasionally may be necessary to intercept or disclose electronic communications.
Management reserves the right to enter an employee's E-mail file for business purposes.
To this end, employees are required to make their computer passwords available to
management of the fire department. Management may examine E-mail communications
at any time without prior notice or approval of the user.
5. Retrieval of Information
Employees shall not use a code, access a file, or retrieve any stored information, unless
authorized to do so. Employees should not attempt to gain access to other employee's
electronic data without their permission. All computer pass codes must be provided to
management.
6. Purging Electronic Messages
Messages no longer needed for business purposes must be periodically purged by users
from their personal electronic storage areas. After a certain period (generally 6 months)
electronic messages not backed-up to a separate data storage media (disk, CD-ROM, etc.)
may be deleted.
7. Policy Violation
Any employee who discovers a violation of this policy shall immediately notify
management of the fire department, who shall inform the Chief. An employee who
violates this policy or uses the electronic communications for improper purposes shall be
subject to disciplinary action and may be subject to the following:
1. Internet and E-Mail access may be revoked.
2. Access times may be restricted
8. Internet Security Policy
This policy describes the Lisbon Fire Department’s policy regarding Internet use and
security. All Internet users shall be familiar with and comply with these policies.
Questions and concerns about specific policy applications should be directed to an
officer.
8a. Information Movement
All software downloaded from non-Town sources via the Internet must be screened with
virus detection software prior to being invoked. If the downloaded software contains a
virus, worm, or Trojan horse, then the damage will be restricted to the involved machine.
8b. Information Protection
Wiretapping and message interception is straightforward and frequently encountered on
the Internet. Confidential, proprietary, or private information of the fire department must
not be sent over the Internet unless security measures are in place.
Credit card numbers, SCAN numbers, telephone calling card numbers, log-in passwords,
and other parameters that can be used to gain access to goods or services, shall not be
sent over the Internet in readable form.
Exchanges of software between the fire department and any third party shall not proceed
unless a written agreement has first been signed by the Chief. Such an agreement shall
specify the terms of the exchange, as well as the ways in which the software is to be
handled and protected.
Copying of software in a manner that is not consistent with the software vendor's license
is strictly forbidden. Likewise, off-hours participation in pirate software bulletin boards
and similar activities is prohibited. Reproduction of words posted or otherwise available
over the Internet shall be done only with the permission of the author/owner.
8c. Expectation of Privacy
Fire Department employees using town information systems and/or the Internet should
realize that their communications are not automatically protected from viewing by third
parties.
At any time and without prior notice, the fire department reserves the right to examine Email, personal file directories, and other information stored on fire department computers.
8d Access Control
Fire Department employees shall not establish Internet or other external network
connections that could allow non-Town users to gain access Lisbon Fire Department
systems and information.
8e. Reporting Security Problems
Whenever passwords or other system access control mechanisms are lost or suspected of
being stolen or disclosed, management must be notified immediately. All unusual
behavior, such as missing files, frequent system crashes, misrouted messages, etc. shall
be immediately reported management.
I _______________________________________ have fully read and understand the
Internet and Email Usage Policy of the Lisbon Fire Department. I understand that I am
fully responsible for my actions and access while using any communication systems of
the Lisbon Fire Department. By signing below I accept the terms and conditions of this
policy and will report any such security breach or such prohibited activities to the
appropriate officer.
Signature: _____________________________________________ Date: ___________
Witness Signature: _____________________________________________
LISBON FIRE DEPARTMENT
EMERGENCY MEDICAL SERVICES
EXPOSURE CONTROL PLAN
TABLE OF CONTENTS
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
IX.
X.
XI.
Index
Definitions
Purpose
Responsibilities
Exposure determination
Methods of compliance
A.
Universal precautions
B.
Engineering controls
C.
Work practices
D.
Housekeeping
HIV/HBV laboratories/production facilities
Hepatitis B vaccination
Bloodborne exposure evaluation and follow-up
Labeling
Training
Records
Page
2
2
3
3
3
7
7
8
9
9
10
11
I.
Definitions
A.
B.
C.
D.
E.
F.
G.
H.
I.
I.
J.
K.
L.
M.
Blood – Human blood, human blood components and products made from
human blood
including immune globulin, albumin and factors 8 and 9.
Bloodborne pathogen – Microorganisms capable of causing disease that are
present in human blood or other potentially infectious material. These
include, but are not limited to, hepatitis B virus, human immunodeficiency
virus, hepatitis C virus, malaria, syphilis, adult T-cell leukemia/lymphoma,
viral hemorrhagic fever.
Body substance isolation – Assumption that all body fluids are potentially
contaminated with blood and should be handled appropriately.
Contaminated – Presence or reasonably anticipated presence of blood or
other potentially infectious material.
Decontamination – Use of physical or chemical means to remove, inactivate
or destroy bloodborne pathogens on a surface or item to the point where
they are no longer capable of transmitting infectious particles.
Engineering controls – Devices that isolate or remove bloodborne pathogen
hazards from the workplace.
Exposure incident – Specific eye, mouth, other mucous membrane, nonintact skin or parenteral contact with blood or other potentially infectious
material.
HBV – Hepatitis B virus.
HCV – Hepatitis C virus.
HIV – Human immunodeficiency virus.
Occupational exposure – Reasonably anticipated skin, eye mucous
membrane or parenteral contact with blood or other potentially infectious
materials that may result from the performance of an employee’s duties.
Other Potentially Infectious Materials
1.
The following human body fluids: Any body fluid that is visibly
contaminated with blood, and all body fluids in situations where it
is difficult or impossible to differentiate between body fluids;
semen, vaginal secretions, cerebrospinal fluid, synovial (joint)
fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic
fluid, saliva in dental procedures.
2.
Any unfixed tissue or organ from a human except intact skin.
3.
HIV-containing cell or tissue cultures, organ cultures and HIV- or
HBV-containing culture medium or other solutions; and blood,
organs or other tissues from experimental animals infected with
HIV or HBV.
Parenteral – Piercing mucous membrane or skin barrier through such events
as needle sticks, human bites, cuts and abrasions.
Personal Protective Equipment (PPE) – Specialized clothing or equipment
worn by an employee for protection against a hazard. General work
N.
O.
P.
II.
Purpose - The purpose of the Lisbon Fire Department Exposure Control Plan is
to:
A.
B.
C.
D.
III.
clothes not intended to function as protection against a hazard are not
considered to be personal protective equipment.
Specimen – Any human or animal solid or liquid which requires or may
require special handling to control potential pathogens, germs and/or other
physical or chemical hazards (e.g. avulsed tissue, amputated body parts,
blood soaked clothing.
Source individual – Any individual, living or dead, whose blood or other
potentially infectious material may be a source of occupational exposure to
the employee.
Universal precautions – The approach to infection control which assumes
that all human blood and certain human body fluids are treated as if known
to be infectious.
Eliminate or minimize occupational exposure of employees to blood or
other potentially infectious material
Inform employees of their rights and responsibilities related to potential
exposure to bloodborne pathogens.
Outline procedures and engineering controls to eliminate or minimize
occupational exposure of employees to blood and other potentially
infectious materials.
Comply with OSHA Bloodborne Pathogens Standard 29 CFR 1910.1030.
Responsibility
A. It is the responsibility of the Director of EMS to:
1. Review the exposure plan annually.
2. Provide education and training for employees.
3. Recommend engineering controls and work practices to eliminate or
minimize employee exposure to blood or other potentially infectious
material.
4. Assure the equipment and supplies in appropriate sizes are readily available
and accessible at the work site.
B. It is the responsibility of the Lisbon Fire Department officer or senior
emergency medical technician at the scene of an emergency to
mandate/enforce the use of the engineering controls and work practices
outlined below to eliminate or minimize employee exposure to blood or
other potentially infectious material.
C.
It is the responsibility of all Lisbon Fire Department employees to:
1.
Apply the dictates of the Exposure Control Plan during all fire
department operations.
2.
Report exposures promptly.
3.
4.
IV.
Attend training programs as scheduled.
Complete recommended screening and follow-up procedures.
Exposure Determination
A.
The potential for exposure to bloodborne pathogens exists for all
employees of the Lisbon Fire Department in the job classifications of:
1.
Firefighter
2.
Emergency medical technician
3.
Equipment operator
4.
Officers
5.
Director of EMS
6.
Deputy Chief
7.
Chief
B. Additional tasks and procedures performed by member of the Lisbon Fire
Department that could result in occupational exposure include:
1.
Maintenance/repair of facilities in a contaminated equipment area.
2.
Inadvertently entering a contaminated area before clean
up/decontamination is completed.
V.
Methods of compliance
A.
Universal precautions (see work practices, section V (D) below) will be
observed by all members of the Lisbon Fire Department to prevent or
minimize contact with blood or other potentially infectious material.
Since differentiation of body fluid types is difficult in emergency medical
care, all body fluids from all patients will be considered potentially
infectious.
B.
Engineering controls
1.
The needle portion of intravenous catheters and syringes will be
placed directly into contaminated sharps containers as soon as
feasible following the procedure without recapping.
If
extraordinary circumstances require recapping, it will be
accomplished by the one-hand scoop technique. No needle will be
bent, broken or sheared before disposal. The Lisbon Fire
Department purchases and requires the use of safety-engineered
sharps (needles, blood lancets) to prevent accidentally needle-stick
exposure to blood/body fluids.
2.
Automatic retractable lancets will be used for all blood glucose
measurements. The device will be placed into a contaminated
sharps container as soon as feasible following the procedure.
3.
All medications will be supplied in a prefilled state when
commercially available to minimize the use of needles and
syringes to draw up medication. Injectors for prefilled medications
will have needle guards whenever commercially available.
4.
Needles and syringes with needles attached will be deposited into a
contaminated sharps container as soon as feasible following use.
Needles/contaminated sharps will not be bent, broken, sheared or
recapped before disposal.
5.
Contaminated sharps containers will be of suitable size to entirely
contain the discarded devices. They will be:
a.
Closable
b.
Puncture resistant
c.
Leak-proof on sides and bottom
d.
Labeled with the biohazard symbol
e.
Color-coded red if the biohazard symbol is not present.
All contaminated sharps containers will be maintained in an
upright position. They will be positioned in an easily accessible
location to the patient care area. When the contents reach the
“full” line, the container is to be closed and transported to
Elmbrook Memorial Hospital for disposal.
Single use
contaminated sharps containers will meet the same criteria listed
above and be carried to the patient location if care will be provided
outside the ambulance. Single use contaminated sharps containers
will be closed at the end of the call and transported when
convenient to Community Memorial Hospital for disposal.
6.
7.
C.
No reusable sharps will be used by the department.
Work practices
1.
Handwashing
a.
Handwashing facilities are provided in multiple locations in
with appropriate liquid hand soap dispensers and paper
toweling. Bar soap and/or community-use cloth towels will
not be used.
b.
Handwashing will not be done in the sink where food
preparation and dishwashing occur.
c.
At the scene of the emergency where handwashing is not
feasible, an appropriate antiseptic hand cleanser will be
used (e.g., Calstat, Hibistat). As soon as feasible, hands
will be washed with soap under running water.
d.
Hands will be washed with soap and running water as soon
as feasible following removal of gloves and other personal
protective equipment.
e.
Skin and mucous membranes will be washed/flushed as
soon as feasible following contact with blood or other
potentially infectious material.
2.
Work area practices
a.
Eating or drinking in the patient compartment of the
ambulance is prohibited. Food or drink may only be
3.
4.
present in the driver’s compartment (cab) if there is no
possible contamination by blood or other potentially
infectious material. Personnel must wash and change
contaminated clothing before entering the cab.
b.
No cosmetics, including lip balm, may be applied in the
patient care area. Contact lenses cannot be removed or
replaced in the patient care areas.
c.
No blood or other potentially infectious material may be
placed at any time in a refrigerator, freezer or other area
where food is stored or prepared.
d.
All visible contamination spills will be wiped up
immediately using germicidal disposable wipes and
decontaminated as soon as feasible using Cavicide or
other appropriate solution provided by the Lisbon Fire
Department for that purpose.
e.
All potentially contaminated waste will be removed from
the scene of an emergency by Lisbon Fire Department
personnel using appropriate precautions as outline in this
document.
f.
Any specimen transported must be contained in a leakproof, spill-proof container appropriately labeled/identified
as a biohazard.
g.
No DeLee mucous traps or other devices will be used if
they require the application of suction by mouth.
The Director of EMS is responsible for assuring that all equipment
has been appropriately decontaminated or labeled prior to shipping
or servicing.
Personal Protective Equipment
a.
The Lisbon Fire Department will provide appropriate
personal protective equipment to all employees without
charge. Such equipment will be cleaned and replaced as
necessary by The Lisbon Fire Department without charge
to employees.
b.
All personal protective equipment will be present and
readily accessible at the work site.
c.
Gloves
(1)
Disposable gloves will be worn on all EMS calls
during patient contact:
(a)
When any blood or other potentially
infectious material are present or when
contact can be reasonably predicted.
(b)
When suctioning or performing any airway
procedure.
(2)
Powder-free non-latex gloves are provided for
general use.
(3)
d.
e.
f.
Disposable gloves will be changed as soon as
feasible when obviously contaminated or when the
integrity is compromised (tear, puncture).
(4)
Disposable or utility gloves will be worn when
cleaning or disinfecting equipment or
environmental surfaces.
(5)
Utility gloves may be decontaminated and reused
but must be discarded and replaced when cracked,
peeling, torn, punctured or no longer functions as an
effective barrier.
(6)
Disposable gloves will not be reused.
Masks, eye protection and/or face shields covering the
eyes, nose and mouth will be worn whenever splashes,
sprays, splatter or droplets of blood or other potentially
infectious material can be anticipated to contaminate the
face or mucous membranes of the employee(s).
(1)
Masks will cover the nose and mouth, be changed
whenever moist and be discarded at the conclusion
of the call.
(2)
Goggles or glasses will be equipped with solid side
shields.
(3)
Face shields will extend from the forehead above
the eyebrows down past the chin and be wide
enough and shaped to prevent splashes/spray
contamination from the side.
(4)
HEPA masks, size to be determined by the annual
fit test, will be worn whenever there is the potential
for exposure to active respiratory tuberculosis.
Gowns, aprons and other protective body clothing will be
worn whenever there is risk of contamination of clothing.
Water-repellent gowns and Tyvek suits will be available on
all calls.
Guidelines for the use of personal protective equipment
include:
Gloves
Uncontrolled bleeding
Controlled bleeding
X
X
Eye
Protectio
n
X
Mask
X
Turn Out
Gear/Gown/
Tyvek suit
X
Gloves
Childbirth
Intubation
Suctioning
IV/IM procedures
X
X
X
X
Eye
Protectio
n
X
X
X
Mask
X
X
X
Turn Out
Gear/Gown/
Tyvek suit
X
5.
D.
The lieutenant at each station is responsible for daily oversight and
enforcement of all standards related to work practices.
Housekeeping
1.
Nondisposible laryngoscope blades and other metal objects (e.g.
scissors) will be cleaned as soon as feasible after use by scrubbing
with detergent under running water to remove any tissue or fluids,
then soaked in Metricide 28 sterilizing solution or other
comparable solution provided by The Lisbon Fire Department for
this purpose, following label directions.
2.
The ambulance patient compartment will be maintained in a clean
and sanitary condition at all times.
a.
Contaminated work areas will be wiped up immediately
with germicidal disposable wipes and decontaminated as
soon as feasible with Cavicide or other suitable surface
disinfectant provided by City of Brookfield Fire
Department. The work area must be decontaminated
before the unit can respond to another call.
b.
In addition to appropriate cleaning of the patient
compartment and equipment after each run, there will be a
generalized cleaning:
(1)
Weekly
(a)
Vehicle interior (exterior cabinets, open
shelves, ceiling, walls, floor, chairs,
benches)
(b)
Stretcher
(c)
Stair chair
(d)
Backboards, KED
(e)
Splints
(f)
In-station EMS clean up area
(2)
Monthly
(a)
Interior compartment of all kits
(b)
Interior compartments of the vehicle
c.
All bins, pails, cans and other cleaning receptacles will be
inspected after use and decontaminated as necessary with
Cavicide or other suitable surface disinfectant provided
by The Lisbon Fire Department..
d.
Contaminated broken glass will not be picked up directly
with hands.
3.
Laundry
a.
Contaminated laundry is defined as containing blood or
other potentially infectious material in a sufficient quantity
so that the contaminating substance drips from, pours from,
is released by squeezing or wringing the laundry or releases
dried flakes of the contaminating substance.
b.
Contaminated laundry will be bagged in color-coded red
containers at the point of use and transported as soon as
feasible to Elmbrook Memorial Hospital for
decontamination.
c.
Gloves will be worn when handling contaminated linen.
d.
Uniforms, turnout gear, EMS jackets and other clothing
soiled with blood or other potentially infectious material
less than the “contaminated” level will be removed as soon
as feasible and laundered at the department. No
contaminated clothing will be taken home for cleaning.
Personnel will follow laundry procedures posted at each
station.
e.
Employees are to shower as soon as feasible following
removal of contaminated clothing.
4.
The lieutenant at each station is responsible for daily oversight and
enforcement of all standards related to housekeeping.
VI.
There are no HIV or HBV Research Laboratories or Production Facilities in the
response area of Lisbon Fire Department
VII.
Hepatitis B Vaccination
A.
B.
C.
All new employees of the Lisbon Fire Department will receive a training
program addressing bloodborne pathogens at the time of assignment to
tasks where there is a potential for bloodborne pathogen exposure.
Hepatitis B vaccination will be made available to new employees
following the training program and within 10 working days of assignment
to tasks where there is a potential for bloodborne pathogen exposure. The
vaccination will be:
1.
Made available at no cost to the employee.
2.
Made available at a reasonable time and place.
3.
Performed by an appropriated health care professional appointed
by the fire department
4.
Provided according to the current U.S. Public Health Service
recommendations.
The employee has the right to refuse Hepatitis B vaccination by signing
the waiver presented by the department. If, at a later date, the employee
elects to receive the vaccination, the employer will provide it at that time
as outlined in VII-B above.
D.
Employees who have ongoing contact with patients or blood/other
potentially infectious material or who are at risk for injuries with
contaminated sharp instruments or needle sticks will be tested for antibody
to Hepatitis B surface antigen 30 to 60 days after completion of the
vaccination series.
1.
Employees who do not respond to the primary vaccination series
will be revaccinated with a second series and titer levels rechecked
30 to 60 days after the second series is completed.
2.
E.
F.
VIII.
Employees who do not respond to the second vaccination series
will be considered to be non-reactors to the vaccine and will be
referred for appropriate medical evaluation and treatment after any
exposure.
Employees who have previously received the Hepatitis B vaccination
series and/or have antibody testing indicating the employee is immune do
not need to be revaccinated.
Future recommendations for Hepatitis B from the U.S. Public Health
Service will be instituted by Lisbon Fire Department.
Bloodborne exposure evaluation and follow-up
A.
Any employee who has reason to suspect he/she has been exposed to
blood or other potentially infectious material will report that potential exposure to his/her
immediate supervisor within one hour of occurrence.
B.
Upon receipt of a report of a potential exposure, the employee’s
immediate supervisor will arrange for the employee to report within one hour to
Community Memorial Hospital Emergency Department for medical evaluation.
1.
The exposed employee will complete: (Note: All forms included in the
Exposure Packet located at Station 1. Copies are carried on all fire department apparatus.)
a.
b.
c.
d.
e.
2.
3.
Exposure Incident Reporting Form
“Employee Work Related Incident Report”
Follow Up of Employee Exposure to Blood/Body Fluids
“Employee Restriction Responsibility Form”
“Medical and Worker’s Compensation Claim
Authorization”
The supervisor of the exposed employee will complete
a.
“Employer’s First Report of Injury or Disease for Wausau
Insurance Co.”
b.
“Employee Work Related Incident Investigation Report”
If the employee seeks medical attention as a result of the
injury/exposure, the following forms must also be completed and
submitted.
a.
Health Care Professional Written Opinion Post Exposure
Follow Up Evaluation
b.
“Attending Physician’s Report – Return to Work
Recommendations”
“Job Function Evaluation Form” (back side of Return to
Work Recommendations)
Note: An Attending Physician’s Report – Return to Work
Recommendations” must be .completed at the end of each
follow-up medical appointment
The exposed employee will notify the attending physician of the
current location of the individual who was the source of the blood
or other potentially infectious material.
a.
If the source individual was transported to Community
Memorial Hospital Emergency Department, the attending
physician will be asked to obtain consent and test the
source patient for Hepatitis B, Hepatitis C, HIV and any
other potentially communicable diseases that the physician
may suspect.
b.
If the source individual was transported to another
emergency department, the Officer on the transporting unit
will notify the source individual’s attending physician and
request testing of the source patient for Hepatitis B,
Hepatitis C, HIV and any other potentially communicable
disease that the physician may suspect. The attending
physician will be given the name of the exposed employee
and a telephone number where the employee can be
contacted. The results of that testing should be forwarded
to the exposed employee by the source individual’s
attending physician or his/her designee.
c.
If the source individual is not transported to a hospital, the
Officer on the scene will explain the situation and request
the source individual consent (or request consent from an
individual able to provide consent for the source) to testing
for HBV, HCV and HIV. Consent forms for the blood
draw and testing will be carried on all ambulances in the
exposure packet. The blood tube and consent form(s) will
be labeled and transported to Community Memorial
Hospital with the exposed employee for testing.
d.
If the source individual is deceased, the Waukesha County
Medical Examiner will be contacted from the scene by the
Officer in charge, notified that the deceased is the source
individual for a significant exposure and permission sought
to draw blood for testing. The Medical Examiner may elect
to transport the body and arrange for testing at another
facility. The results of the test will be given to the exposed
employee as outlined in section VIII (B) (4) (b) above by
the medical examiner or the attending physician of the
source individual or designee.
e.
Any problems with obtaining consent from the source
individual should be reported as
c.
4.
3.
4.
soon as feasible to the Director of EMS who will attempt to
contact the individual or appropriate authority and gain
consent for testing for bloodborne pathogens.
The attending physician at Community Memorial will evaluate the
exposed employee and:
a.
Provide counseling to the employee on recommended
medical care.
b.
Prescribe the appropriate medical care.
c.
Provide a copy of his/her written opinion following
exposure to blood/other potentially infectious material
including:
(1)
Recommendation for post exposure Hepatitis B
vaccination.
(2)
Documentation that the exposed person has
obtained appropriate information
about bloodborne pathogens, results of the
evaluation and signs/symptoms to report if they
occur.
d.
Complete the “Attending Physicians Return to Work
Recommendations Form” if appropriate
The exposed employee may obtain appropriate follow-up medical
care and screening as ordered by the attending physician from:
a.
Community Memorial Hospital.
b.
Medical Associates Occupational Health Department or the
agency contracted by Lisbon Fire Department for employee
health issues.
c.
Personal physician.
IX.
Labeling
A.
All contaminated materials will be placed in appropriate receptacles
marked with the biohazard legend and/or in red-colored bag/containers.
B.
Any bag/container that contains contaminated waste will be taken to
Community Memorial Hospital for appropriate decontamination/disposal.
X.
Training
A.
All new employees will receive training in bloodborne pathogens and
personal protective equipment at the time of assignment to department
apparatus.
B.
All employees of the Lisbon Fire Department will receive annual training
on bloodborne pathogens. Content will include:
1.
Location of the department copy of 29 CFR 1910.1030 and the
Lisbon Fire Department Exposure Control Plan.
2.
General review of epidemiology, signs and symptoms of
bloodborne pathogens
3.
Modes of transmission of bloodborne pathogens.
4.
C.
XI.
Recognition of tasks that may involve exposure to blood or other
potentially infectious material.
5.
Methods to reduce or eliminate exposure to blood or other
potentially infectious material to include:
a.
Engineering controls.
b.
Work practices.
c.
Personal protective equipment (selection, types, use,
location, removal, handling, decontamination, disposal).
d.
Hepatitis B vaccination program.
e.
Procedure following a significant exposure.
f.
Post exposure evaluation and follow-up.
g.
Use of labeling on contaminated equipment and supplies.
Training will be conducted by the Director of EMS or a designee
knowledgeable in the subject and matter and will include opportunities for
questions.
Records
A.
1.
2.
3.
4.
5.
B.
C.
D.
The Lisbon will maintain records of employee
occupational exposures for the duration of employment plus 30 years as
required by rule, containing:
Name
Social security number
Vaccination status
Results of examination, testing and follow-up related to employee health
maintenance
Significant exposure incidents
The hospital/agency providing medical evaluation, follow-up and
treatment of employees with occupational exposure to blood or other
potentially infectious material will maintain confidential medical records
of examinations, medical testing and follow-up procedures for the duration
of the employee’s career plus 30 years. Should the agency’s contract not
be renewed or the agency cease doing business, those records will be
transferred to the new agency named by the Lisbon Fire Department.
Training records for all employees of the Lisbon Fire Department will
include:
1.
Date of training.
2.
Curriculum outline for each presentation.
3.
Instructor for each presentation and his/her qualifications.
4.
Employees attending each presentation, including job title.
All records will be made available upon request to the Assistant Secretary
of Labor for Occupational Safety and Health Director of the National
Institute for Occupational Safety and Health, Department of Health and
Human Services, or designee.
E.
The Director of EMS is responsible for annual review and appropriate
updates of the Lisbon Fire Department Exposure Control Plan as required
by rule.
Lisbon Fire Department
Probationary Test
Revised October of 2009
The Lisbon Fire Department provides a very high quality of service by relying
heavily on the skills and commitment of its members. The most valuable resource the
department deploys is the individuals who make up the membership. All those who
graduate to full member status must understand that they are placing themselves in a very
special situation; they deliver emergency services to the Lisbon citizens in need and in
most cases are not backed up by any other agency. The fire department personnel are the
only and often the final line of aid people can call on. As full members of this
organization you are promising that you are aware of the seriousness of this vocation and
are willing to commit to the challenge of being prepared for the days you will be called
upon to perform your duties. This probationary test is a right of passage and is a
significant milestone in your Lisbon careers. The probationary testing is given to assure
the fire and EMS service providers are ready to participate in their full capacity,
exercising their acquired skills and knowledge.
In order to qualify for the test the candidate must complete and be certified in at
least two categories, depending on the career path choice. An example would be
completing Firefighter I and EMT basic classes. EMS only personnel would be expected
to complete EMT basic and IV tech. The fire only candidate would be expected to have
completed Firefighter I, II or MPO. The testing process is divided into two parts, a
written and a practical. The written is again divided into 3 components. Component I is
a general test focusing on our SOG’s, procedures, expected conduct, rules, radios, our
geographical area, and general knowledge about the department. Component II is on fire,
consisting of fire science and specific equipment related to Lisbon questions, Component
III is EMS, also from the EMT curriculums and specific Lisbon criteria questions. The
practical is divided into two parts as well, one focusing on EMS, the other on fire, but
there is much cross-over as we all need to be proficient in tasks in both areas. The
candidate should also have completed the four hour driving experiences on each of the
vehicles. Much of that practice relates to the hands-on-test.
This testing is designed to be a positive learning experience; there will be some
remediation during the practical portion to promote a successful completion. The written
will be graded to accommodate the different levels of certified personnel taking the exam.
Example; The EMS test passing grade of 75% for the EMT basic/fire person and a
required 85% passing grade for the EMS only candidate.
The following list of subjects will be seen on the tests and can be used as a
general guide for the candidate to prepare for.
General Fire Department Component:
1. Standard Operating Guidelines concerning conduct, discipline, call
groups, safety, private vehicle/ emergency vehicle driving.
2. Chain of command, F.D. structure.
3. Addressing system, north/south/east/west coordinates for major roads
and targeted facilities, Town ordinance concerning addresses, the 7
zones, major subdivision names, Lisbon area borders as it relates to
our neighbors, and road name aliases.
4. Knox box locations, standard response staging points for major
targeted facilities.
5. Standard for manpower numbers in providing mutual aid.
6. Radio modeling, correct verbal usage, talks groups, 800 trunk vs. VHF
radios, pager use, call priorities/response, and radio settings.
7. Town burning ordinance.
8. Attendance requirements, training start times.
9. Personal equipment issue and care of.
10. General knowledge of the history of the Department.
Fire Component:
1. Fire science, flammable ranges for common liquids & gasses, attack
stream characteristics, standard flows, classes of fire, elements of fire,
fire conditions, smoke conditions, hazardous conditions.
2. Specific equipment information, such as capacities, ranges, limits,
sizes, and capabilities about Lisbon’s
ladders/appliances/vehicles/hose/nozzles/meters/pumps
3. Self contained breathing apparatus, donning/maintenance/filling.
4. Personal protective equipment
5. Tender operations.
EMS Component:
1. Basic life support, vital signs, CPR, airway.
2. Waukesha/Lisbon EMS protocols
3. Drugs, which level of provider administers, restrictions of scheduled
narcotics, standing orders vs. on-line direction.
4. Rescue operations, scene control, safety
5. Equipment locations and quantities
6. Immobilization, extrication,
7. Documentation
LISBON FIRE DEPARTMENT
1. 2600 Good Hope Co
2. 2600 Richmond Co
3. 2601 Chief Brahm
4. 2602 Assistant Chief Mason
5. 2603 Unassigned
6. 2604 Captain Tiarks
7. 2605 Captain Gabel
8. 2606 Lieutenant Bujak
9. 2607 Lieutenant Hafemeister
10. 2608 Lieutenant Heier
11. 2609 Lieutenant Kopplin
12. 2610 Lieutenant Unassigned
13. 2611 Lieutenant Mertens
14. 2612 Lieutenant Buening
15. 2613 Lieutenant J. Drager
16. 2614 Lieutenant A. Brahm
17. 2615 Lieutenant Meyer
18. 2616 Bark River Captain Bathke
19. 2617 Bark River Captain Petersen
20. 2618 Bark River Captain Staus
21. 2619 On-call EMS personnel
22. 2651 Ambulance
23. 2652 Ambulance
24. 2653 Ambulance
25. 2661 Engine
26. 2662 Engine
27. 2663 Engine
28. 2681 Grass fire truck
29. 2686 Response vehicle
30. 2687 On-call response vehicle
31. 2688 Utility Command Vehicle
32. 2689 ATV
33. 2691 Tender
34. 2693 Tender
35. 2695 Tender
1/05/2008
LISBON FIRE DEPARTMENT
OPERATING GUIDELINES
INTER-FACILITY TRANSPORTS
Approved by: Chief Douglas Brahm
Approved by: Dr. Dennis Shepherd
Purpose
To define guidelines for response to, operations during, and documentation of inter-facility EMS transports
and ensure that the Lisbon Fire Department provides timely, quality service while maintaining availability
for emergency responses.
Company Assignment
Requests for inter-facility transports will be made through the Dispatch office. The requesting facility shall
use the proper code information to activate the Lisbon Fire Department through Waukesha County
Communications. An Ambulance company will be assigned to the call using the following guidelines:

The on-call group will be responsible to activate the proper EMS crew per the requested level of
response and answer the call in the expected time frames.

If Lisbon is unable to comply with the request as a result of all ambulances being in service, a call to
the requesting facility shall be made from the on-duty officer to either officially deny the transport or
to negotiate a alternate time.

The on-call officer will arrange for a callback of ALS personnel if needed to cover the Town for
additional calls.
Response
A company assigned to a transport shall react / respond in the same parameters as emergency alarm
priorities with the following exceptions:

In circumstances when a specific transport time is requested that is later in the day.

If the company receives an emergency call while enroute on an alpha transport, they are to take the
emergency call. On-call officer will be responsible for ensuring another ambulance is assigned to the
non-emergency call.
All radio communications with dispatch will used in the same manner as a 9-1-1 call, enroute, arrival
1st facility, enroute, arrival 2nd facility, clearing, availability, in quarters.

Transport Procedures
Upon arrival at the facility check in at the nurse’s station. The nurses, facility staff, and patients are to be
treated with the utmost respect at all times. Obtain the following information:
1.
Specific patient destination information.
2.
Determine if there are any specific patient care or patient needs required for or during transport.
Ensure that there are no treatments that are going to continue during transport that are beyond your
scope of practice.
Fill out the top portion of the Physicians Certification Statement (PCS) and obtain a signature on
it.
 A PCS shall be filled out on all transports. Fill out the top portion only, “Medical Necessity
Information” must be filled out by the facility staff.
 Obtain a physician’s signature on the PCS. If the physician is unavailable to sign the form, a
facility staff nurse can sign it.
 Make sure the entire form is completely filled out.
 The PCS is to be sent to Administration with the incident report, do not leave the PCS at the
hospital.
Obtain any patient belongings that need to be transported with the patient. Document what was
transported and who the items were left on arrival at the receiving facility.
Obtain any discharge orders or patient records required for the receiving facility.
Obtain any nurse’s notes to assist in writing the incident report. Whenever possible, obtain or
make a copy of the face sheet and include it with the report.
3.
4.
5.
6.
Patient Transport
The procedure for transporting patients during transports shall be the same as transporting
a patient for a 9-1-1 call. Except for the driver, Lisbon Fire Department personnel shall be in the patient
module with the patient. Baseline vital signs must be obtained on all patients. Monitor the patient
throughout the transport, if complications or an emergency situation arises treat the patient in accordance
with Lisbon Fire Department and Waukesha County EMS protocols.
Delivering the Patient to the Receiving Facility
On arrival at the receiving facility proceed to and enter at designated entrance if a specific entrance was
Identified, or to the normal ambulance entrance if no specific entry point was designated. Check in at the
nurse’s station. The nurses, facility staff, and patients are to be treated with the utmost respect at all times.
Give the facility staff the patient’s name and any appropriate documents, and determine where the patient
needs to go. Deliver the patient to the appropriate room / area, be sure any of the patient’s belongings that
were brought with the patient are left with them, and the facility staff is aware of this. Complete the
required Lisbon Fire Department incident reports and leave a copy with the facility staff.
Returning to Service
The apparatus should be returned to service in the same manner as a 9-1-1 incident (Sanitized, linens
changed, etc).
Reports
File a written EMS incident report and enter a report in the Lisbon Fire Department call log system.
The written report is filed using the same report forms and following the same procedures used for
emergency incidents.
The PCS is to be filed with the packet of paper work and placed in the HIPPA box.
LISBON FIRE DEPARTMENT
EMERGENCY RESPONSE STANDARD OPERATING
GUIDELINES
The Lisbon Fire Department has created this guideline to ensure
adequate response times to all emergency incidents within the Town of
Lisbon and any other municipalities requesting the aid of the fire
department. If any situations arise that would be contrary to this guideline, it
will be left to the discretion of the OIC (officer in charge) to decide on a
resolution.
All personnel that are on duty will remain within a five minute
response to the fire station they are assigned to. The five minute response
time is measured from time of alarm to the moment when personnel are at
the station ready to respond to the incident. This will be accomplished while
complying with all state laws regarding vehicle operation. All members are
also required to comply with all Lisbon SOG’s related to personal vehicle
response to the station.
If personnel are found to not be able to comply within the five minute
response as they currently respond, it is expected that they will make
arrangements to ensure they will be able to meet this requirement. The
preferred arrangements would be staying at the station that they are assigned
to. As mentioned the final discretion will be left to the OIC.
Any questions or concerns that can not be resolved between the
member and the OIC regarding this SOG, shall be directed to the Fire Chief
for further review.
Adopted
TOWN OF LISBON
DRUG AND ALCOHOL POLICY
Drug-Free Workplace Policy
It is the policy of the Town of Lisbon to provide a drug-free workplace for all of its
employees. The Town requires that employees neither use, nor be under the influence of, a
controlled substance(s), and that a zero tolerance standard shall prevail in the workplace. The
Town recognizes the importance of maintaining a safe, efficient, and healthful workplace, as
well as the social responsibility to provide assistance to it’s employees to the extent possible.
Therefore, employees are expected to report for work free from the influence of substances that
could inhibit their ability to perform their duties.
Reporting of Drug Conviction
All Town employees are hereby notified that the unlawful manufacture, distribution,
dispensing, possession or use of a controlled substance is strictly prohibited in the workplace.
Furthermore, this law makes it a condition of employment that all Town employees abide by the
“Drug-Free Workplace Policy” and notify the Town (your immediate supervisor) of any criminal
drug statute conviction for a violation occurring in the workplace no later than five (5) days after
such conviction. Within ten (10) days of receiving such notice of conviction, the Town will
notify the appropriate Federal contracting or granting agency as required. Within thirty (30)
days of learning of a workplace drug conviction, the Town will:
1. Require the employee to satisfactorily participate in a Drug Assistance or
Rehabilitation Program that is approved by the Town; or
2. Take appropriate personnel action as identified below.
An employee’s failure to abide by the terms of the above paragraph will result in
disciplinary action up to, and including, termination of employment. The actual action taken will
be based upon the seriousness of the offence, the employee’s past employment record, and the
employee’s willingness to participate in drug abuse assistance or rehabilitation.
Prevention and Rehabilitation
The goals of this policy are prevention and rehabilitation whenever possible, rather than
discipline or termination. The Town provides access to drug and alcohol counseling,
rehabilitation, and the Employee Assistance Program for all of its regular employees. The
Town’s group health insurance provides benefits for rehabilitation services, and the Town treats
drug addiction the same as other illnesses and provides for a leave of absence under the
provisions of the Family and Medical Leave Act for treatment of drug related illnesses. The
Town also recognizes drug abuse as a potential health and safety problem. Employees needing
help dealing with such problems are encouraged to use the Employee Assistance Program and
health insurance plans as appropriate. Employees may telephone the Town EAP provider, for
additional information. Conscientious efforts to seek such help will not jeopardize any
employee’s job, and contacts with the EAP, initiated only by the employee, will not be known
nor noted in any personnel record.
Leave of Absence Prior to Testing
An employee shall be permitted to take a leave of absence for the purpose of undergoing
treatment pursuant to a Drug Assistance or Rehabilitation Program approved by the Town for
drug use. The leave of absence must be requested prior to the commission of any act subject to
disciplinary action.
Because drug use can seriously jeopardize the health and safety of employees and the
public, it is the responsibility of the Town to maintain a drug-free workplace at all times. As part
of this effort, the Town will continue to provide access to an Employee Assistance Program for
current regular Town employees, will administer appropriate pre-employment drug testing in
conjunction with the pre-employment physical examination to assure that new Town employees
are not drug abusers, and will provide training and education to inform employees of the dangers
of drug abuse in the workplace. It is the responsibility of all Town employees to abide by the
terms of this policy as a condition of employment.
Town of Lisbon
Drug and Alcohol Testing Policy
Purpose
The Department of Transportation (DOT) and the Federal Highway Administration
(FHWA) have issued a rule (49 CFR Parts 40 and 382) requiring alcohol and controlled
substance testing of drivers who are required to have a Commercial Drivers License. These rules
include procedures for urine testing and breath alcohol testing. The purpose of this policy, then,
is to establish an alcohol and controlled substances testing program to help prevent accidents and
injuries resulting from the misuse of these substances by drivers of commercial motor vehicles.
Consequently the Town of Lisbon has established the following alcohol misuses prevention
program and anti-drug program, as well as the subsequent enforcement of violations for its
employees conducting safety-sensitive job functions. (Employees should also refer to the
Town’s “Drug-Free Workplace Policy” which addresses the strict enforcement of workplace
controlled substance usage.)
Policy
For purposes of this policy, The Town of Lisbon and the DOT strictly prohibit the use of
alcohol and/or controlled substances by its employees and volunteers who are performing, or
ceasing to perform the following safety-sensitive job functions:
1. Operation of commercial motor vehicle;
2. Repair and maintenance of a commercial motor vehicle;
3. Control the movement of commercial motor vehicles (i.e., dispatcher)
4. Directly supervising employees who perform safety-sensitive job functions.
Prohibited
Safety-sensitive employees may not consume alcohol:
1. Four (4) hours before performing a safety-sensitive function;
2. While performing a safety-sensitive function;
3. After a fatal accident, unless the employee has been tested or eight (8) hours have
elapsed from the actual time of the accident; or
4. After a non-fatal accident unless the employee’s involvement can be completely
discounted as a contributing factor to the accident the employee has been tested, or eight (8)
hours have elapsed from the actual time of the accident.
The unauthorized use of any controlled substance is strictly prohibited in all situations.
Required Conditions of Testing
Refusal to take a required test will result in removal of that employee from their
assignment(s) which in turn, may result in discipline up to, and including, discharge.
Testing must be conducted in the following situations:
1.
Pre-employment:
Prior to the first time an employee performs safety-
sensitive functions for the Department (i.e., new employment, job transfer, etc.), the employee
shall be screened for alcohol and controlled substances. A positive result will result in a
disqualification from further consideration for the vacancy or eligibility list.
2.
Probable Cause:
a. In a situation where an employee is either acting in an impaired manner and/or
the supervisor has probable cause to believe the employee is using, in possession of, or is under
the influence of alcohol or drugs (i.e., smell of alcohol), the supervisor should seek a
corroborating opinion from another supervisor or manager prior to immediately removing the
employee from the job.
NOTE: Probable cause means a suspicion based on a specific personal observation by a
supervisor or another, that can be described regarding the appearance, behavior, job
performance, speech or breath odor of an employee. It also means receipt of information about
an employee’s suspected drug use from a reliable source.
b. Once the employee has been removed from the job the supervisor is to contact
the Department Liaison. If contact cannot be made at that time, the supervisor is to proceed
through the next step of this procedure and make contact with the Department Liaison as soon as
possible thereafter.
c. The supervisor is to then transport the employee to the collection site for drug
testing immediately, or no later than two (2) hours of having observed the behavior. The
supervisor is to wait at the clinic with the employee until the breath test has been completed or
the urine sample has been taken.
d. Once the drug testing has been completed and a positive confirmatory test
result has been received (0.02 percent or above), the employee will not be permitted to drive
his/her own vehicle home at that time. The employee must make alternative arrangements in
order to leave the collection site.
e. The employee is to be advised not to report for work as she/he will be placed
on administrative leave without pay. If a blood alcohol test has been administered, the Town
will contact the employee once the test results are known (this normally takes 24-48 hours) and a
decision has been made as to the employee’s status.
f. The results of the drug testing will be sent directly to the supervisor. When the
results are obtained, the employee’s supervisor and department head will meet with the person to
determine the appropriate course of action to be taken. This is a confidential process. Test
results will be held strictly confidential and are not to be discussed or shared with anyone who
does not need to know. Likewise, a supervisor must not discuss the suspected reason for a
referral or termination with anyone who does not need to know.
g. Once the test has been completed and the employee has been sent home, the
supervisor must submit a written report to the Department Liaison outlining, in detail, the event
and the behavior observed that led the supervisor to believe the employee was under the
influence of alcohol and/or drugs. This report is to be done within twenty-four (24) hours of the
testing.
3.
Random: This test is used in order to eliminate risks associated with illegal or
unauthorized drug and alcohol use. Random alcohol and drug testing will be conducted just
before, during, or just after an employee’s performance of safety-sensitive duties. The employee
will be randomly selected for testing from a “pool” of employees subject to testing. The testing
dates and times are unannounced and are with unpredictable frequency throughout the year.
The minimum annual percentage rate for random alcohol and drug testing shall be a
twenty-five percent (25%) and fifty percent (50%) respectfully, of the average number of safetysensitive positions. The FHWA will annually publish its decision to increase or decrease the
minimum annual percentage rate for random alcohol and drug testing based upon the reported
violation rate for the entire commercial vehicle industry. For example, if the Town has one
hundred twenty (120) employees who are required to submit to testing, the DOT regulations
specify that random testing will be performed at a rate of fifty (50%), then sixty (60) employees
must be tested each year - which translates to five (5) employees per month.
The selection of employees for random testing shall be administered by Marshfield
Laboratories using a scientifically-valid method. This method will be a computer software-based
random selection program that is matched with employee social security numbers. A monthly
list of confidential numbers will be generated and forwarded to the supervisor in order that they
may make arrangements for testing. Under this selection process, each employee will have an
equal chance of being tested each time selections are made.
In the event an employee tests positive for either alcohol or controlled substances, the
employee will be subject disciplinary action up to, and including, discharge.
4.
Post-Accident: As soon as practical following an accident involving a
commercial motor vehicle, the Town shall test an employee driver for alcohol and controlled
substances. This testing will be required if:
a. The accident involved the loss of human life; or
b. The employee receives a citation under State or local law for a moving traffic
violation arising from an accident.
The alcohol breath test is required to be administered within two (2) hours following the
accident, and the drug test is to be administered within thirty-two (32) hours of the accident.
An employee who is subject to post-accident testing shall remain readily available for
such testing or may be deemed by the department to have refused to submit to testing.
5.
Return to Duty/Follow-up: This test is used to maintain abstinence and to prevent
relapse by employees during and after drug treatment. The Town will ensure that before an
employee returns to duty, requiring the performance of a safety-sensitive job function, after
engaging in conduct prohibited in this policy, the driver shall undergo a return-to-duty alcohol
and/or controlled substance test with a result indicating an alcohol concentration of less than 0.02
percent and a verified negative result for controlled substance use. In any event, an employee
will not be allowed to return to duty without first having been evaluated by the Town EAP
provider in order to determine the employee’s fitness for duty.
Following a determination that an employee is in need of assistance in resolving
problems associated with alcohol misuse and/or use of controlled substances, the Town will
ensure that the employee is subject to unannounced follow-up alcohol and/or controlled
substances testing in consultation with a substance abuse professional. Consequently, the
employee will be given at least six (6) random tests during the next year with the possibility of
follow-up testing for up to sixty (60) months.
6.
Voluntary: This testing provides an opportunity for all employee(
management, supervisory and non-supervisory) not part of the random pool to demonstrate a
commitment to the goal of a drug-free workplace.
Test Procedures
NOTE: The Town has entered into an alcohol and drug testing agreement with the
Marshfield Clinic. Testing will be done on both urine and breath (blood alcohol may be required
when necessary). Marshfield Clinic will handle taking the sample (in standard collection kits)
from the hours of 9:00 a.m. until 5:00 p.m. and Marshfield Clinic will handle taking the sample
at all other non-regular business hours. The health provider will be responsible for sseing that
the samples are sent to Marshfield Laboratory for screening and assisting in the interpretation of
the results. Drug testing is not to be done anywhere but at Marshfield Clinic, unless specifically
authorized by the supervisor.
Alcohol
Employees will be required to submit to breath testing using an Evidential Breath Testing
(“EBT”) device. A State-certified Breath Alcohol Technician (“BAT”) will administer an initial
screening test, unless the employee tests positive for alcohol, then the BAT will conduct a
confirmation test (the Town will take action based only upon the positive results of the
confirmation test, 0.04 percent or greater).
Preparation For Breath Alcohol Testing
1.
When the employee enters the collection site, the BAT will require him/her to
provide positive identification (i.e., photo I.D. or Employee Identification.)
2.
The BAT will explain the test procedure.
3.
Employees will be required to complete and sign various forms used to document
the testing process. Refusal to sign the test form(s) will be regarded as a refusal to take the test.
4.
Employees will be instructed to blow forcefully into the mouthpiece for at least
six (6) seconds or until the EBT indicates that an adequate amount of breath has been obtained..
5.
If an employee tests positive during the screening test, she/he shall not eat, drink,
put any object or substance into their mouth and, to the extent possible, not belch during the
twenty (20) minute waiting period before the confirmation test.
6.
Refusal of an employee to complete and sign the test form, to provide breath, to
provide adequate amount of breath, or failure to cooperate with the testing process in a way that
prevents the completion of the test, will be considered a disciplinable offence up to, and
including, termination.
If a confirmation alcohol test measures 0.04 percent or greater, the Town is required to:
1.
Remove the employee from the safety-sensitive position;
2.
Refer the employee to the Town EAP for assessment, participation, and a
subsequent determination of an alcohol problem; and
3.
The employee will subsequently be given at least six (6) random tests during the
next year with the possibility of follow-up testing for up to sixty (60) months.
If the confirmation test level is between 0.02 and 0.039 percent, the employee will be
removed from the safety-sensitive position and either be re-tested or removed for a minimum of
24 hours.
In the event that an employee is required to comply with breath testing as a result of a law
enforcement investigation, the employee will submit to the examination. The test will be
considered enforceable for purposes of this policy, if the testing officer is a qualified BAT and
that the EBT that was used for the test has been certified by the State of Wisconsin or the Town
of Lisbon.
Blood Alcohol Testing
Blood alcohol testing is authorized only in the following circumstances:
1.
When policy rules require a post-accident or reasonable suspicion test, and an
EBT is not readily available for either a screening or confirmation test, or if there is an EBT
available only for a screening test.
2.
When an employee attempts and fails to provide an adequate amount of breath,
blood alcohol testing may be used for both screening and confirmation test purposes.
Upon conclusive finding of a positive (0.04 percent or greater) blood alcohol test result,
the employee has seventy-two (72) hours in which to require a test of the split specimen.
Pending receipt of the result of the analysis of the split specimen, the employee shall not perform
safety-sensitive functions, unless the employee has met conditions set forth in this policy for a
return to safety-sensitive functions following a test result of 0.04 percent or greater. (For
explanation of “split-specimen” refer to the “Controlled Substances” section below.)
Controlled Substances
The Town has established its anti-drug program through its “Drug-Free Workplace
Policy” which strictly prohibits the unlawful manufacture, distribution, dispensing, possession,
or unauthorized use of a controlled substance in the workplace. Furthermore, any abnormal
manner that may infer an employee is under the influence of a controlled substance is addressed
in the “Probable Cause Testing” section described previously.
For purposes of this policy, the Town will utilize, at a minimum, a five (5) panel drug
screen consisting of the following drugs:
1.
Tetrahydrocannabinol (Marijuana drug);
2.
Cocaine;
3.
Anphetamines;
4.
Opiates (including Heroine);
5.
Phencyclidine (PCP)
Drug testing is conducted by analyzing an employee’s urine specimen (through a certified
testing lab). This procedure will include a split specimen. Each urine specimen is subdivided
into two (2) bottles labeled “primary” and a “split” specimen. Both bottles are sent to a lab.
Only the “primary” is opened and used for the urinalysis. The “split” specimen bottle remains
sealed and is stored at the lab. If the analysis of the primary specimen confirms the presence of
illegal controlled substances, the employee has seventy-two (72) hours to request the split
specimen be sent to another certified laboratory for analysis.
In some cases, the employee may be unable to provide a urine specimen. After a
reasonable waiting period, not to exceed one (1) hour, the supervisor may terminate the testing
procedure. The Town will proceed with laboratory testing based on blood testing alone.
Preparation For Drug Testing
1.
When the employee enters the collection site, the employee will be required to
provide positive identification (i.e., photo I.D. or employee identification).
2.
The employee will be instructed to provide at least 45 ml. Of urine under the split
sample method of collection. This will be done in a specifically designated “donor” bathroom.
3.
The urine sample shall be divided into a primary specimen (30 ml.) and a split
specimen (15 ml.).
4.
If the test result of the primary specimen is positive, the employee may request,
within seven-two (72) hours, that the Medical Review Officer (“MRO”) direct that the split
specimen be tested in a different DHHS-certified laboratory for presence of the drug(s) for which
a positive result was obtained in the test of the primary specimen.
5.
Removal from performing a safety-sensitive function is not stayed pending the
result of the test of the split specimen.
6.
If the result of the test of the split specimen fails ro reconfirm the presence of the
drug(s) or drug metabolite(s) found in the primary specimen, the MRO shall cancel the test.
7.
Employees will be required to complete and sign various forms used to document
the testing and chain of custody process. Refusal to sign the test form(s) will be regarded as a
refusal to take the test.
8.
Refusal by an employee to complete and sign the test and chain of custody forms,
to provide urine, to provide an adequate amount of urine (per case base), or otherwise fail to
cooperate with the testing process in a way that prevents the completion of the test will be
considered a disciplinable offense.
As with an alcohol misuse violation, the Town is required to act upon a positive drug test
result in the following manner:
1.
Remove the employee from the safety-sensitive position. This removal cannot
take place until the employee has been allowed to meet or speak with a MRO in order to
determine that the positive drug test did not result from the unauthorized use of a controlled
substance;
2.
Refer the employee to the Town EAP for assessment and subsequent compliance
with recommended rehabilitation after a determination of a drug problem has been made;
3.
Employee must be evaluated by a substance abuse professional or MRO and
determined to be fit to return to work prior to their release of the employee;
4.
Employee must have a negative result on a return-to-duty drug test. Follow-up
testing to monitor the employee’s continued abstinence from drug use may be required.
Town employees are to notify their supervisor when taking any physician prescribed
medication or therapeutic drug. It is the responsibility of the employee to inform their physician
of the type of safety-sensitive function that they perform in order that the physician may
determine if the prescribed substance could interfere with the safe and effective performance of
their duties or operation of Town equipment.
Questions
Any employee having questions with respect to the scope of this policy and it’s contents
may contact the Department Liaison.
Detach and return this page to the Supervisor after you have read and understood
this manual.
________________________________________________________________________
I acknowledge receipt of the Town of Lisbon Drug and Alcohol Testing Policy on the
date indicated below.
SIGNED:
_______________________________________
DATED:
_______________________________________
Code of Ethics v2
Lisbon Fire Department
We recognize that being permitted to be a part of this organization is both an honor and an
expression of public faith. We openly accept the honor of our office as a public trust, to be held
only so long as we remain true to the legal, ethical and moral values of the Town of Lisbon and
it's Fire Department.
We dedicate ourselves to the department in order to further the mission of the department; the
preservation of human life and the protection of property.
We understand and hereby recognize and commit that our actions must always remain above
reproach.
We will remain honest in thought and deed in both personal and official life, and commit that we
will strive to conduct our affairs in a wholesome manner.
We will be exemplary in obeying the laws of the land and the regulations of this department as
unlawful conduct of any kind is violates the trust we hold.
Information of a confidential nature learned in the course of our duties will be kept in strict
confidence unless its revelation is absolutely necessary to fulfill our obligation and released only
as permitted by department guidelines and the law.
We will never permit personal feelings, prejudices, animosities or friendships to influence our
decisions.
We will be constantly mindful of the welfare of others.
We will never act maliciously or resort to coarse, violent, profane, or insolent language or
gestures even in the face of extreme provocation.
No expression or use of language which might be considered insulting or demeaning, concerning
race, sex, religion, politics, national origin, lifestyle, or other characteristics will be tolerated.
Dress Code
Lisbon Fire Department
Revised 8-1-2010
Purpose
The purpose of the dress code is to make members readily identifiable to the public and law
enforcement, instill public confidence in the Department by promoting a uniform, professional
appearance as well as to maintain a safe working environment. Members shall make every effort
to comply with this code but emergency response is our core mission and members shall not
delay their emergency response because of dress. Members who know they cannot comply with
the code shall seek the approval of the Fire Chief in order to remain in compliance with its
provisions.
Uniform Classification & Use
Short sleeve shirts shall be worn during Central Daylight Saving Time and Long Sleeve Shirts
shall be worn during Central Standard Time unless otherwise directed, except that a long sleeve
shirt shall be worn with the Class A uniform at all times. Members shall safeguard all uniform
items in their possession.




Class A uniform; dark blue dress jacket, blue/white long sleeve uniform shirt, black tie,
T-shirt, dark blue dress pants, black belt, plain black socks (white sox are acceptable if
boots are worn) and black leather shoes/boots. T-shirt logos, designs or text shall not be
visible through the uniform shirt. Shall be worn at formal functions as authorized by the
Fire Chief.
Class B uniform; blue/white uniform shirt - long sleeve (with black tie) or short sleeve
(no tie), T-shirt, work pants (dark blue Dickies/EMS pants), dark blue or black belt, plain
black, white or dark blue socks and black leather boots/work shoes. Officers wear black
pants & socks. T-shirt logos, designs or text shall not be visible through the uniform
shirt. Shall be worn at monthly business meetings, public events and as authorized by the
Fire Chief.
Class C (work) uniform; dark blue shirt/T-shirt with Lisbon Fire Department name
and/or patch, work pants ( dark blue Dickies/EMS pants) or dark blue shorts, dark blue or
black belt, plain black, white or dark blue socks and black leather boots/work shoes.
Shall be worn when on duty and more formal uniforms are not required.
Turnout gear; helmet, Nomex hood, safety glasses, structural firefighting coat, structural
firefighting gloves, bunkers, suspenders, socks and structural firefighting boots. Worn as
per SOG 2-1 for all fire calls, motor vehicle crashes, other calls for service, approved
training and as directed by the Fire Chief.
Uniform Appearance & Insignia



Uniforms shall be clean and pressed at all times.
Uniform and work shirts shall either be tucked in or completely cover the midriff area
and back at all times.
Blue/white uniform shirt:
o LFD patch on left shoulder
o Wisconsin EMT or FF patch (FF patch only for non-EMTs) on right shoulder
o Lapel pins with edge on collar stitching and bottom of insignia/bugle toward point
of collar
o Badge left chest of shirt
o Name plate just above right pocket flap
o Other acceptable pins:
 One Length of Service Award - left flap, inner
 One Wisconsin EMT, FF or Nurse pin - right flap, inner
 Use of Uniforms and Garments Bearing the LFD Name and/or Patch







Members shall wear their Class C (work) uniform or at a minimum an outer garment
bearing the name and/or patch of the Lisbon Fire Department when responding to calls
and not wearing their turnout gear. Members should keep a shirt and/or jacket in their
locker and/or personal vehicle to put over other civilian clothing when unexpectedly
responding to calls.
Turnout gear shall be worn for the authorized activities above only and shall ordinarily be
kept at the member's assigned station. Members authorized to direct respond to calls and
other members authorized to carry their turnout gear may do so but shall be responsible
for its maintenance and security.
Members wearing apparel that displays the name and/or patch of the Lisbon Fire
Department shall conduct themselves in accordance with the code of ethics at all times.
Apparel that displays the name and/or patch of the Lisbon Fire Department shall not be
worn in places where alcoholic beverages are sold/served without the approval of the Fire
Chief.
Alcoholic beverages shall not be consumed while wearing department uniforms without
the permission of the Fire Chief.
Members working full and/or part time shall be attired in their Class C (work) uniform
unless activities require other attire. In such cases they shall have their work uniform or
turnout gear readily available to don prior to responding to a call.
Members purchasing their own garments with the name and/or patch of the Lisbon Fire
Department are encouraged to buy garments that are dark blue and can be worn in
conjunction with the uniform and this dress code.
Personal Appearance




All members are to maintain a clean and professional appearance. Hair will be clean,
well-groomed and safe. Any hairstyle considered unsafe shall be trimmed accordingly or
bound to eliminate the hazard. Males shall be clean shaven other than approved facial
hair which does not interfere with the performance of the face piece as per SOG 2-1 and
personal hygiene shall be such that perfume, breath, body odor and/or other smells are
not offensive.
Members shall not wear jewelry, other than a watch with the following exceptions.
Simple stud earrings, necklaces that are completely concealed beneath a garment at all
times and rings that do not interfere with the wear and proper performance of firefighting
and BSI gloves are acceptable.
Tattoos shall be covered at all times while wearing apparel that displays the name and/or
patch of the Lisbon Fire Department as well as when on duty at department facilities and
in view of the public. Small, innocuous tattoos may be left uncovered with the
permission of the Fire Chief.
Appropriate under garments shall be worn at all times and these garments shall not be
visible. Firefighters should remember that 100% cotton undergarments afford the best
safety during firefighting operations.

Members shall ensure that garments fit and appear modest in any and all physical
positions such that all private body parts are completely covered, including female
cleavage and that they are not so tight as to be unnecessarily revealing. Ease of motion
while performing firefighting and EMS duties without fear of unnecessary exposure is
essential to the successful completion of our duties.
Violations of the dress code may result in discipline up to and including dismissal.
1-10-05
Memo: Policy Change
To: Lisbon Fire Department Personnel
From: Chief Douglas Brahm
The priority response system implemented, with WCC dispatch, has been in use
since October of 2004. In evaluating the responses, for this period, it is
determined some changes are required.
Changes now in affect (modified 1-10-05)
1. Omega
All vehicles respond non-emergent
2. Alpha
1st vehicle emergent, following vehicles non-emergent
3. Bravo
1st two vehicles emergent, following vehicles non-emergent
4. Charlie
All vehicles respond emergent
5. Delta
All vehicles respond emergent
6. Echo
All vehicles respond emergent
Douglas J. Brahm
Lisbon Fire Chief
Waukesha County EMS Medical Guidelines
2009
WAUKESHA COUNTY
EMS GUIDELINES AND STANDARDS OF CARE (Approved 5-6-09)
NUMBER
001
002
003
004
005
006
007
008
009
010
011
012
013
014
015
016
017
018
019
020
021
022
023
024
025
026
027
028
029
030
031
032
033
034
035
036
037
038
039
040
041
042
043
GUIDELINE/STANDARD
SECTION I – DRUG PROFILES
Adenosine
Albuterol
Amiodarone
Aspirin
Atropine
Dextrose
Diazepam (Valium)
Diphenhydramine (Benadryl)
Epinephrine
Furosemide (Lasix)
Glucagon
Lidocaine
Morphine Sulphate
Naloxone(Narcan)
Nitroglycerin
Procainamide
Sodium Bicarbonate
Ammonia Inhalants
Atrovent (Ipratropium)
Vasopressin
Calcium Chloride
Thiamine
Midazolam (Versed)
Dopamine
Flumazenil (Romazicon)
Magnesium Sulfate
Methylprednisolone (Solu-Medrol)
Metoclopramide (Reglan)
Activated Charcoal without Sorbitol
Butorphanol Tartrate (Stadol)
Diltiazem (Cardizem)
Etomidate (Amidate)
Fentanyl Citrate
Hydromorphone (Dilaudid)
Ketorolac (Toradol)
Lorazepam (Ativan)
Meperidine (Demerol)
Nalbuphine (Nubain)
Nitrous Oxide
Promethazine (Phenergan)
Succinylcholine
Vecuronium
Mark-1 Auto-Injectors
PAGE
I-6
I-7
I-8
I-9
I-10
I-11
I-12
I-13
I-14
I-15
I-16
I-17
I-18
I-19
I-20
I-21
I-22
I-23
I-24
I-25
I-26
I-27
I-28
I-29
I-30
I-31
I-32
I-33
I-34
I-35
I-36
I-37
I-38
I-39
I-40
I-41
I-42
I-43
I-44
I-45
I-46
I-47
I-48
044
045
046
047
048
049
050
051
052
Ondansetron Hydrochloride (Zofran)
Nitroglycerin Drip
Levalbuterol Hydrochloride (Xopenex)
Ziprasidone Hydrochloride (Geodon)
Propofol (Diprivan)
Metoprolol (Lopressor)
Ketamine (Ketalar, Ketanest, Ketaset)
Enalapril (Vasotec)
Cyanokit
I-49
I-50
I-52
I-53
I-54
I-55
I-56
I-57
I-58
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
SECTION II – GENERAL GUIDELINES FOR CARE
Assessment Parameters
Documentation
History and Physical Examination
Medication Administration
Oxygen Administration
Routine Medical Care
Universal Precautions
Physical and Chemical Restraint
Refusal of Care
Medical Control Interaction
Transfer of Care
Analgesia
Sedation
Hospital Destination / Transport / Bypass
Hospital Diversion
Tactical Environment
Red Light and Siren Safe Transport Recommendations
II-1
II-4
II-8
II-10
II-15
II-16
II-17
II-19
II-21
II-24
II-25
II-27
II-29
II-30
II-31
II-33
II-35
201
202
203
204
205
206
SECTION III – AIRWAY AND RESPIRATORY
PROBLEMS
Airway Obstruction
Bronchial Asthma
Chronic Obstructive Pulmonary Disease
Inhalation Injury
Respiratory Arrest
Respiratory Distress
III-1
III-3
III-4
III-5
III-6
III-7
301
302
302a
303
304
305
SECTION IV – CARDIAC PROBLEMS
Cardiac Dysrhythmias
Cardiopulmonary Arrest
Cardiopulmonary Arrest CCR
Chest Pain/Discomfort
Congestive Heart Failure
Do Not Resuscitate (DNR), Obvious Death
IV-1
IV-2
IV-4
IV-5
IV-7
IV-8
401
402
SECTION V – MEDICAL PROBLEMS
Abdominal Pain, Problems
Allergic Reactions
V-1
V-2
403
404
405
406
407
408
409
410
411
412
413
414
415
416
Altered Level of Consciousness
Behavioral/Psychiatric Problems
Bites and Stings
Diabetes Mellitus
Headache
Hypertension
Hyperthermia, Fever
Hypothermia
Intoxication, Substance Abuse
Poisoning, Overdose, Toxins
Seizure
Stroke, Cerebral Vascular Accident, Transient Ischemic
Attack
Syncope
Cyanide Poisoning
501
502
503
504
505
506
507
508
SECTION VI – TRAUMA PROBLEMS
Abuse, Assault
Burns
Drowning
Electrocution
Hypotension/Shock
Blunt, Penetrating, Lacerating Trauma
Major/Multiple Trauma
Crush Syndrome
V-3
V-4
V-5
V-7
V-8
V-9
V-10
V-11
V-12
V-13
V-14
V-15
V-16
V-17
VI-1
VI-2
VI-3
VI-4
VI-5
VI-6
VI-7
VI-13
SECTION VII – OBSTETRICAL, GYNECOLOGICAL PROBLEMS
601
Obstetrical, Gynecological Complaints
VII – 1
1001
1002
GUIDELINES FOR PRACTICAL SKILLS
SECTION VIII – GENERAL SKILLS
Physical Assessment
Blood Pressure Auscultation / Orthostatic Blood Pressure
VIII-1
VIII-4
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
SECTION IX - AIRWAY INTERVENTIONS
Oxygen Equipment Preparation
Suctioning
Pocket Mask Ventilation
Bag-Valve-Mask Ventilation
Magill Forceps
Oral Airway
Nasopharyngeal Airway
Combi-Tube and King LTS-D
Endotracheal Intubation
Nasotracheal Intubation
Positive End Expiratory Pressure (PEEP)
Extubation
Nasogastric Tube Placement
Tracheostomy Care
IX-1
IX-3
IX-6
IX-8
IX-10
IX-12
IX-13
IX-14
IX-19
IX-21
IX-23
IX-25
IX-27
IX-29
2015
2016
2017
2018
2019
2020
Thoracentesis
Cricothyroidotomy
Continuous Positive Airway Pressure (CPAP)
Rapid Sequence Intubation
Impedance Threshold Device (ResQPOD)
Laryngeal Mask Airway (LMA)
IX-32
IX-34
IX-36
IX-38
IX-40
IX-42
3001
3002
3003
3004
2005
3006
3007
3008
3009
3010
3011
3012
3013
3014
3015
SECTION X – CIRCULATORY INTERVENTIONS
Blood Samples
Peripheral IV Lines
External Jugular IV Lines
Intraosseous Infusion
Pericardiocentesis
Defibrillation
Synchronized Cardioversion
12 Lead Electrocardiogram
ECG Monitoring
Transcutaneous Pacing
Accessing Existing Central Lines
EZ-IO Insertion
AED Guidelines
Auto-Pulse CPR Device
Inducing Hypothermia after ROSC
X-1
X-3
X-6
X-8
X-10
X-12
X-15
X-17
X-19
X-21
X-23
X-25
X-27
X-30
X-32
4001
4002
4003
4004
4005
4006
4007
4008
4009
4010
4011
4012
SECTION XI – MEDICATION ADMINISTRATION
SKILLS
Blood Glucose Measurement
Preparation of Medication for Administration
IV Bolus Administration
IV Drip Administration
Nebulized Medication
Endotracheal Administration
Intramuscular Administration
Subcutaneous Administration
Rectal Administration
Oral/Sublingual Administration
Mark-1 Auto-Injector
Intranasal Administration
XI-1
XI-2
XI-5
XI-7
XI-9
XI-12
XI-14
XI-16
XI-18
XI-20
XI-22
XI-24
5001
5002
5003
5004
5005
5006
5007
5008
5009
SECTION XII – TRAUMA SKILLS
Hemorrhage Control, Bandaging
Eye Injuries
Seated-Patient Extrication Device
Pneumatic Anti-Shock Garment
Spinal Stabilization
Board Splint
Rigid Board Splint, Joint Injuries
Pro Splints
Sling and Swathe
XII-1
XII-3
XII-5
XII-7
XII-9
XII-13
XII-15
XII-17
XII-19
5010
5011
5012
5013
5014
Traction Splint
Thoracic Injuries
Helmet Removal
Tourniquet Application
Hemostatic Agents
XII-21
XII-23
XII-25
XII-27
XII-29
6001
6002
SECTION XIII – OBSTETRICAL SKILLS
Obstetrical Delivery
Newborn Assessment and Intervention
XIII-1
XIII-4
SECTION XIV – STATE STANDARDS
SECTION XV – EMSC PEDIATRIC PROTOCOLS
BLS ALS
Index
XIV-1
XV-1
DRUG PROFILE
Initial Date: 11/01/01
Service Director’s
Signature
Last Review/Revision: 11/08
Profile Number: 001
Medical Director’s
Signature
The following is the basic information and guideline for use of:
ADENOSINE
Approved for use
by:
EMT
Advanced EMT
EMTIntermediate
XX
Paramedic
XX
DRUG ACTION:
Blocks the AV node to slow conduction and treat reentry conditions (tachyarrhythmias)
INDICATIONS FOR USE
Symptomatic supraventricular tachycardia
CONTRAINDICATIONS
Allergy to the drug
Heart block
Drug-induced tachycardias (e.g. from cocaine)
Atrial Flutter and Atrial Fibrillation
SIDE EFFECTS
Headache
Facial flushing
Chest pressure
Nausea
SPECIAL NOTES:
Very short duration of action, must enter the circulation and get to the heart within 10-20
seconds
Pregnancy category C
USUAL DOSE
Adult: 6 mg IV bolus followed by 10-20 ml flush; second dose 12 mg IV bolus followed
by flush
Pediatric: 0.1 mg/kg IV bolus followed by a 10-20 ml flush, maximum of 6 mg; second
dose 0.2
mg/kg followed by flush, maximum 12 mg
MONITOR, REPORT, DOCUMENT
Continuous ECG
Attempt to capture conversion on ECG paper
Vital signs before and within 5 minutes after administration.
END
DRUG PROFILE
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 11/08
Profile Number: 002
The following is the basic information and guideline for use of:
ALBUTEROL
Approved for use
by:
EMT
XX
Advanced EMT
XX
EMTIntermediate
XX
Paramedic
XX
DRUG ACTION:
Bronchodilator
INDICATIONS FOR USE
Acute bronchospasm (asthma, COPD)
CONTRAINDICATIONS
Allergy to the drug
SIDE EFFECTS
Headache
Tachycardia
Hypertension
SPECIAL NOTES:
Monitor patients with cardiovascular disease
Pregnancy category C
USUAL DOSE
Adult and Pediatric: 2.5 mg (O.5 ml) nebulized with 2.5 ml saline (total of 3 ml)
MONITOR, REPORT, DOCUMENT
Monitor ECG in patients with cardiac history or over age 45
Vital signs within 5 minutes of administration and at completion of treatment
END
DRUG PROFILE
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 11/08
Profile Number: 003
The following is the basic information and guideline for use of:
AMIODARONE
Approved for use
by:
EMT
Advanced EMT
EMTIntermediate
XX - bolus
only
Paramedic
XX
DRUG ACTION:
Antiarrhythmic
INDICATIONS FOR USE:
Ventricular tachycardia, ventricular fibrillation {Intermediate and Paramedic}
Wide complex Atrial Fib/Flutter (ie greater than 160 bpm) {Paramedic only – on line
medical control}
CONTRAINDICATIONS:
Allergy to the drug
Heart block
Bradycardia
Neonates, infants
Known or suspected drug-induced dysrhythmia (e.g. from cocaine)
Cyclic drug usage
SIDE EFFECTS:
Bradycardia
Hypotension
Congestive heart failure
Heart block
SPECIAL NOTES:
Pregnancy category D
USUAL DOSE:
300 mg IVP for ventricular fibrillation or pulseless ventricular tachycardia (may repeat 150mg
IVP once in 3-5 minutes if needed)
150 mg IV bolus over 10 minute period for stable ventricular tachycardia (consider dilution in
250 ml or less of NS and run piggyback IV drip for ease of administration)
1 mg/min drip for maintenance
Pediatric: 5 mg/kg
MONITOR, REPORT, DOCUMENT
Continuous ECG
Vital signs within 5 minutes before and after administration
END
DRUG PROFILE
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 11/08
Profile Number: 004
The following is the basic information and guideline for use of:
ASPIRIN (ACETYLSALICYLIC ACID, ASA)
Approved for use
by:
EMT
XX
Advanced EMT
XX
EMTIntermediate
XX
Paramedic
XX
DRUG ACTION:
Anti-inflammatory
Relieves fever
Impedes blood clotting
INDICATIONS FOR USE
Given to patients with signs/symptoms of ischemic chest pain (suspected myocardial
infarction)
CONTRAINDICATIONS
Allergy to the drug
Bleeding disorders
Affirmative answer to any question in the special note section below.
(Note: Should not be given to children with fever associated with acute viral illness –
Reye’s Syndrome)
SIDE EFFECTS
Nausea
Gastrointestinal bleeding
Rash
Tinnitus
SPECIAL NOTES:
Low doses are more effective for anti-clotting effect
Ask patient:
Have you taken any aspirin already today?
Are you allergic to aspirin?
Do you have any bleeding disorder?
Pregnancy category D
USUAL DOSE
162-324 mg chewable tables (2-4 baby aspirin)
MONITOR, REPORT, DOCUMENT
Vital signs within 5 minutes after administration
END
DRUG PROFILE
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision:: 11/08
Profile Number: 005
The following is the basic information and guideline for use of:
ATROPINE
Approved for use
by:
EMT
Advanced EMT
EMT-Intermediate
XX
Paramedic
XX
DRUG ACTION:
Block the effects of the vagus nerve (blocks parasympathetic nerve)
INDICATIONS FOR USE
Symptomatic bradycardia, heart blocks, asystole (adults), Pulseless electrical activity
with a slow rate
Organophosphate poisoning
CONTRAINDICATIONS
Allergy to the drug
Glaucoma
Heart Blocks with QRS complexes greater than 0.12 mm
SIDE EFFECTS
Palpitations
Tachycardia
Blurred vision
Dry mouth
Elevated blood pressure
SPECIAL NOTES:
Pregnancy category C
USUAL DOSE
Adults: 0.5-1 mg for cardiac; 2-3 mg for organophosphate poisoning
Pediatric: 0.02 mg/kg (for rhythms associated with activities causing increased vagal
tone)
Minimum dose 0.1 mg
MONITOR, REPORT, DOCUMENT
Pulse rate before and after administration
Vital signs within 5 minutes after administration
Continuous ECG
END
DRUG PROFILE
Initial Date: 11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision:: 11/08
Profile Number: 006
The following is the basic information and guideline for use of:
DEXTROSE
Approved for use
by:
EMT
Oral only
Advanced EMT
XX
EMTIntermediate
XX
Paramedic
XX
DRUG ACTION:
Provides calories for metabolic needs
INDICATIONS FOR USE
Hypoglycemia
CONTRAINDICATIONS
Increased intracranial pressure
Alcoholic in delirium tremors
SIDE EFFECTS
Hyperglycemia
SPECIAL NOTES:
Will cause tissue sloughing if infiltrated
Must be diluted before administration to children
Especially in children, IM Glucagon should be considered prior to attempting peripheral IV and IV Dextrose.
Consider Thiamine in malnourished or suspected alcoholics
USUAL DOSE:


In the patient greater than100 pounds with an altered level of consciousness, who is unable to safely take oral glucose
and with a blood glucose level less than 60 mg/dL, administer 25 grams Dextrose IV bolus.
In the patient less than100 pounds but at least 2 years old, Glucagon IM should be considered prior to attempting an
IV and giving Dextrose. If Dextrose is indicated, administer 500 mg/kg (0.5 grams/kg) Dextrose diluted 1:1 with NS.
Draw up the dose calculated into a large syringe and dilute (draw into the same syringe) with an equal volume of NS.
For patients younger than 2 years, contact medical control for appropriate dose and dilution of dextrose (deleted
reference to ml/kg).

In the patient who can safely eat or drink, oral glucose (Glutose) replacement is preferred.
 Instruct patient that the gel must be swallowed
 Allow patient to self-administer gel incrementally or assist with squeezing gel into patient’s mouth incrementally.
 Repeat as necessary until you arrive at the hospital or mental status is normal and blood sugar is equal to or
greater than 80 mg/dL.


If the patient is not responding to oral glucose and blood sugar continues to be low, consider IV dextrose
administration.
For patients in whom an IV cannot be established:
 For patients who weigh more than 44 pounds, administer 1 mg Glucagon IM (see drug profile # 011).
 For pediatric patients (less than 44 pounds) administer 0.5 mg Glucagon IM (See drug profile # 011)
MONITOR, REPORT, DOCUMENT
Changes in level of consciousness
Blood sugar before and after treatment
Vital signs within 5 minutes after administration
Watch carefully for infiltration
END
DRUG PROFILE
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision:: 11/08
Profile Number: 007
The following is the basic information and guideline for use of:
DIAZEPAM (VALIUM)
Approved for use
by:
EMT
Advanced EMT
EMTIntermediate
XX – For
Seizures only
Paramedic
XX
DRUG ACTION:
Central nervous system depressant
Muscle relaxant
INDICATIONS FOR USE
Continuous or recurrent seizures, status epilepticus
Sedation for procedures
CONTRAINDICATIONS
Allergy to the drug
Hypotension
Altered level of consciousness
Intoxication
SIDE EFFECTS
Hypotension
Rash
Respiratory depression
Bradycardia
SPECIAL NOTES:
Controlled substance (federal regulations), addictive
Pregnancy category D
USUAL DOSE
Adult:
2-5 mg IV, (rectally if unable to establish an IV line)
Pediatric:
0.05-0.1 mg/kg IV, maximum of 8 mg.
diazepam
0.5 mg/kg rectally, maximum of 20 mg [Can use an equal dose of Diastat (rectal
gel)]
MONITOR, REPORT, DOCUMENT
Vital signs and respiratory assessment within 5 minutes after administration
Altered level of consciousness
Seizure activity
END
DRUG PROFILE
Last Review/Revision:: 11/08
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Profile Number: 008
The following is the basic information and guideline for use of:
DIPHENHYDRAMINE (BENADRYL)
Approved for use
by:
EMT
Advanced EMT
EMTIntermediate
Paramedic
XX
DRUG ACTION:
Antihistamine, blocks histamine’s effect on smooth muscle in the respiratory, circulatory and
gastrointestinal systems. Histamine causes bronchoconstriction, vasodilation and GI
spasms
INDICATIONS FOR USE
Allergic reactions
CONTRAINDICATIONS
Allergy to drug
Glaucoma
Newborns
SIDE EFFECTS
Drowsiness, confusion
Seizures
Tachycardia
Blurred vision
Nausea, vomiting
SPECIAL NOTES:
Pregnancy category B
USUAL DOSE
12 and older: 25-50 mg IV or PO
Younger than 12 years old: 1.25 mg/kg, maximum of 25 mg IV or PO
MONITOR, REPORT, DOCUMENT
Vital signs within 5 minutes after administration
END
DRUG PROFILE
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 11/08
Profile Number: 009
The following is the basic information and guideline for use of:
EPINEPHRINE (ADRENALIN)
Approved for
use by:
EMTEMT
Advanced EMT
Intermediate
Paramedic
XX (IM 1:1,000)
XX (IM 1:1000) for
XX
XX
for anaphylaxis*
anaphylaxis
*Requires Operational Plan if not using auto-injector
DRUG ACTION:
Increases heart rate and force
Vasoconstriction
Bronchodilation
INDICATIONS FOR USE
Asthma (1:1000 IM) (EMT-Intermediate and Paramedic only)
Anaphylaxis (1:1000 IM)
Patients in cardiopulmonary arrest while CPR is in progress (IV bolus 1:10,000)
(Intermediate and Paramedic only)
CONTRAINDICATIONS
Glaucoma
Shock other than anaphylactic
SIDE EFFECTS
Headache
Palpitations
Hypertension
Tachycardia
SPECIAL NOTES:
Don’t mix with alkaline solutions (sodium bicarbonate)
Epi-Pen = 0.3 mg
Epi-Pen Jr. = 0.15 mg (less than 60 pounds)
Pregnancy category C
USUAL DOSE
IM dose (1:1,000) (1 mg in 1 ml)
0.1-0.3mg 1:1000 for anaphylaxis. For asthma (Intermediate and Paramedic use
only),
May repeat in 5 minutes if no improvement or worsening of condition with medical
control
approval
IV/IO dose (1:10,000) (1 mg in 10 ml) Cardiopulmonary arrest
Adult: 1 mg IV/IO, 2 mg ET
Pediatrics less than 60 pounds:
0.01 mg/kg dose, 0.1 mg/kg ET dose
MONITOR, REPORT, DOCUMENT
Breath sounds, vital signs within 5 minutes after administration
Effect on heart rate
Continuous ECG monitoring
END
DRUG PROFILE
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 11/08
Profile Number: 010
The following is the basic information and guideline for use of:
FUROSEMIDE (LASIX)
Approved for use
by:
EMT
Advanced EMT
EMTIntermediate
XX
Paramedic
XX
DRUG ACTION:
Diuretic
INDICATIONS FOR USE
Not recommended for routine pre-hospital treatment of acute congestive heart
failure/pulmonary edema unless diagnosis of CHF/pulmonary edema confirmed
CONTRAINDICATIONS
Allergy to the drug
Anuria (no urine output, e.g. dialysis patient)
Hypotension (Systolic BP less than 90 mmHg)
SIDE EFFECTS
Hypotension
Rash
SPECIAL NOTES:
Long term use can result in electrolyte imbalance and dehydration
Use with caution in patients with allergy to sulfa drugs
Pregnancy category C
USUAL DOSE
40 mg IV bolus
MONITOR, REPORT, DOCUMENT
Daily maintenance dose
Vital signs, respiratory assessment within 5 minutes after administration
Any urinary output
END
DRUG PROFILE
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/08
Profile Number: 011
The following is the basic information and guideline for use of:
GLUCAGON
Approved for
use by:
EMT
XX **optional**
Advanced EMT
XX
EMTIntermediate
XX
Paramedic
XX
DRUG ACTION:
Raises blood glucose by stimulating liver to release stored glycogen (sugar) and
converting fats and proteins to glucose
INDICATIONS FOR USE
Hypoglycemia
CONTRAINDICATIONS
Allergy to the drug
History of pheochromocytoma (tumor which secretes epinephrine)
SIDE EFFECTS
Hypotension
Nausea, vomiting
Respiratory distress
SPECIAL NOTES:
May be repeated in 20 minutes if no response. IV glucose must be given if patient doesn’t respond to glucagon.
Drug is supplied in a powdered form and must be reconstituted in the solution supplied with the powder.
Patient needs to eat carbohydrates as soon as awake and able to swallow safely.
In the pediatric patient, IM Glucagon should be administered prior to attempting peripheral IV and IV Dextrose.
Pregnancy category B
USUAL DOSE
In the patient who can safely eat or drink, oral glucose replacement is preferred.
Instruct patient that the gel must be swallowed
Allow patient to self-administer gel incrementally or assist with squeezing gel into
patient’s mouth incrementally.
Repeat as necessary until tube content has been consumed.
For patients in whom an IV cannot be established:
For patients who weigh more than 44 pounds, administer 1 mg Glucagon IM.
For pediatric patients (less than 44 pounds) administer 0.5 mg Glucagon IM
Intranasal dosing same as above IM dosing
MONITOR, REPORT, DOCUMENT
Vital signs within 5 minutes after administration
Changes in level of consciousness
Blood sugar before and after administration
END
DRUG PROFILE
Last Review/Revision:: 11/08
Profile Number: 012
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
The following is the basic information and guideline for use of:
LIDOCAINE
Approved for use
by:
EMT
Advanced EMT
EMTIntermediate
XX-bolus only
Paramedic
XX
DRUG ACTION:
Antiarrhythmic (ventricular)
INDICATIONS FOR USE
Ventricular arrhythmias (PVCs, ventricular tachycardia, ventricular fibrillation)
Local and bone marrow anesthetic for placement of IO line
CONTRAINDICATIONS
Allergy to this or other “caine” drug
Heart blocks
SIDE EFFECTS
Seizures
Hypotension
Bradycardia
SPECIAL NOTES:
If allergic to other local anesthetics (e.g. Novocain), contact medical control prior to
administration
Pregnancy category B
USUAL DOSE
1-1.5 mg/kg IV, maximum dose 3 mg/kg
2-4 mg/min maintenance dose
For IO placement:
0.5-1 ml 2% solution infiltrated subcutaneously at IO site
Adult: 20-40 mg (1-2 ml) of 2% Lidocaine IO bolus over one minute
Pediatric: 0.5 mg/kg of 2% Lidocaine IO bolus
Note: 2% Lidocaine = 20 mg/ml
MONITOR, REPORT, DOCUMENT
Continuous ECG
Vital signs within 5 minutes after administration
END
DRUG PROFILE
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision:: 11/08
Profile Number: 013
The following is the basic information and guideline for use of:
MORPHINE SULFATE
Approved for use
by:
EMT
Advanced EMT
EMTIntermediate
XX
Paramedic
XX
DRUG ACTION:
Long acting narcotic analgesic (pain relief)
Central nervous system depressant
INDICATIONS FOR USE
Chest pain of cardiac origin
Burns (moderate to severe pain)
Extremity trauma (moderate to severe pain)
Contact medical control prior to any other use
CONTRAINDICATIONS
Allergy to the drug
Hypotension
Head, chest, abdominal trauma
Respiratory depression
SIDE EFFECTS
Decreased level of consciousness
Bradycardia
Hypotension
Nausea, vomiting
Respiratory depression
SPECIAL NOTES:
Addictive, federal regulations apply
Can be reversed with naloxone (see drug profile 014)
Pregnancy category C (D in long-term use or high dose)
USUAL DOSE
2-5 mg slow IV bolus over 2-3 minutes, may be repeated for severe pain (adult)
0.05 mg/kg (pediatric)
MONITOR, REPORT, DOCUMENT
Effect on pain level
Effect on respiratory rate and effort
Vital signs within 5 minutes after administration
END
DRUG PROFILE
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 11/08
Profile Number: 014
The following is the basic information and guideline for use of:
NALOXONE (NARCAN)
Approved for use
by:
EMT
Advanced EMT
XX
EMTIntermediate
XX
Paramedic
XX
DRUG ACTION:
Reverses narcotic-induced respiratory depression and altered level of consciousness
INDICATIONS FOR USE
Suspected narcotic overdose in patients with altered level of consciousness
CONTRAINDICATIONS
Allergy to the drug
SIDE EFFECTS
Tremors
Tachycardia
Nausea, vomiting
SPECIAL NOTES:
May induce narcotic withdrawal in addicts (Nausea, vomiting, diaphoresis, tachycardia,
hypertension)
Duration of action of naloxone may be shorter than the narcotic and the patient may
relapse
Consider contact of Poison Control (1-800-222-1222).
Pregnancy category C
USUAL DOSE
Adults: 0.4 – 2 mg slow IV, IM, repeated in 2-3 minutes
Pediatric: 0.01 mg/kg first dose; 0.1 mg/kg second and subsequent doses, maximum
dose
2 mg
Intranasal dose same as IV/IM dosing
MONITOR, REPORT, DOCUMENT
Changes in level of consciousness
Vital signs within 5 minutes after administration
END
DRUG PROFILE
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision:: 11/08
Profile Number: 015
The following is the basic information and guideline for use of:
NITROGLYCERIN
Approved for use
by:
EMT
Advanced EMT
XX (Patient
XX
assisted) *
*Requires Operational Plan
EMTIntermediate
XX
Paramedic
XX
DRUG ACTION:
Vasodilator
Decreases venous return
INDICATIONS FOR USE
Chest pain of cardiac origin (ischemic), angina
Acute congestive heart failure
CONTRAINDICATIONS
Hypotension (systolic pressure less than 100 mm/Hg)
Use of sildenafil (Viagra) within the past 24 hours
Use of tadalafil (Cialis) or vardenafil (Levitra) within past 48 hours
SIDE EFFECTS
Headache
Hypotension (systolic pressure less than 100 mm/Hg)
Tachycardia
SPECIAL NOTES:
Drug is sensitive to light and moisture
IV access should be established prior to administration of nitroglycerine unless vital signs are
stable and you are assisting the patient in taking his/her own medication.
Pregnancy category C
USUAL DOSE
Adults: 0.4 mg sublingually, may repeat every 3-5 minutes for 15 minutes. Check with
medical control for additional doses.
MONITOR, REPORT, DOCUMENT
Vital signs and pain assessment within 5 minutes after administration
Blood pressure before and after administration
END
DRUG PROFILE
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision:: 11/08
Profile Number: 016
The following is the basic information and guideline for use of:
PROCAINAMIDE
Approved for use
by:
EMT
Advanced EMT
EMTIntermediate
Paramedic
XX
DRUG ACTION:
Antiarrhythmic
INDICATIONS FOR USE
Ventricular tachycardia, ventricular fibrillation, PVCs
CONTRAINDICATIONS
Allergy to the drug
Heart block
Torsades des pointes
SIDE EFFECTS
Hypotension
Bradycardia
Heart block
Nausea, vomiting
Rash
SPECIAL NOTES:
Monitor the width of the QRS and the blood pressure
Pregnancy category C
USUAL DOSE
Adult: 50-100 mg IV bolus over 5 minute period until:
QRS is 50% wider than at start of medication administration
Maximum dose of 17 mg/kg has been given
Effect on dysrhythmia achieved
Special pediatric considerations: 15 mg/kg over 30-60 minutes only for ventricular
tachycardia
with pulses
MONITOR, REPORT, DOCUMENT
QRS duration
ECG changes
Vital signs before and within 5 minutes after administration
END
DRUG PROFILE
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision:: 11/08
Profile Number: 017
The following is the basic information and guideline for use of:
SODIUM BICARBONATE
Approved for use
by:
EMT
Advanced EMT
EMTIntermediate
DRUG ACTION:
Neutralizes acids
INDICATIONS FOR USE
Treat metabolic acidosis associated with cardiopulmonary arrest
Ventricular dysrhythmias secondary to cyclic antidepressants
CONTRAINDICATIONS
Alkalosis
SIDE EFFECTS
Alkalosis
SPECIAL NOTES:
Must be diluted for neonates
Pregnancy category C
USUAL DOSE
1 mEq/kg
MONITOR, REPORT, DOCUMENT
Changes in level of consciousness
ECG changes
Vital signs within 5 minutes after administration
END
Paramedic
XX
DRUG PROFILE
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 11/08
Profile Number: 018
The following is the basic information and guideline for use of:
AMMONIA INHALANTS
Approved for use
by:
EMT
XX
Advanced EMT
XX
EMTIntermediate
XX
Paramedic
XX
DRUG ACTION:
Olfactory stimulant, reflex respiratory stimulant, elevates blood pressure
INDICATIONS FOR USE
Patient who presents with an altered level of consciousness after other physical causes
have been ruled out.
CONTRAINDICATIONS
Patient is alert and oriented
Medical cause for the altered level of consciousness has been established
SIDE EFFECTS
Irritation of respiratory membranes, pharynx, esophagus
SPECIAL NOTES:
Rule out all medical and traumatic causes for altered level of consciousness before
using ammonia inhalants
DO NOT insert ammonia inhalants into any orifice or place under oxygen mask
May irritate patient
USUAL DOSE
One capsule, broken and waved under the patient’s nose during inhalation
MONITOR, REPORT, DOCUMENT
Change in level of consciousness
Vital signs within 5 minutes after administration
END
DRUG PROFILE
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision:: 11/08
Profile Number: 019
The following is the basic information and guideline for use of:
IPRATROPIUM (ATROVENT)
Approved for use
by:
EMT
XX **
EMTAdvanced EMT
Intermediate
XX
XX
**optional**
Paramedic
XX
DRUG ACTION:
Bronchodilator
INDICATIONS FOR USE
Maintenance therapy in patients with Chronic Obstructive Pulmonary Disease (COPD)
Bronchospasm
CONTRAINDICATIONS
Allergy to the drug, soybeans, peanuts
Glaucoma
SIDE EFFECTS
Dry mouth
Headache
Nausea, vomiting, cramping
Tachycardia
SPECIAL NOTES:
Most often used in combination with or immediately following albuterol
Not recommended to be used alone in acute respiratory distress
May use pre-mixed combination with Albuterol for first adult treatment (ie “Duo-Neb”)
Pregnancy category B
USUAL DOSE
0.5 mg nebulized with 2.5 ml saline (total of 3 ml)
0.25 mg nebulized for children less than 12 years of age
MONITOR, REPORT, DOCUMENT
Monitor ECG in patients with cardiac history or over age 45
Vital signs and breath sounds within 5 minutes of administration and at completion of
treatment
END
DRUG PROFILE
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision:: 11/08
Profile Number: 020
The following is the basic information and guideline for use of:
VASOPRESSIN
Approved for use
by:
EMT
Advanced EMT
EMTIntermediate
XX
Paramedic
XX
DRUG ACTION:
Peripheral vasoconstriction
INDICATIONS FOR USE
Cardiac arrest patients in ventricular fibrillation, pulseless ventricular tachycardia,
asystole or pulseless electrical activity (as an option in place of initial or second dose of
epinephrine)
CONTRAINDICATIONS
Conscious patients with coronary artery disease
Allergy
SIDE EFFECTS
Pallor
Bronchial constriction
Uterine contraction
SPECIAL NOTES:
Vasopressin may be given in place of the 1st or 2nd dose of epinephrine (see drug profile #009)
in the cardiac resuscitation protocol
Pregnancy category C
USUAL DOSE
Adults: 40 Units IV or IO, one dose only
MONITOR, REPORT, DOCUMENT
Electrocardiogram
Vital signs and breath sounds within 5 minutes of administration
END
DRUG PROFILE
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 11/08
Profile Number: 021
The following is the basic information and guideline for use of:
CALCIUM CHLORIDE
Approved for use
by:
EMT
Advanced EMT
EMTIntermediate
Paramedic
XX
DRUG ACTION:
Cardiac stimulant, increases force of contraction
Calcium as an element is required for many physiological activities
INDICATIONS FOR USE
Calcium channel blocker overdose
Elevated potassium (hyperkalemia)
Low calcium (hypocalcemia)
CONTRAINDICATIONS
Patient taking digitalis (Use with caution)
Ventricular tachycardia
Ventricular fibrillation
SIDE EFFECTS
Bradycardia
Arrhythmias
Syncope
Cardiac arrest
SPECIAL NOTES:
Flush line before administering sodium bicarbonate (causes precipitation)
Be sure the IV is not infiltrated, causes tissue sloughing
Pregnancy category C
USUAL DOSE
Adult: 100-500 mg IV bolus
Pediatric: 20 mg/kg, maximum dose 500 mg
MONITOR, REPORT, DOCUMENT
Continuous ECG
Vital signs before and within 5 minutes after administration
END
DRUG PROFILE
Initial Date: 11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 11/08
Profile Number: 022
The following is the basic information and guideline for use of:
THIAMINE
Approved
for use by:
EMT
Advanced EMT
EMTIntermediat
e
Paramedic
XX
DRUG ACTION:
Allows breakdown of Glucose
INDICATIONS FOR USE:
Alcoholic patients and those who are malnourished
CONTRAINDICATIONS:
Allergy to the drug
SIDE EFFECTS: n/a
SPECIAL NOTES:
Helpful prior to administration of glucose in alcoholic or those malnourished
Pregnancy category A
USUAL DOSE:
100 mg IVP
MONITOR, REPORT, DOCUMENT:
Vital signs before and within 5 minutes after administration
END
DRUG PROFILE
Initial Date: 11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 1/05/09 Profile Number: 023
The following is the basic information and guideline for use of:
Midazolam (Versed)
Approved for
use by:
EMT
Advanced EMT
EMTIntermediate
Paramedic
XX
DRUG ACTION:
Central nervous system depressant
INDICATIONS FOR USE:
Sedation for patients prior to intubation and cardioversion
Seizure management
CONTRAINDICATIONS:
Allergy to the drug
hypotension
SIDE EFFECTS:
Hypotension, respiratory depression, bradycardia, disinhibition resulting in agitation
SPECIAL NOTES:
Always have advanced airway equipment ready prior to use. Always preoxygenate prior to
use. Can reverse with Romazicon (see drug profile 025)
Pregnancy category D
USUAL DOSE:
Adults – 2-5 mg
Maximum RSI dose 10 mg.
Seizures: 2-5 mg IV/IM (may repeat in 5 minutes) (Titrate IV bolus dose
to effect)
Pediatrics – 0.05 mg/kg (not to exceed adult dose)
Seizures: 0.05 mg/kg-0.1 mg/kg IV/IM (may repeat in 5 minutes)(Titrate
IV bolus
dose to effect)
Rectal Dose 0.1 mg/kg; maximum total dose 5 mg
Intranasal dose: Same as IV dose
MONITOR, REPORT, DOCUMENT:
Continuous ECG and Oxygen Saturation monitoring.
Vital signs before and within 5 minutes after administration.
END
DRUG PROFILE
Initial Date: 11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 11/08
Profile Number: 024
The following is the basic information and guideline for use of:
DOPAMINE
Approved for
use by:
EMT
Advanced EMT
EMTIntermediate
Paramedic
XX
DRUG ACTION:
Vasoconstriction
Low doses cause renal and mesenteric vasodilation
Increases force of contraction of heart to increase cardiac output
INDICATIONS FOR USE:
Hypotension not associated with hypovolemia
CONTRAINDICATIONS:
Allergy to the drug
Tachydysrhythmia
Ventricular fibrillation
Hypovolemia
SIDE EFFECTS:
Hypertension, tachydysrhythmia (dose related), increased myocardial oxygen demand
SPECIAL NOTES:
If hypotension related to hypovolemia, tachydysrhythmia are very common.
MAO’s may potentiate the effect of Dopamine
Pregnancy category C
USUAL DOSE:
Mix 400 mg in 250 cc of normal saline and titrate for effect
Typical range 5-10 mcg/kg/min
Titrate dose to BP systolic of 100 mmHg
MONITOR, REPORT, DOCUMENT:
Continuous ECG
Vital signs before and within 5 minutes after administration.
END
DRUG PROFILE
Initial Date: 11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 11/08
Profile Number: 025
The following is the basic information and guideline for use of:
Flumazenil (ROMAZICON)
Approved for
use by:
EMT
Advanced EMT
EMTIntermediate
Paramedic
XX
DRUG ACTION:
Reversal of sedative effects of benzodiazepines
INDICATIONS FOR USE:
Known pure benzodiazepine overdose, Versed reversal
To be used only with the approval of on-line medical control
CONTRAINDICATIONS:
Allergy to the drug
Cyclic antidepressant overdose, mixed overdose, dysrhythmias, wide QRS, chronic
benzodiazepine use
SIDE EFFECTS:
Headache, dizziness, dysrhythmias, seizures, vomiting
SPECIAL NOTES:
Used in patients with respiratory failure secondary to pure benzodiazepine overdose.
Not to be used as part of routine unresponsive patient care. Contact medical control
before
administration
Pregnancy category C
USUAL DOSE:
Initial dose 0.2 mg IVP. Repeat dose to max of 1 mg if needed
MONITOR, REPORT, DOCUMENT:
Continuous ECG
Vital signs before and within 5 minutes after administration.
END
DRUG PROFILE
Initial Date:
12/05/2002
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 11/08
Profile Number: 026
The following is the basic information and guideline for use of:
MAGNESIUM SULFATE
Approved for use
by:
EMT
Advanced EMT
EMTIntermediate
Paramedic
XX
DRUG ACTION:
Central nervous system depressant, anticonvulsant, antiarrhythmic, bronchial smooth
muscle relaxant
INDICATIONS FOR USE
Obstetrical: Eclampsia
Cardiovascular: Refractory ventricular fibrillation or pulseless ventricular tachycardia,
torsades
de pointes
Respiratory: Status asthmaticus
CONTRAINDICATIONS
Hypotension
Heart blocks
SIDE EFFECTS
Flushing
Respiratory depression
Drowsiness
Muscle weakness
Nausea, vomiting
SPECIAL NOTES:
Use with caution in patients receiving digitalis
Calcium chloride can be used as an antidote if respiratory depression occurs
Pregnancy Class A
USUAL DOSE:
1-4 grams IV given at a rate of 1 gram/minute
MONITOR, REPORT, DOCUMENT
Vitals signs, respiratory, cardiovascular and neurologic status within 5 minutes of
administration and every 15 minutes thereafter.
END
DRUG PROFILE
Initial Date: 12/05/2002
Profile Number: 027
Last /Review, Revision:
11/08
Service Director’s
Signature
Medical Director’s
Signature
The following is the basic information and guideline for use of:
METHYLPREDNISOLONE (SOLU-MEDROL)
Approved for use
by:
EMT
Advanced EMT
EMTIntermediate
Paramedic
XX
DRUG ACTION:
Adrenal corticosteroid
INDICATIONS FOR USE
Decrease inflammation
Suppress immune reactions (e.g. anaphylaxis)
Spinal cord injuries (new)
CONTRAINDICATIONS
Allergy
Children Less than 2 years of age
Tuberculosis or AIDS
Use with caution in patients with a history of peptic ulcer, congestive heart failure,
liver or kidney disease, diabetes mellitus
SIDE EFFECTS
Insomnia
Heartburn
Mood swings
Delayed wound healing
Increased susceptibility to infection
Hypertension
SPECIAL NOTES:
Provided in a Mix-O-Vial. Follow manufacturer’s recommendations to reconstitute
Pregnancy category C
USUAL DOSE
125 mg (adult)
2 mg/kg (pediatric), maximum dose 125 mg
30 mg/kg over 2-3 minutes for spinal cord injuries
MONITOR, REPORT, DOCUMENT
Continuous ECG
Vital signs before and within 5 minutes after administration
END
DRUG PROFILE
Initial Date: 12/05/2002
Service Director’s
Signature
Last /Review, Revision: 11/08
Profile Number: 028
Medical Director’s
Signature
The following is the basic information and guideline for use of:
METOCLOPRAMIDE (REGLAN)
Approved for use
by:
EMT
Advanced EMT
EMTIntermediate
Paramedic
XX
DRUG ACTION:
Antiemetic, GI stimulant (increases peristalsis)
INDICATIONS FOR USE
Nausea and vomiting (adults)
CONTRAINDICATIONS
Allergy to metoclopromide or procaine/procainamide
History of pheochromocytoma, seizure disorder, kidney or liver failure, Parkinson’s disease, GI
bleeding, bowel obstruction
SIDE EFFECTS
Fatigue
Drowsiness
Dystonic reactions (muscle spasm, fixed postures, strange movement patterns
SPECIAL NOTES:
Diphenhydramine (Benadryl) can be used to treat dystonic reactions
Pregnancy category B
USUAL DOSE
10 mg over 1-2 minutes IV bolus (adults)
MONITOR, REPORT, DOCUMENT
Continuous ECG
Vital signs before and within 5 minutes after administration
END
DRUG PROFILE
Initial Date: 1/5/05
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/08
Profile Number: 029
The following is the basic information and guideline for use of:
ACTIVATED CHARCOAL (WITHOUT SORBITOL)
Approved for
use by
EMT
Advanced EMT
EMTIntermediate
Paramedic
XX
XX
XX
XX
DRUG ACTION:
Absorbs ingested toxins and toxicants
INDICATIONS FOR USE
Suspected orally ingested overdose in patients with normal level of consciousness
CONTRAINDICATIONS
Depressed level of consciousness
Active vomiting
SIDE EFFECTS
Constipation
Nausea, vomiting
Bowel obstruction
Pulmonary aspiration
Corneal abrasions may occur if charcoal inadvertently gets into the eyes
SPECIAL NOTES:
Consider contact with Poison Control Center
Rapid ingestions may invoke vomiting. Be prepared to clear and monitor the patient’s
airway
Container must be shaken thoroughly and frequently during administration.
Continue to assess patient and be prepared to manage airway difficulties.
Pregnancy category D
USUAL DOSE
Adults and children: 1 gram activated charcoal/kg of body weight, administered orally
Usual adult dose: 25-50 grams
Usual child dose: 12.5-25 grams
MONITOR, REPORT, DOCUMENT
Changes in level of consciousness
Vital signs within 5 minutes after administration
END
DRUG PROFILE
Initial Date: 1/1/05
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 11/08
Profile Number: 030
The following is the basic information and guideline for use of:
BUTORPHANOL TARTRATE (STADOL)
Approved for use
by:
EMT
Advanced EMT
EMTIntermediate
DRUG ACTION:
Synthetic narcotic analgesic, central nervous system depressant
INDICATIONS FOR USE
Moderate to severe pain
CONTRAINDICATIONS
Head, chest, abdominal trauma
Allergy to the drug
Undiagnosed abdominal pain
CHF, Myocardial infarction
SIDE EFFECTS
Respiratory depression
Altered level of consciousness
Hypotension
Bradycardia
Nausea/vomiting
SPECIAL NOTES:
May precipitate withdrawal in addicts
Can be reversed with naloxone (Narcan)
Pregnancy category C
USUAL DOSE:
0.5-2 mg slow IV bolus over 2-3 minutes (adults)
MONITOR, REPORT, DOCUMENT
Vital signs, response to medication
END
Paramedic
XX
DRUG PROFILE
Initial Date: 10/30/2004
Last Review/Revision:
11/08
Profile Number: 031
Service Director’s
Signature
Medical Director’s
Signature
The following is the basic information and guideline for use of:
DILTIAZEM (Cardizem)
Approved for use
by:
EMT
Advanced EMT
EMTIntermediate
Paramedic
XX
DRUG ACTION:
Calcium Channel Blocker, Calcium Channel Antagonist
INDICATIONS FOR USE:
Atrial Fibrillation with rapid ventricular rate (greater than 160/minute)
Atrial Flutter with rapid ventricular rate (greater than 160/minute)
Multifocal Atrial Tachycardia with rapid ventricular rate (greater than 160/minute)
Paroxysmal Supraventricular Tachycardia (PSVT) with rapid ventricular rate (greater
than 160/minute)
CONTRAINDICATIONS:
Sick Sinus Syndrome
Second or Third- Degree AV block
Severe Hypotension
Cardiogenic Shock
Atrial Fibrillation or Atrial Flutter associated with WPW syndrome
Use of IV Beta Blockers
Ventricular Tachycardia
Wide-Complex Tachycardia of unknown origin
SIDE EFFECTS
Chest Pain
Bradycardia
Congestive Heart Failure
Syncope
Ventricular Dysrhythmias
First and Second- Degree AV blocks
Nausea and Vomiting
Atrial Flutter
SPECIAL NOTES:
For use with on-line medical control order only (no standing orders)
Pregnancy Safety- Category C (generally considered safe for use during labor)
Use with caution in patients with impaired renal or hepatic function
Hypotension may occasionally result – usually related to rate of delivery
PVC’s may be present on conversion of PSVT to sinus rhythm
Treatment of resultant hypotension: Calcium Chloride (100mg/ml) 2mg/kg IVP (usually
2ml)
USUAL DOSE:
Adult:
Start with 10mg dose IVP over 2 min. Re-evaluate, Repeat if needed
Maximum initial dose = 0.25mg/kg (usual concentration = 25mg/5ml)
Pediatric: Not recommended
MONITOR, REPORT, DOCUMENT
Rhythm strip/12 Lead EKG before administration and after administration
Vital signs within 5 min of administration
Watch for Bradycardia and Hypotension, and any Heart Blocks
END
DRUG PROFILE
Initial Date: 1/1/05
Last /Review, Revision:
11/08
Profile Number: 032
Service Director’s
Signature
Medical Director’s
Signature
The following is the basic information and guideline for use of:
ETOMIDATE (AMIDATE)
Approved for use
by:
EMT
Advanced EMT
EMTIntermediate
Paramedic
XX
DRUG ACTION:
Non-barbiturate hypnotic, sedative
Onset of action within 60 seconds, duration of action 3-5 minutes
INDICATIONS FOR USE
Short acting anesthesia as premedication for endotracheal intubation, cardioversion or
pacing
CONTRAINDICATIONS
Labor, delivery
Allergy to the drug
SIDE EFFECTS
Nausea, vomiting
Hypo- or hypertension
Tachy- or bradycardia, arrhythmias
Respiratory depression
Involuntary muscle movements
SPECIAL NOTES:
Use with caution is elderly patients
Not recommended for pediatric patients
Pregnancy category C, unknown excretion in breast milk
USUAL DOSE
0.2-0.3 mg/kg IV bolus into a free-flowing IV line
Not recommended for children under age 10
MONITOR, REPORT, DOCUMENT
Continuous ECG
Vital signs before and within 5 minutes after administration
END
DRUG PROFILE
Initial Date: 1/1/05
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 11/08
Profile Number: 033
The following is the basic information and guideline for use of:
FENTANYL CITRATE
Approved for use
by:
EMT
Advanced EMT
EMTIntermediate
Paramedic
XX
DRUG ACTION:
Short acting narcotic analgesic
Central Nervous System depressant
INDICATIONS FOR USE
Moderate to Severe pain
Adjunct to rapid sequence intubation (RSI)
CONTRAINDICATIONS
Hypotension (if less than 90mm Hg or greater than 60mm Hg below baseline consider
contacting medical control)
Allergy to the drug
SIDE EFFECTS
Respiratory depression
Dizziness
Altered level of consciousness
Bradycardia
SPECIAL NOTES:
Can be reversed with naloxone
Use with caution in patients with respiratory, liver or kidney disease, seizure disorder
Protect from light
USUAL DOSE:
Titrate to effect
25-100 micrograms slow IV over 2-3 minutes (adult)
1 mcg/kg slow IV over 2-3 minutes (pediatric moderate to severe pain)
Contact medical control for additional dosing
Intranasal dosing same as IV dosing
MONITOR, REPORT, DOCUMENT
Vital signs, response to medication
END
DRUG PROFILE
Initial Date: 1/1/05
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/08
Profile Number: 034
The following is the basic information and guideline for use of:
HYDROMORPHONE (DILAUDID)
Approved for use
by:
EMT
Advanced EMT
EMTIntermediate
Paramedic
XX
DRUG ACTION:
Long acting narcotic analgesic, central nervous system depressant
INDICATIONS FOR USE
Moderate to severe pain
CONTRAINDICATIONS
Allergy to the drug
Head, chest, abdominal trauma
Undiagnosed abdominal pain
SIDE EFFECTS
Headache
Hypotension
Bradycardia
Respiratory depression
Nausea/vomiting
SPECIAL NOTES:
Addictive
Can be reversed with naloxone
Can precipitate seizures in patients with convulsive disorders
Use with caution in patients with respiratory disease/depression
Pregnancy category C
USUAL DOSE:
0.5 - 1 mg slow IV bolus over 2-3 minutes (1 mg hydromorphone is equivalent to 7.5
mg morphine)
Not recommended for pediatric patients
MONITOR, REPORT, DOCUMENT
Vital signs, response to medication
END
DRUG PROFILE
Initial Date: 1/1/05
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 11/08
Profile Number: 035
The following is the basic information and guideline for use of:
KETOROLAC (TORADOL)
Approved for
use by:
EMT
Advanced EMT
EMTIntermediate
Paramedic
XX
DRUG ACTION:
Nonsteroid anti-inflammatory, analgesic, antipyretic
INDICATIONS FOR USE
Mild to moderate pain
CONTRAINDICATIONS
Allergy to NSAIDS or aspirin
Possibility of surgery in near future (increases bleeding)
Head injuries
Renal insufficiency
SIDE EFFECTS
Gastrointestinal irritation
Edema
Hypertension
Dizzy
SPECIAL NOTES:
Pregnancy category C
USUAL DOSE:
Adult: 30 mg IV, 60 mg IM
Geriatric, known renal failure: 15 mg IV, 30 mg IM
MONITOR, REPORT, DOCUMENT
Vital signs, response to medication
END
DRUG PROFILE
Initial Date:
10/30/2004
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/08
Profile Number: 036
The following is the basic information and guideline for use of:
LORAZEPAM (ATIVAN)
Approved for use
by:
EMT
Advanced EMT
DRUG ACTION:
Sedative, anticonvulsant (benzodiazepine)
INDICATIONS FOR USE
Seizures
Status epilepticus
Premedication for cardioversion
Sedation
Chemical restraint
CONTRAINDICATIONS
Allergy to the drug
Glaucoma
SIDE EFFECTS
Hypotension
Amnesia
Respiratory depression
Nausea, vomiting
SPECIAL NOTES:
Can be reversed with flumazenil
Can be given rectally if IV access is not available
Short shelf life if not refrigerated
Pregnancy category D
USUAL DOSE:
0.5-2 mg IV bolus (adult)
0.05 – 0.1 mg/kg (pediatric)
MONITOR, REPORT, DOCUMENT
Vital signs, response to medication
END
EMTIntermediate
XX – for
seizures only
Paramedic
XX
DRUG PROFILE
Initial Date: 1/5/05
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 11/08
Profile Number: 037
The following is the basic information and guideline for use of:
MEPERIDINE (DEMEROL)
Approved for use
by:
EMT
Advanced EMT
EMTIntermediate
DRUG ACTION:
Narcotic analgesic, central nervous system depressant
INDICATIONS FOR USE
Moderate to severe pain
CONTRAINDICATIONS
Allergy to the drug
Head, chest or abdominal trauma
Undiagnosed abdominal pain
MAO inhibitors
SIDE EFFECTS
Respiratory depression
Nausea, vomiting
Abdominal cramps
Blurred vision
Pinpoint pupils
Altered level of consciousness, hallucinations
SPECIAL NOTES:
Addictive
Can be reversed with naloxone
Pregnancy category B (D at term)
USUAL DOSE:
25-50 mg IV
MONITOR, REPORT, DOCUMENT
Vital signs, response to medication
END
Paramedic
XX
DRUG PROFILE
Initial Date: 1/1/05
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 11/08
Profile Number: 038
The following is the basic information and guideline for use of:
NALBUPHINE (NUBAIN)
Approved for use
by:
EMT
Advanced EMT
DRUG ACTION:
Synthetic narcotic analgesic
INDICATIONS FOR USE
Moderate to severe pain
CONTRAINDICATIONS
Allergy to the drug
Head, chest or abdominal trauma
Undiagnosed abdominal pain
SIDE EFFECTS
Respiratory depression
Headache
Hypotension
Bradycardia
Nausea, vomiting
Blurred vision
Altered level of consciousness
SPECIAL NOTES:
May precipitate withdrawal in addicts
Can be reversed with naloxone (see drug profile 014)
Pregnancy category C
USUAL DOSE:
2-5 mg IV
MONITOR, REPORT, DOCUMENT
Vital signs, response to medication
END
EMTIntermediate
Paramedic
XX
DRUG PROFILE
Initial Date: 1/1/05
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 11/08
Profile Number: 039
The following is the basic information and guideline for use of:
NITROUS OXIDE*
*Currently under pilot project study for use in 9-1-1 services
Approved for use
by:
EMT
Advanced EMT
EMTIntermediate
Paramedic
XX *
DRUG ACTION:
Analgesic and anesthetic gas, central nervous system depressant
INDICATIONS FOR USE
Moderate to severe pain
Reduction of anxiety, particularly in pediatric patients
CONTRAINDICATIONS
Allergy to the drug
Head, chest or abdominal trauma
Unable to follow simple directions
Pneumothorax
Abdominal distention/bowel obstruction
Altered level of consciousness or unable to understand instructions
Decompression sickness (bends)
SIDE EFFECTS
Dizzy
Nausea, vomiting
Altered level of consciousness
Hallucinations
SPECIAL NOTES:
Self administered by inhalation
Mixed 50:50 with oxygen
Inhalation is associated with spontaneous abortion (consideration for both patient and
rescuer
who may be pregnant)
Be sure the driver and patient compartments are well ventilation
USUAL DOSE:
Inhalation until pain is relieved or patient drops mask
MONITOR, REPORT, DOCUMENT
Vital signs, response to medication
END
DRUG PROFILE
Initial Date:
10/30/2004
Service Director’s
Last Review/Revision:
11/08
Profile Number: 040
Signature
Medical Director’s
Signature
The following is the basic information and guideline for use of:
PROMETHAZINE (Phenergan)
Approved for use
by:
EMT
Advanced EMT
EMTIntermediate
Paramedic
XX
DRUG ACTION:
Antihistamine, Antiemetic
INDICATIONS FOR USE:
Nausea and Vomiting
Motion sickness
CONTRAINDICATIONS:
Allergy to the drug
Comatose states
Patients with history of dystonic reactions (Excessive muscle tone, muscle spasm and
postural abnormalities after taking certain medications)
Seizure disorders
Hypotension
Current bronchospasm secondary to asthma or COPD
Concomitant use of other anticholinergic drugs (Atropine, Monoamine Oxidase
Inhibitors, etc.)
Patient with history of Neuroleptic Malignant Syndrome (NMS)
Patients who are CNS depressed (alcohol, barbiturates, narcotics)
Children with unknown etiology for vomiting
SIDE EFFECTS
Sedation & Respiratory depression
May impair mental and physical ability
Allergic reaction
Dysrhythmias (tachycardia. bradycardia)
Blurred vision (dilated pupils)
Dystonic reactions (muscle spasm, fixed postures, strange movement patterns)
Lower seizure threshold
SPECIAL NOTES:
Use with caution in patients who are using other sedating medications
Use precaution in patients with asthma, peptic ulcer, and bone marrow depression
IM injection is the preferred route (take care to avoid intra-arterial injection)
Dystonic reactions can be treated with Diphenhydramine (Benadryl) 25-50mg IVP
Pregnancy Safety - Category C (generally considered safe for use during labor) (? Breast
milk)
USUAL DOSE:
Adult: 12.5 – 25mg IM
Pediatric: 0.5 – 1mg/kg IM, Not for younger than 2 y/o
MONITOR, REPORT, DOCUMENT
Vital signs within 5 min of administration, Altered LOC, Drowsiness, Dysrhythmias,
effectiveness
END
DRUG PROFILE
Initial Date: 1/1/05
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 11/08
Profile Number: 041
The following is the basic information and guideline for use of:
SUCCINYLCHOLINE
Approved for use
by:
EMT
Advanced EMT
EMTIntermediate
EMTParamedic
XX
DRUG ACTION:
Depolarizing neuromuscular blocker, onset of action 60-90 seconds, duration 4-5
minutes
INDICATIONS FOR USE
Skeletal muscle paralytic used to facilitate endotracheal intubation
CONTRAINDICATIONS
Allergy to the drug
Penetrating eye injuries
Narrow angle glaucoma
History of malignant hyperthermia
SIDE EFFECTS
Muscle fasciculations
Wheezing
Respiratory depression
Apnea
Arrhythmias (bradycardia, sinus arrest)
Hypertension or hypotension
Increased intraocular pressure
Increased intracranial pressure
SPECIAL NOTES:
Should not be administered unless personnel are confident they will be able to intubate
An alternative airway should be immediately available in case you are unable to intubate.
Lidocaine, beta blockers, magnesium sulfate and other neuromuscular blockers enhance
the
blocking action
Paralytic action does not affect the level of consciousness or pain sensation, patients
receiving the drug must also receive sedation
Paralysis starts in the eyelids and jaw, progresses to extremities, abdomen and finally
diaphragm and intercostals
Pregnancy category C
USUAL DOSE:
1-1.5 mg/kg IV
MONITOR, REPORT, DOCUMENT
Vital signs, pulse oximetry, respiratory and cardiovascular status
END
DRUG PROFILE
Initial Date: 1/1/05
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 1/1/09
Profile Number: 042
The following is the basic information and guideline for use of:
VECURONIUM
Approved for use
by:
EMT
Advanced EMT
EMTIntermediate
Paramedic
XX
DRUG ACTION:
Nondepolarizing neuromuscular blocker, paralysis of muscle fibers
INDICATIONS FOR USE
Muscle relaxation to facilitate endotracheal intubation when succinylcholine is
contraindicated
To extend period of paralysis after intubation with succinylcholine
CONTRAINDICATIONS
Allergy to the drug
SIDE EFFECTS
Wheezing
Respiratory depression
Apnea
Arrhythmias (bradycardia, sinus arrest)
Hypertension or hypotension
Increased intraocular pressure
Increased intracranial pressure
SPECIAL NOTES:
Should not be administered unless personnel are confident they will be able to intubate
An alternative airway should be immediately available in case you are unable to intubate
Lidocaine, beta blockers, magnesium sulfate and other neuromuscular blockers enhance
the
blocking action
Paralytic action does not affect the level of consciousness nor pain sensation, patients
receiving the drug must also receive sedation
Pregnancy category C
USUAL DOSE:
0.08-0.1 mg/kg IV
Onset of paralysis in 1 minutes, lasts 25-30 minutes
MONITOR, REPORT, DOCUMENT
Vital signs, pulse oximetry, respiratory and cardiovascular status
END
DRUG PROFILE
Initial Date: 1/1/05
Last Review/Revision: 11/08
Profile Number:
043
Service Director’s
Signature
Medical Director’s
Signature
The following is the basic information and guideline for use of:
MARK-1 AUTO-INJECTORS (aka DuoDote®)
EMTApproved for
EMT
Advanced EMT
Intermediate
use by
XX
XX
XX *
Paramedic
XX
*Requires Operational Plan
DRUG ACTION:
Reverses toxic effects of chemical nerve agents (Sarin, Soman, Tabun, VX) or
organophosphates (pesticides) in Weapons of Mass Destruction situations
INDICATIONS FOR USE
Mark 1 kit use is strictly intended for personal protection. Mark 1 auto-injectors may be
used if signs and symptoms of poisoning by one of the above agents is present or if
known exposure has occurred prior to signs or symptoms.
CONTRAINDICATIONS
Allergy to atropine or pralidoxime
SIDE EFFECTS
Atropine: blurred vision, increased blood pressure, palpitations, tachycardia
Pralidoxime: Tachycardia, nausea, vomiting, visual disturbances, hypertension
SPECIAL NOTES:
Mark 1 kits may be self-administered or administered by another EMT
Immediately evacuate the contaminated area.
If dermal (skin) exposure has occurred, decontamination is critical and should be done
with standard decontamination procedures.
Consider request for ALS transport or intercept. Intermediate(99) and Paramedic level
providers carry Atropine as one of their standard medications. Continued prehospital treatment with Atropine is essential to survival.
Mark-1 kits are not intended for treatment of patients. Mark-1 kits are for “rescue” of
EMS
providers.
HazMat or Disaster stockpile Mark-1 kits may be used to treat any victim per local
HazMat
guidelines.
USUAL DOSE
Adult EMS personnel: 1 atropine auto-injector, followed by 1 pralidoxime autoinjector (Note: Mark 1 kits are now marked as DuoDote® and contain both
medications in a single syringe)
MONITOR, REPORT, DOCUMENT
Respiratory rate and quality of respirations
Changes in level of consciousness
Vital signs within 5 minutes after administration
Decontamination procedures
END
DRUG PROFILE
Initial Date:
08/23/06
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision:: 11/08
Profile Number: 044
The following is the basic information and guideline for use of:
ONDANSETRON HYDROCHLORIDE (ZOFRAN)
Approved for use
by:
EMT
Advanced EMT
EMTIntermediate
Paramedic
XX
DRUG ACTION:
Antiemetic
INDICATIONS FOR USE
Nausea and vomiting
CONTRAINDICATIONS
Known hypersensitivity to the drug
Use with caution in patients on Selective Serotonin Reuptake Inhibitors (SSRIs: i.e.
Paxil, etc),
Those on multiple SSRIs, or those who may have overdosed on a SSRI medication
SIDE EFFECTS
Headache
Constipation
Sensation of flushing or warmth
SPECIAL NOTES:
Zofran is not effective in preventing motion-induced nausea and vomiting
Pregnancy category B
USUAL DOSE:
4 mg slow IV bolus (adults) over greater than 30 seconds
0.1 slow mg/kg IV bolus for patient less than 40 kg (pediatric)
4 mg slow IV bolus for patient greater than 40 kg (pediatric)
MONITOR, REPORT, DOCUMENT
Continuous ECG
Vital Signs before and within 5 minutes after administration
END
DRUG PROFILE
Initial Date:
08/23/06
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision:: 11/08
Profile Number: 045
The following is the basic information and guideline for use of:
NITROGLYCERIN DRIP
Approved for use
by:
EMT
Advanced EMT
EMTIntermediate
EMTParamedic
XX
DRUG ACTION:
Vasodilator
Decreased venous return
INDICATIONS FOR USE
Chest pain of cardiac origin (ischemic), angina unrelieved with at least three sublingual
nitroglycerin sprays/tablets
Acute Congestive Heart Failure/Pulmonary Edema requiring careful blood pressure
control
Angina with systolic blood pressures less than120 but greater than 100 who may not
tolerate sublingual administration
Angina with right ventricular myocardial infarction who may not tolerate larger doses
of nitrates
CONTRAINDICATIONS
Hypotension (systolic pressure less than100 mmHg)
Use of sildenafil (Viagra) within the past 24 hours
Use of tadalafil (Cialis), vardenafil (Levitra) within the past 48 hours
SIDE EFFECTS
Headache
Hypotension (systolic pressure less than100 mmHg)
Tachycardia
Use with caution in patients with inferior AMI
SPECIAL NOTES:
Drug is sensitive to light and moisture
Medication is stored in a glass bottle
Medication must be administered with approved nitroglycerin IV tubing
Medication must be administered with infusion pump to ensure precise flow rates
Pregnancy Category C
USUAL DOSE:
Adults:
Infusion 50 mg in 250 ml (200 micrograms per ml)
Angina: Start infusion rate of 3-6 ml/hour (10-20 micrograms/min) and increase this
infusion rate by 3-6 ml/hour (10-20 micrograms/min) every 3-5 minutes up to a rate of
12 ml/hour is reached (40 micrograms)
If systolic blood pressure drops quickly, is below 90 mmHg, or patient becomes
hemodynamically unstable, decrease drip rate or stop administration accordingly.
If chest pain/discomfort is relieved and blood pressure is stable, maintain current drip
rate.
If higher doses are needed, contact medical control
Hypertensive emergencies with CHF/pulmonary edema: Blood pressure greater than
180/100, start infusion at 12 ml/hour (40 micrograms/min) and contact medical control
NITROGLYCERIN DRIP 50 mg in 250 ml
Dose mcg/min
Flow rate ml/hr
10
3
15
4.5
20
6
25
7.5
30
9
35
10.5
40
12
45
13.5
50
15
55
16.5
60
18
65
19.5
MONITOR, REPORT, DOCUMENT
Continuous ECG
Vital Signs and pain assessment every 3-5 minutes during administration
Blood pressure before and after increases in medication dose
END
70
21
75
22.5
80
24
DRUG PROFILE
Initial Date:
8/23/06
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 11/08
Profile Number: 046
The following is the basic information and guideline for use of:
LEVALBUTEROL HYDROCHLORIDE (XOPENEX)
Approved for use
by:
EMT
Advanced EMT
EMTIntermediate
Paramedic
XX
DRUG ACTION:
Bronchodilator
INDICATIONS FOR USE
Treat or prevent bronchospasms of bronchial asthma
CONTRAINDICATIONS
Hypersensitivity to the drug or to albuterol
Children less than 6 years of age unless specific physician prescription
Women who are breast feeding
SIDE EFFECTS
Headache
Dizziness
Tremors
Tachycardia
SPECIAL NOTES:
Use with caution in patients with cardiovascular disease, seizure disorders or diabetes
mellitus
Pregnancy category C
USUAL DOSE
Adult: 0.63 – 1.25 mg by nebulizer
Pediatrics (6-11 years old): 0.31 mg by nebulizer
MONITOR, REPORT, DOCUMENT
Vital signs before and within 5 minutes of administration
Breath sounds and respiratory effort
Monitor ECG in adults over 40 years of age or with cardiac history
END
DRUG PROFILE
Initial Date:
9/28/06
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 11/08
Profile Number: 047
The following is the basic information and guideline for use of:
ZIPRASIDONE HYDROCHLORIDE (GEODON)
Approved for use
by:
EMT
Advanced EMT
EMTIntermediate
Paramedic
XX
DRUG ACTION:
Antipsychotic
INDICATIONS FOR USE
Patients suspected to be experiencing excited delirium
CONTRAINDICATIONS
Hypersensitivity to Geodon
Known history of : QT prolongation, Acute MI (within 3 months), Uncompensated Heart
failure
Known current use of other agents that prolong QT (ie. Sotalol, Quinidine, Risperidone,
Haloperidol, etc.. )
Known history of Neuroleptic Malignant Syndrome or Tardive Dyskinesia
Known current use of other agents that cause dystonia (ie. Compazine, Phenergan,
Reglan, etc. )
Bradycardia or heart block
SIDE EFFECTS
Orthostatic Hypotension, Seizures, Hyperthermia
SPECIAL NOTES:
Consider 10mg dosage for those greater than 65 years of age or those less then 120
pounds
Pregnancy category C
Onset time 10-20 min.
Should be avoided in patients known to be currently (within last 3 days) using Geodon
When used with benzodiazepines may cause significant hypotension and respiratory
depression
May precipitate extrapyramidal or dystonic reaction
USUAL DOSE
Adult (post puberty): 10 – 20 mg IM (not approved IV)
Reconstitute vial with 1.2ml of Sterile Water (20mg / ml)
Pediatric: Not approved
MONITOR, REPORT, DOCUMENT
Continuous ECG and Oxygen Saturation monitoring as soon as practical
Closely monitor airway and manage/support accordingly
Vital signs and behavior before if possible and every 5 minutes after administration if
possible.
Document details demonstrating high likelihood of excited delirium
END
DRUG PROFILE
Initial Date:
8/23/06
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 11/08
Profile Number: 048
The following is the basic information and guideline for use of:
PROPOFOL (DIPRIVAN)*
*For Interfacility Services with Approved Training Plan and competency components
Approved for use
EMTby:
EMT
Advanced EMT
Intermediate
Paramedic
XX *
DRUG ACTION:
Rapid acting hypnotic
Decreases vascular resistance
INDICATIONS FOR USE
Sedation
Induction and maintenance of anesthesia
CONTRAINDICATIONS
Increased intracranial pressure
Impaired cerebral circulation
Children less than 3 years of age
SIDE EFFECTS
Involuntary muscle movements
Apnea (common during induction
Hypotension
Nausea and vomiting
Burning/stinging at the IV site
SPECIAL NOTES:
Rapid onset (40 sec), lasts 3-12 hours
Lower dose for elderly
Use with caution in the debilitated, those with cardiovascular, respiratory or renal disease
Rapid administration produced severe hypotension and respiratory depression
Pregnancy category B
USUAL DOSE
5 micrograms/kg/min for 5 minutes until peak effect reached
MONITOR, REPORT, DOCUMENT
Vital signs before administration and every 3-5 minutes during administration
END
DRUG PROFILE
Initial Date:
3/28/07
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Profile Number: 049
The following is the basic information and guideline for use of:
Metoprolol (Lopressor)
Approved for use
by:
EMT
Advanced EMT
EMTIntermediate
EMTParamedic
XX
DRUG ACTION:
Beta-adrenergic blocker (predominately cardioselective – Beta 1)
INDICATIONS FOR USE
Acute Coronary Syndrome (ST Elevation MI – STEMI)
Rare pre-hospital use (only with specific on-line medical control): Narrow complex
SVT, A Fib with RVR, Hypertension
CONTRAINDICATIONS
Bradycardia (HR less then 50)
AV Blocks (except 1st degree)
Hypotension (BPs less then 100 mmHg)
Acute CHF
COPD
Asthma
Concurrent allergic reaction from any cause
Raynaud’s disease
Cocaine use
Known allergy
SIDE EFFECTS
Bradycardia, hypotension, precipitation or exacerbation of CHF, peripheral vasospasm,
Bronchial Spasm
SPECIAL NOTES:
Use caution in patients with inferior wall MI (prone to bradycardia and hypotension)
It is not unusual to increase time between doses if concern for bradycardia or hypotension
Not an ideal beta-blocker for treatment of hypertension
Any administration of Metoprolol requires on-line medical control
USUAL DOSE
Preparation: 1mg/ml in 5 ml syringe
Adults: 5mg slow IV push – Dose may be repeated every 5 minutes to max of 15mg
total infused (it is very uncommon for more then 2 doses to be administered in
the prehospital setting)
MONITOR, REPORT, DOCUMENT
Continuous ECG monitoring
Vital signs every 5 minutes after administration and between doses.
Be sure to include as part of verbal and written report
DRUG PROFILE
Initial Date:
1/5/09
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision:
Profile Number: 050
The following is the basic information and guideline for use of:
KETAMINE (KETALAR, KETANEST, KETASET)
Approved for use
by:
EMT
Advanced EMT
EMTIntermediate
EMTParamedic
XX
DRUG ACTION:
Dissociative anaesthetic with hypnotic, analgesic and amnesic effects, stimulates central
nervous system,
INDICATIONS FOR USE
1) Sedation of a violent individual, particularly after “Taser” use to subdue the person
(suspected excited delirium) {Recognize off label use – can not be routinely supported as
general practice}
2) Pain management for extremely painful condition that will not be effectively treated
with opiates (ie. Entrapment and crush with need for rapid extrication)
3) Sedative / induction agent for asthmatic requiring intubation
CONTRAINDICATIONS
1) Head injury (increases intracranial pressure) {current research indicates drug may be
safe in head injury but study numbers are small – need larger studies to change
practice – use with head injury is considered off label and can not be routinely
supported}
2) Allergy to medication
SIDE EFFECTS
Tachycardia
Hypertension
Decreased level of consciousness
Respiratory depression, short period of apnea following administration if administered IV
rapidly
Hallucinations (as drug is wearing off)
Salivation
SPECIAL NOTES:
Medical control contact required for on line orders
Psychological dependence common, illicit use common, Schedule III drug
Pregnancy : Category D
USUAL DOSE
1-1.5 mg/kg IVP
3-5 mg/kg IM
MONITOR, REPORT, DOCUMENT
END
DRUG PROFILE
Initial Date:
1/05/09
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision:
Profile Number: 051
The following is the basic information and guideline for use of:
Enalapril (Vasotec)
Approved for use
by:
EMT
Advanced EMT
EMTIntermediate
EMTParamedic
XX
DRUG ACTION:
Angiotension Converting Enzyme Inhibitor (ACE inhibitor)
INDICATIONS FOR USE
1) Hypertensive emergency (ie. BPs greater than 180, BPd greater than 110) with CHF /
Pulmonary Edema
CONTRAINDICATIONS
1)
2)
3)
4)
5)
Allergy to med or class of drug
Previous problem with cough or tongue/lip swelling with “some blood pressure med”
Angioedema history
Pregnancy
Normal tensive or Hypotension patients
SIDE EFFECTS
Hyperkalemia (chronic use)
Renal failure (chronic use)
SPECIAL NOTES:
Medical control contact required for on line orders
Third line agent and should not be considered until NTG and CPAP have been used
Pregnancy category : D
USUAL DOSE
0.625 – 1.25mg IVP
MONITOR, REPORT, DOCUMENT
END
DRUG PROFILE
Initial Date: 12/1/08
Service Director’s
Signature
Last Review/Revision:
Profile Number: 052
Medical Director’s
Signature
The following is the basic information and guideline for use of:
Hydroxocobalamin (Cyanokit)
Approved for use
by:
EMT
EMT Intermediate
Technician
EMTIntermediate
EMTParamedic
xx
DRUG ACTION:
Hydroxocobalamin binds to cyanide molecules and is converted to
cyanocobalamin, which is
then eliminated from the body in the urine.
INDICATIONS FOR USE
Known or suspected cyanide poisoning. To be administered only after
consultation with
medical control.
CONTRAINDICATIONS
Known allergy to hydroxocobalamin.
SIDE EFFECTS
Elevated blood pressure.
Headache.
Nausea and vomiting.
Infusion site reaction, generalized rash and or ‘flushing’ reaction.
Potential for anaphylactic type reactions.
SPECIAL NOTES:
Hydroxocobalamin is incompatible for administration in the same IV with numerous
medications,
including dopamine, dobutamine, fentanyl, and nitroglycerine. Initiate a
second IV exclusively for administration of hydroxocobalamin.
Hydroxocobalamin interferes with numerous laboratory tests. If possible, draw a ‘rainbow’ of
blood tubes prior to administration to facilitate further evaluation of the patient upon arrival to the
ED (1 dark green, 1 mint green, 2 lavender, 1 gold top, and 1 blue top).
USUAL DOSE
Cyanokit contains:
Two 250 ml glass vials, each containing 2.5 grams hydroxocobalamin for
injection.
Two sterile transfer spikes.
One sterile IV infusion set.
One quick use reference guide.
One package insert.
Diluent (normal saline) is not included.
Once reconstituted in normal saline, hydroxocobalamin must be stored at a
temperature above
freezing and less than 104F and discarded if not used within 6
hours.
Adult Administration of Hydroxocobalamin
Starting adult dose: Two 2.5 g vials (5 g) diluted in 200 ml normal saline (100 ml per 2.5 g
vial), administered by IV infusion over 15 minutes.
Depending upon severity of poisoning and clinical response, a second dose of 5 g may be
administered for a total dose of 10 g.** The rate of the infusion for the second dose may range
from 15 minutes (for patients in extremis) to 120 minutes depending on the patient’s condition.
Pediatric Administration of Hydroxocobalamin
Starting pediatric dose: 70 mg/kg dose over 15 minutes. Prepare 2.5 g ampule in 100 ml
normal saline. This results in solution containing 25 mg/ml.*
Depending upon severity of poisoning and clinical response, a second dose of 70 mg/kg may
be administered for a total dose of 140 mg/kg.** The rate of the infusion for the second dose
may range from 15 minutes (for patients in extremis) to 120 minutes depending on the patient’s
condition.
*Example: 10 kg child would receive 70 mg/kg x 10kg = 700mg dose.
700 mg dose / (25 mg / ml of solution) = 28 ml dose administered over 15 minutes.
**Example: If after administration of first dose, the patient has severe persistent symptoms,
such as ongoing seizures or coma, or hypotension (BP <100 systolic in adult), contact medical
control for consideration of administration of second dose of hydroxocobalamin.
MONITOR, REPORT, DOCUMENT
Initiate continuous cardiac and pulse oximetry monitoring.
Vital signs every 10 to 15 minutes.
Report and document any adverse reactions or significant change in patient clinical status,
or, significant deviations in vital signs or cardiac rhythm.
END
Blank
II
GUIDELINE/STANDARD OF CARE
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 101
The following content will be considered the Guideline/Standard of care for:
ASSESSMENT PARAMETERS
The following parameters will be assessed by the EMT and the presence or absence of findings
documented on the EMT run report:
RESPIRATORY SYSTEM
Parameters
Respiratory rate
Chest wall movement
Lung/breath sounds
Presence of signs of dyspnea
Descriptive terms
30 seconds X2 (15 seconds X4 if regular)
Deep, shallow, normal
Clear, wet, decreased, absent, wheeze, congested
Retractions, nasal flaring, grunting, stridor,
drooling, pursed lip breathing, length of word
strings
Adult patients:
The patient in MODERATE
The patient in SEVERE respiratory
respiratory distress will exhibit any of distress will exhibit any of the
the following:
following:
Respiratory rate greater than 28
Respiratory rate less than8 or greater than
36
Able to speak in full sentences
Unable to speak in full sentences
Good aeration into bases of lung fields
Poor aeration into bases of lung fields
Presence of retractions
Presence of retractions
Use of accessory muscles
Use of accessory muscles
Nasal flaring
Pediatric patients less than1 year
The pediatric patient less than 1 year
The pediatric patient less than 1 year
old in MODERATE respiratory
old in SEVERE respiratory distress
distress will exhibit any of the
will exhibit any of the following:
following:
Respiratory rate 50-60
Respiratory rate less than20 or greater
than 60
Retractions
Retractions
Good aeration in lung bases
Poor aeration in lung bases
Able to cry
Nasal flaring
Grunting
Cyanosis
Pediatric patients 1-2 year
The pediatric patient 1-2 years old in
The pediatric patient 1-2 years old in
MODERATE respiratory distress will SEVERE respiratory distress will
exhibit any of the following:
exhibit any of the following:
Respiratory rate 40-50
Respiratory rate less than20 or greater
than 50
Retractions
Retractions
FairGood aeration in lung bases
Poor aeration in lung bases
Grunting
Cyanosis
Assessment parameters (cont)
Pediatric patients 2-5 years
The pediatric patient 2-5 years old The pediatric patient 2-5 years old in
in MODERATE respiratory
SEVERE respiratory distress will exhibit
distress will exhibit any of the
any of the following:
following:
Respiratory rate 40-50
Respiratory rate less than20 or greater than 40
Retractions
Retractions
Fair  Good aeration in lung bases
Poor aeration in lung bases
Able to talk
Unable to speak
Cyanosis
Drooling
Pediatric patients 6-8 years
The pediatric patient 6-8 years old The pediatric patient 6-8 years old in
in MODERATE respiratory
SEVERE respiratory distress will exhibit
distress will exhibit any of the
any of the following:
following:
Respiratory rate 40-50
Respiratory rate less than12 or greater than 36
Retractions
Retractions
Fair  Good aeration in lung bases
Poor aeration in lung bases
Able to talk
Unable to speak
Cyanosis
Drooling
Pediatric patients greater than 8 years
The pediatric patient greater than The pediatric patient greater than 8 years
8 years old in MODERATE
old in SEVERE respiratory distress will
respiratory distress will exhibit
exhibit any of the following:
any of the following:
Respiratory rate 40-50
Respiratory rate less than8 or greater than 40
Retractions
Retractions
FairGood aeration in lung bases
Poor aeration in lung bases
Able to talk
Unable to speak
Cyanosis
Drooling
CARDIOVASCULAR SYSTEM
Parameters
Presence of heart tones
Presence and location of pulses
Blood pressure
Electrocardiogram
Jugular vein distention (JVD)
Capillary Refill Time (CRT)
Skin temperature and color
Hydration status
Descriptive terms
Present, absent, muffled
Full, weak, regular, irregular, absent
Systolic, diastolic, palpated, orthostatic
Monitoring and 12 leads as needed
Distended, flat
In seconds
Normal, hot, cool, diaphoretic, pale, flushed,
cyanotic, jaundice
Dehydrated, normal
Presence and location of edema
(next page)
Pitting edema will mean indentation into the
tissue can be made with a finger and the “pit”
is still visible after the finger is removed
Assessment parameters (cont)
NERVOUS SYSTEM
Parameters
Level of consciousness
Document with specific
descriptions of the patient’s response to
verbal or painful stimuli
Pupils
Peripheral circulation, sensation,
movement
Descriptive terms
Alert, oriented X3, altered, coma, ability
to follow directions
Initial and subsequent assessments of
the level of pain should be made after
each intervention intended to alter the
level and at such other times as deemed
necessary by the EMT.
Attempt to quantify the intensity of pain
by asking the patient to “rate” it on a scale
of 0 to 10 with 10 being the worst pain
ever experienced. Subsequent assessment
of the degree of pain should also be made
on the 0 to 10 scale so increases and
decreases in perceived pain can be
assessed.
PERL, reactive, size (mid, dilated, pin)
Present, absent, numbness, weakness,
paralysis
PAIN
MUSCULOSKELETAL SYSTEM
Parameters
Range of motion
Peripheral circulation, sensation,
movement
Signs of injury
Skin color and temperature
Swelling
Descriptive terms
Specific motions
Present, absent, numbness, weakness,
paralysis, color
Deformity, crepitus, soft tissue injury
Normal, hot, cool, pale, flushed, cyanotic
Location and description
ABDOMEN
Parameters
Associated symptoms
Elimination patterns
Presence of signs of pathology
REPRODUCTIVE SYSTEM (female)
GYNECOLOGICAL
Vaginal bleeding, discharge (amount,
odor, color)
Last menstrual period (LMP)
Obstetrical history (number of
pregnancies, live births, etc.)
Previous surgery/problems
Descriptive terms
Nausea, vomiting, guarding
Urination, defecation
Guarding, hematemesis, melena,
distention, rigidity, bruise, penetrating
trauma, scars
OBSTETRICAL
Prenatal care
Contractions (frequency, intensity)
Crowning
Complications
Hypertension, toxemia
Bleeding
Chronic medical conditions:
Cardiovascular
Diabetes
END
GUIDELINE/STANDARD OF CARE
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 102
The following content will be considered the Guideline/Standard of care for
DOCUMENTATION
Documentation




Initial assessment findings and any subsequent changes in the patient’s condition will be
documented on the EMS run report
Any deviation from any Guideline/Standards for Care will be documented on the EMS run
report.
All pertinent information obtained will be documented in the appropriate section of the EMS
run report.
A patient care report must be completed for all patients assessed by the prehospital team.
Acceptable charting abbreviations: SEE NEXT THREE PAGES
33
__
a
AAA
Aneurysm
Abd
ACLS
Support
AED
Defibrillator
AG
AHA
AICD
Defibrillator
AIDS
Syndrome
ALS
AMA
AMI
amp
amt
ant
approx
ARC
ASA
(Aspirin)
ASAP
ASHD
Disease
BBB
Bilat
Bld
Bld/s
BLS
34
BP
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
BS
Cervical Immobilizer Device
Chloride
Centimeter
Circulation, Movement,
59
CID
Cl
cm
CMS
Sensation
CNS
CO
CO2
60
C/O
Complaining Of
61
COPD
Pulmonary
CP
CPR
Resuscitation
CRT
C-section
C-spine
CSF
CSM
Movement
CVA
CVP
D&C
D/C
dec
d/c
DKA
DOA
DOE
DM
DNR
D/T
Dx
EBL
ECG
ED
e.g.
ECG
epi
ET
ETA
ETOH
eval
exam
exc.
F
f
FB
freq
Fx
GFC
Chronic Obstructive
Disease
Chest Pain
Cardiopulmonary
52
Before
(Triple A) Abdominal Aortic
53
54
55
Abdomen
Advanced Cardiac Life
56
57
58
Automatic External
Administrative Guideline
American Heart Association
Automatic Implanted Cardiac
62
63
64
Acquired Immune Deficiency
65
66
Advanced Life Support
Against Medical Advice
Acute Myocardial Infarction
Ampule
Amount
Anterior
Approximately
Aids Related Complex
Acetylsalicylic Acid
67
68
69
70
71
72
73
74
75
76
As Soon As Possible
Arteriosclerotic Heart
77
78
79
Bundle Branch Block
Bilateral
Blood
Blood Sugar
Basic Life Support
80
Blood Pressure
85
Breath
Sounds,
Blood
Sugar, Bowel Sound
BSA37
Body Surface Area
BSI38
Body Substance Isolation
BVM
39
Bag Valve Mask
40 c
With
41 C
Centigrade
42 CA
Cancer, Carcinoma
43 CABG
Coronary Artery Bypass
44 Graft
45 CAD
Coronary Artery Disease
46 card
Cardiac
47 cath
Catheter
48 cc
Cubic Centimeter
49 CC
Chief Complaint
50 Chemo
Chemotherapy
51 CHF
Congestive Heart Failure
81
82
83
84
35
86
36
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
Central Nervous System
Carbon Monoxide
Carbon Dioxide
Capillary Refill Time
Cesarean Section
Cervical Spine
Cerebral Spinal Fluid
Circulation, Sensation and
Cerebral Vascular Accident
Central Venous Pressure
Dilatation and Curettage
Discontinue
Decrease
Discontinue
Diabetic Ketoacidosis
Dead On Arrival
Dyspnea on Exertion
Diabetes Mellitus
Do Not Resuscitate
Due To
Diagnosis
Estimated Blood Loss
Electrocardiograph
Emergency Department
For Example
Electrocardiogram
Epinephrine
Endotracheal
Estimated Time of Arrival
Alcohol
Evaluation
Examination
Except
Fahrenheit
Female
Foreign Body
Frequency
Fracture
Guideline for Care
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
GI
gm
GPS
GSW
gtts
GYN
HA
Heent
HepA
HepB
HepC
HHN
HIV
Virus
HOH
H&P
Examination
HPI
hr
HR
HTN
Hx
ICU
IM
IN
incr.
Inf.
Inj
Int.
IO
IV
JVD
KED
Kg
Lt.
LA
lac.
lat.
lb.
LCTA
L&D
LLQ
LL
L/min
LMP
LOC
loc
LPM
LUQ
L-spine
m
Gastrointestinal
Gram
Guideline for Practical Skill
Gun Shot Wound
Drops
Gynecology
Headache
Head, Eye, Ear, Nose, Throat
Hepatitis A (or HAV)
Hepatitis B (or HBV)
Hepatitis C (or HCV)
Hand Held Nebulizer
Human Immunodeficiency
52
53
54
55
56
57
58
59
60
61
62
63
64
65
Hard of Hearing
History and Physical
66
67
68
History of the Present Illness
Hour
Heart Rate
Hypertension
History
Intensive Care Unit
Intramuscular
Intranasal
Increasing
Inferior
Injury
Internal
Intraosseous
Intravenous
Jugular Vein Distention
Kendrick Extrication Device
Kilogram
Left
Left Arm
Laceration
Lateral
Pound
Lungs Clear to Auscultation
Labor and Delivery
Left Lower Quadrant
Left Leg
Liters per Minute
Last Menstrual Period
Level of Consciousness
Loss of Consciousness
Liters per Minute
Left Upper Quadrant
Lumbar Spine
Male
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
M
Meter
MAST
Medical Anti-Shock Trousers
max
Maximum
mcg
Microgram
MCC
Motorcycle Crash
MCI
Mass Casualty Incident
MD
Medical Doctor
mg
Milligram
MG
Medical Guideline
MI
Myocardial Infarction
min
Minute
misc
Miscellaneous
ml
Milliliter
mm
Millimeter
mmHG
Millimeters of Mercury
mod
Moderate
MOI
Mechanism of Injury
mos.
Months
MVA
Motor Vehicle Accident
MVC
Motor Vehicle Crash
N/A
Not Applicable
NAD
No Acute Distress
NC
Nasal Cannula
neg.
Negative
NG
Nasogastric
NKA
No Known Allergies
NKDA
No Known Drug Allergies
no.
Number
NPO
Nothing by Mouth
NS
Normal Saline
NSR
Normal Sinus Rhythm
NTG
Nitroglycerin
N&V
Nausea and Vomiting
occ.
Occasional
orientx3
Oriented to Time, Place,
Person
os
Mouth
oz
Ounce
p
After
P
Pulse
PAC
Premature Atrial Complex
palp
Palpation
PASG
Pneumatic Anti-Shock
Garment
PE
Physical Examination,
Pulmonary Emboli
PERL
Pupils Equal, React to Light
PERRL
Pupils Equal, Round, React
to Light
PJC
Premature Junctional
Complex
Private (Personal) Medical
43
PMD
Doctor
PMH
PNB
PND
Dyspnea
po
POC
pos
poss
PRN
pt.
prox
PTA
PVC
Complex
q.
R
Rt
RA
re
resp
RL
RLQ
R/O
RR
RUQ
Rx
s
SIDS
Syndrome
sig.
SL
SOB
SOC
SpO2
SQ
SubQ
S/Sx
stat
STD
Sx
Sz
44
Temp
Temperature
45
TB
TBSA
TIA
TKO
Tx
unk
URI
Tuberculosis
Total Body Surface Area
Transient Ischemic Attack
To Keep Open
Transport
Unknown
Upper Respiratory Infection
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
46
47
48
49
50
51
52
53
Past Medical History
Pulseless Non-Breather
Paroxysmal Nocturnal
54
55
56
57
By Mouth (orally)
Position of Comfort
Positive
Possible
As Necessary
Patient
Proximal
Prior to Arrival
Premature Ventricular
Every
Respirations
Right
Right Arm
Regarding
Respiratory
Right Leg
Right Lower Quadrant
Rule Out
Respiratory Rate
Right Upper Quadrant
Treatment
Without
Sudden Infant Death
Significant
Sublingual
Shortness of Breath
Standard of Care
Pulse Oximetry
Subcutaneous
Subcutaneous
Signs and Symptoms
Immediately
Sexually Transmitted Disease
Symptom
Seizure
58
UTI
VF
VS
w/
WNL
w/o
y/o
Urinary Tract Infection
Ventricular Fibrillation
Vital Signs
With
Within Normal Limits
Wide Open, Without
Year Old
SYMBOLS





∆





Less than
Greater than
Approximately
Increased
Decreased
Change
Positive
Negative
Therefore
Psychiatric
Equal
59
60
61
62
63
64
65
66
67
68
69
70
71
1
GUIDELINE/STANDARD OF CARE
2
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 103
3
4
The following content will be considered the Guideline/Standard of care for:
5
HISTORY AND PHYSICAL EXAMINATION
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
History and physical assessment will include:
 Assure scene safety and observe universal precautions. (see guideline 107)
 Obtain general impression of the patient and conduct initial assessment of the mental status,
airway, breathing and circulation.
 Determine Nature of Illness or Mechanism of Injury
 Determine number of patients.
 Consider the need for manual cervical spinal stabilization.
 Determine the need for and request additional resources.
 Introduction of self and other members of the team to the patient and significant others in the
environment as appropriate.
 The EMT who will ultimately complete the patient care report will obtain the history.
 The patient/historian is encouraged to describe the situation is his/her own words.
 A general assessment of the scene will be included.
 The history of the present illness (HPI) will include: (OPQRST)

Chief complaint - why did the patient/family request help at this time?

Onset, origin – What were you doing when the problem started?

Provokes – What makes the problem worse? Better?

Quality – What does it feel like? Describe the feeling, pain, etc.

Region/Radiation – Where is the problem located? Do you have pain or discomfort
anywhere else?

Severity – On a scale of 0 to 10, with 0 being none and 10 being the worst, what number
would you give your symptom, pain.

Time/Treatment – When did it start? How long have you had it? Is it there all the time
or does it come and go? Has the patient done any interventions prior to EMS arrival?

Are there any other associated symptoms?
 The past medical history (PMH) will include: (SAMPLE)

Signs and symptoms

Allergies

Medications

Past medical history

Last meal or oral intake

Events before the emergency
 The physical assessment will include:

Mental status (alert, oriented, altered level of consciousness [LOC], coma) using AVPU
scale.

Vital signs (respirations, pulse, blood pressure).

Breath sounds (clear, wet, decrease, absent, wheeze, congested).

ECG (unless monitoring would interfere with patient care--e.g. multiple trauma victim).
1
2
3
4
5
6
7
8
9
10
11
Pupil size and reaction (equal, reactive, midrange, dilated, pinpoint).

Skin color and temperature (Normal, hot, cool, diaphoretic, pale, flushed, cyanotic,
jaundice).

Generalized complaints (weakness, nausea, vomiting, fever, dizziness, numbness,
paralysis).
 Focused assessment (head, neck, chest, abdomen, back, extremities)—Deformities,
Contusions, Abrasions, Penetrations, Burns, Tenderness, Lacerations, Swelling (DCAPBTLS)
 Establish working assessment.
(next page)

1
History and Physical Examination (cont.)
2
3

4
5

Supporting information and/or clarification is documented in the narrative section of the run
report.
Document reason for any deviation from the Guidelines for Care.
6
7
Vital signs:
8
9
10
11
12
13
14
All patients under the care of the EMS team will have a repeat assessment and complete set
of vital signs (respirations, pulse, blood pressure, level of consciousness) obtained and
recorded at least every 15 minutes for a stable patient, every 5 minutes for an unstable
patient.
 Vital signs will be recorded within 5 minutes after the administration of any medication.
END

15
16
17
18
19
Note: State of Wisconsin Standards and Procedures of Practical Skill Manual (July 2008
Rev) is appended and contains additional information on this topic. See index for page
numbers.
GUIDELINE/STANDARD OF CARE
1
2
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 104
3
4
The following content will be considered the Guideline/Standard of care for
5
MEDICATION ADMINISTRATION
6
7
8
The following will be the Guideline/Standard for Care for patients receiving medications in the
prehospital environment:
9
10

11

12

13

14
15

16

17
18

19

20
21
22
23
24

Assure scene safety and observe universal precautions. (See guideline # 107))
Document any medication taken by the patient prior to the arrival of the EMT unit.
Document any known allergies to medications or food.
Obtain initial vital signs, repeat within 5 minutes after the administration of a medication and
at a minimum of 15 minute intervals thereafter.
Record and monitor the electrocardiogram. (see guideline # 3009)
Obtain venous access if necessary. (see guideline # 3002) (For example, pediatric asthmatic who
will receive only nebulized medication may not need an IV access).
Apply appropriate medical guideline/procedure based on the working assessment.
Any medication order that differs from the following usual dose should be questioned or
discussed with the base station physician prior to administration.
For patients less than16 years of age, the pediatric dose for the medication must be
calculated. Contact medical control to ascertain and/or confirm dose and volume to be
administered if there are any questions or concerns.
MEDICATION
Activated
Charcoal (without
Sorbitol)
Adenosine
USUAL ADULT DOSE
25-50 grams
USUAL PEDS DOSE
12.5-25 grams
1st dose-6 mg rapid IV
2nd dose-12 mg rapid IV
3rd dose-12 mg rapid IV
Albuterol
2.5 mg (0.5 ml) nebulized with
2.5 ml saline (total of 3 ml)
1st dose-0.1 mg/kg, maximum 6
mg
2nd dose-0.2 mg/kg, maximum
12 mg
Same as adult
Amiodarone
Atrovent
(Ipratropium)
300 ml for ventricular
fibrillation or pulseless
ventricular tachycardia
150 mg IV bolus over 10
minute period for stable
ventricular tachycardia
1 mg/min drip for maintenance
162-324 mg chewable tablets
0.5-1 mg IV/IO
2 mg ET
2-5 mg IV for symptoms of
organophosphate poison
Max dose 0.04 mg/kg
Minimum dose 0.1 mg
0.5 mg nebulized in 2.5 ml
normal saline
Butorphanol
Tartrate (Stadol)
Calcium
0.5-2 mg IV bolus over 2-3
minutes
100-500 mg IV bolus
Dextrose
25 grams IV bolus
Aspirin
Atropine
5 mg/kg IV/IO
0.02 mg/kg IV/IO
0.1 mg minimum dose
1 mg maximum dose
0.25mg nebulized in 2.5 ml
normal saline for patients less
than 12 years of age
20 mg/kg to a maximum of 500
mg per dose
500 mg/kg (1 ml/kg) to a
MONITOR, REPORT, DOCUMENT
Changes in level of consciousness, Vital signs
within 5 minutes after administration, Poison
control contact
Continuous ECG
Attempt to capture conversion on ECG paper
Vital signs within 5 minutes after administration
Patients with cardiac history or over the age of
45 will have ECG monitoring during
administration,
Vital signs and respiratory assessment within 5
minutes of administration and at completion of
treatment
Continuous ECG
Vital signs within 5 minutes after administration
Vital signs within 5 minutes after administration
Heart rate before/after administration
Blood pressure within 5 minutes of
administration
ECG changes
Vital signs and breath sounds within 5 minutes
of administration
ECG changes
Vital signs within 5 minutes after administration
Response to medication
Effect on cardiac rhythm
Watch carefully for infiltration
Vital signs within 5 minutes after administration
Changes in level of consciousness
Diltiazem
(Cardizem)
10 mg IV over 2 minutes,
repeat as needed, maximum
initial dose 0.25 mg/kg
maximum of 25 grams/dose
Dilute 1:1 with D5W for pediatric
patients less than6 years
Not recommended
Repeat blood sugar measurement
Watch carefully for infiltration
Vital signs within 5 minutes after administration
Rhythm strip/12 lead ECG before and after
administration, Vital signs within 5 minutes after
administration, Observe for bradycardia,
hypotension, heart blocks
MEDICATION
Diphenhydramine
(Benadryl)
USUAL ADULT DOSE
25-50 mg IV or PO
USUAL PEDS DOSE
less than12 years old – 1.25
mg/kg IV or PO
Maximum of 25 mg
5-10 micrograms/kg/min
IV drip premixed bag
5-10 micrograms/kg/
minute IV drip
MONITOR, REPORT, DOCUMENT
Vital signs and respiratory assessment within 5
minutes after administration
Vital signs within 5 minutes of starting drip and
every 10 minutes minimum after patient
stabilized
ECG changes
Watch carefully for infiltration
1:1000
1st dose IV/IO: 0.01 mg/kg of
Breath sounds and vital signs within 5 minutes
Epinephrine
1:1000-1 mg in 1
0.1-0.3 mg IM
1:10,000
of administration
ml vial
1:10,000
ET: 0.1 mg/kg of 1:1000
Effect on heart rate
1:10,000-1 mg
1 mg IV/IO bolus
IM dose 0.1-0.3 mg 1:1000
ECG changes
in 10 ml prefilled
2 mg ET
Vital signs within 5 minutes after administration
0.2=0.3 mg/kg IV bolus into a
Continuous ECG, Vital signs within 5 minutes
Etomidate
free-flowing IV line
after administration
(Amidate)
Titrate to effect
1 mcg/kg slow IV/IN over 2-3
Vital signs within 5 minutes after administration,
Fentanyl
25-100 micrograms slow
minutes)
response to medication
Citrate
IV/IN over 2-3 minutes
20-100 mg IV bolus
2 mg/kg
Daily maintenance dose of Lasix
Furosemide
Maximum 6 mg/kg
Vital signs and respiratory assessment within 5
(Lasix)
minutes of administration
Any urinary output
1 mg IM/IN (greater than 44
0.5 mg IM/IN (less than 44 lbs.)
Vital signs within 5 minutes after administration
Glucagon
lbs.)
Change in level of consciousness
Blood sugar measurement
0.5-1
mg
slow
IV
bolus
over
2Vital signs within 5 minutes after administration,
Hydromorphone
3 minutes
response to medication
(Dilaudid)
30 mg IV, 60 mg IM
0.5 mg/kg
Vital signs within 5 minutes after administration,
Ketorolac
Geriatric” 15mg IV, 30 mg IM
response to medication
(Toradol)
Vital signs within 5 minutes after administration,
Ketamine
1-1.5 mg/kg IVP
response to medication
(Ketalar, Ketanest, 3-5 mg/kg IM
Ketaset)
0.63-1.25 mg by nebulizer
(6-11 years old) 0.31 mg by
Vital signs within 5 minutes after administration,
Levalbuterol
nebulizer
response to medication
(Xopenex)
Dopamine
Lidocaine
1-1.5 mg/kg IV/IO bolus/ET
Drip: 200 mg in 100 ml D5W
run at 2-4 mg/min
Maximum 3 mg/kg IV bolus
For IO placement: 0.5-1 ml
2% solution infiltrated
subcutaneously at site, the 2040 mg (1-2 ml) IO bolus over 1
minute
Under 10 kg: 0.5 mg/kg
10 kg and heavier:
1 mg/kg
For IO placement: 0.5-1 ml 2%
solution infiltrated
subcutaneously at site, the 0.5
mg/kg IO bolus over 1 minute
ECG changes
Vital signs within 5 minutes of administration
MEDICATION
Lorazepam
(Ativan)
Magnesium
Sulfate
USUAL ADULT DOSE
0.5-2 mg IV bolus
Meperidine
(Demerol)
Methylprednisolon
e
(Solu-Medrol)
25-50 mg IV over 2-3 minutes
1-4 grams IV bolus at a rate of
1 gram/minute
Metoclopramide
(Reglan)
125 mg (adult)
2 mg/kg (peds) to max of 125
mg
30 mg/kg over 2-3 minutes IV
bolus (spinal injuries)
10 mg over 1-2 minutes IV
bolus
Morphine
2-5 mg IV bolus
Nalbuphine
(Nubain)
Naloxone
(Narcan)
2-5 mg IV over 2-3 minutes
Nitroglycerin
0.4 mg sublingually
Nitrodrip:
10-20 micrograms/min titrated
for angina
40 micrograms/min for
hypertensive emergency
50:50% mix with oxygen, self
administered by patient by
inhalation
4 mg slow IV bolus over
Nitrous Oxide
Ondansetron
USUAL PEDS DOSE
0.05-0.1 mg/kg
0.4-2 mg IV/IN bolus, ET, IM
0.05 mg/kg
0.01 mg/kg first dose,
0.1 mg/kg second and subsequent
doses, maximum dose 2 mg
IV,IM,IN, ET
N/A
MONITOR, REPORT, DOCUMENT
Vital signs within 5 minutes after administration,
response to medication
Continuous ECG
Vital signs before and within 5 minutes after
administration
Vital signs within 5 minutes after administration,
response to medication
Continuous ECG
Vital signs before and within 5 minutes after
administration
Continuous ECG
Vital signs before and within 5 minutes after
administration
Effect on pain level
Effect on respiratory rate and effort
Vital signs and respiratory assessment within 5
minutes of administration
Vital signs within 5 minutes after administration,
response to medication
Change in level of consciousness after
administration
Vital signs within 5 minutes after administration
Blood pressure prior to administration
Vital signs and pain assessment within 5 minutes
of administration
Vital signs within 5 minutes after administration,
response to medication
0.1 mg/kg slow IV bolus for
Continuous ECG
Hydrochloride
(Zofran)
greater than 30 seconds
Procainamide
(Pronestyl)
50-100 mg IV bolus over 5
minute period, maximum dose
17 mg/kg
patients less than40 kg
4 mg slow IV bolus for patient
greater than 40kg
15 mg/kg over 30-60 minutes
(only for V Tach with pulses)
Vital signs within 5 minutes after administration,
response to medication
Monitor ECG and QRS duration
Vital signs within 5 minutes after administration
MEDICATION
Promethazine
(Phenergan)
USUAL ADULT DOSE
12.5-25 mg IV or IM (IM
preferred route)
Propofol
(Diprivan)
Romazicon
(Flumazenil)
Sodium
Bicarbonate
5 mcg/kg/min for 5 minutes
until peak effect is reached
0.2 mg IV bolus, Repeat to
maximum of 1 mg if needed
1 mEq/kg IV bolus
Succinylcholine
1-1.5 mg/kg IV
Thiamine
Valium
(diazepam)
100 mg IV bolus
5 mg IV bolus, ET, rectally
Vasotec(Enalapril)
0.625 – 1.25mg IVP
Vasopressin
40 units IV or IO, one dose
only
Vecuronium
0.08-0.1 mg/kg
Versed
(Midazolam)
2-4 mg IV/IM/IN bolus slowly. 0.05 mg/kg IV/IM/IN
Repeat every 3 minutes
titrating to desired effect.
Maximum RSI dose 10 mg
10-20 mg IM
Ziprasidone
(Geodon)
Pregnancy categories:
A = No risk demonstrated to the fetus in any trimester
USUAL PEDS DOSE
MONITOR, REPORT, DOCUMENT
0.5-1 mg/kg IV or IM, not for less Vital signs within 5 minutes after administration,
than2 years old, IM preferred
response to medication
route
1 mEq/kg
Dilute for infants 5 kg and
smaller 1:1 with D5W or NS
0.25 mg/kg
Maximum dose 10 mg
Continuous ECG
Vital signs within 5 minutes
Effect on level of consciousness and ECG
changes if given in tricyclic overdose
Vital signs within 5 minutes after administration
Vital signs, pulse oximetry, respiratory and
cardiovascular status
Vital signs and respiratory assessment within 5
minutes of administration
Effect on level of consciousness and seizure
activity
Continuous ECG
Vital signs within 5 minutes after administration,
response to medication
ECG
Vital signs and breath sounds within 5 minutes
of administration
Vital signs, pulse oximetry, respiratory and
cardiovascular status
Continuous ECG
Oxygen saturation
Vital signs within 5 minutes
Vital signs within 5 minutes after administration,
response to medication
B = No adverse effects in animals, no human studies available
C = Only given after risks to the fetus are considered, animal studies have shown adverse reactions, no human studies available
D = Definite fetal risks, may be given in spite of risks if needed in life-threatening conditions
X = Absolute fetal abnormalities, not to be used anytime during pregnancy
GUIDELINE/STANDARD OF CARE
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
S
ignature
Last Review/Revision: 12/18/08
Guideline Number: 105
The following content will be considered the Guideline/Standard of care for
OXYGEN ADMINISTRATION
Oxygen Administration







Assure scene safety and observe universal precautions. (see guideline # 107)
If the equipment is immediately available, obtain baseline pulse oximetry (SPO2) prior to
starting oxygen
Administration devices:

Nasal cannula - 1-6 liter/minute delivering 25-40% concentration

Non-rebreather mask - 12-15 liter/min delivering 90+% concentration (appropriate flow
to keep the reservoir bag inflated).

Bag-valve device with oxygen reservoir - maximum flow rate for 100% concentration
Flow rates:

Patients with a history of chronic obstructive pulmonary disease (COPD) should receive
oxygen at a rate of 2 L/min above their customary amount. Level of consciousness,
respiratory rate and effort must be carefully monitored and the flow rate adjusted
accordingly. Patients in severe distress should receive high flow oxygen.

Patients who complain of chest pain should receive oxygen at a minimum of 4 L/min
during initial evaluations and have flow rates increased if symptoms persist.

Patients with oral or nasopharyngeal airways in place should receive supplemental
oxygen at no less than 4 L/min. Patients with altered levels on consciousness who
require airway adjuncts may require higher flow rates.

Patients who are assessed in moderate respiratory distress should receive oxygen at a
minimum of 6 L/min.

Patients who are assessed in severe respiratory distress should receive oxygen at 12-15
L/min.

Patients who are hypotensive secondary to trauma or who are assessed to have lost a
significant amount of blood should receive oxygen at 10-15 L/min.

Patients who are intubated should be ventilated with a bag-valve device with oxygen
reservoir attachment in use (100%).

Patients in cardiopulmonary arrest should be ventilated with a bag-valve device with
100% oxygen reservoir attachment in use.

Resuscitated cardiac arrest victims should be ventilated with a bag-valve device with
100% oxygen reservoir attachment in use.
Document patient’s response to oxygen therapy, including subsequent pulse oximetry (SPO2)
Document any changes in the flow rate or delivery device for oxygen.
The base physician may order a change in the flow rate and delivery system.
Frequently assess and document the respiratory and circulatory systems when oxygen is in
use for a patient.
 Document reasons for any deviation from the above Guideline for Care.
END

GUIDELINE/STANDARD OF CARE
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 106
The following content will be considered the Guideline/Standard of care for
ROUTINE MEDICAL CARE
The routine medical care of a patient requesting/requiring the services of the Emergency Medical
Services System will include the following:
General Intervention:
Assure scene safety and observe universal precautions. (see guideline # 107)
Allow patient to assume position of comfort unless contraindicated by injuries or other
medical condition.
 Assure clear airway (see guideline # 101,201) consider potential cervical spine injury during airway
maneuvers.
 Determine the degree of respiratory distress (none/mild/moderate/severe).
 Administer supplemental oxygen with a device and at a rate appropriate for the condition of
the patient. (see guideline # 105)
 Assure adequate respiratory exchange, ventilate with supplemental oxygen in those patients
with inadequate or absent respirations, consider intubation (see guideline # 2002-2009)
 Assess for adequate circulation to perfuse the vital organs, Begin CPR as needed.
 Stop all obvious hemorrhage, splint major fractures (see guideline # 5001, 5003-5010).
 Complete the history and physical assessment. (see guideline # 103, 1001)
 Establish the working assessment(s).
 Obtain initial vital signs and repeat at a minimum of 15 minute intervals for a stable patient,
every 5 minutes for an unstable patient. (see guideline # 1002)
 Obtain intravenous access. (see guideline # 3002-3004)
 Monitor the electrocardiogram (see guideline # 3009).
 Consider 12 lead ECG for all patients with chest pain (see guideline # 3008)
 Apply appropriate medical guidelines.
 Contact the base station physician for medical orders as necessary.
 Provide appropriate medical care as ordered.
 Transport to the closest, most appropriate hospital.
 Complete a patient care report, documenting assessment and care (see guideline # 102).
 Document reasons for deviation from the Guideline for Care.
END


Note: State of Wisconsin Standards and Procedures of Practical Skills Manual (July
2008 Rev) is appended and contains step-by-step instructions for: Patient Movement:
Blanket drag, clothes drag, direct carry, direct ground lift, draw sheet move, extremity
lift, one rescuer drag, stair chair, stand and pivot, straddle slide. Consult the index for
page numbers.
GUIDELINE/STANDARD OF CARE
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 107
The following content will be considered the Guideline/Standard of care for
UNIVERSAL PRECAUTIONS
Universal precautions will be observed during all patient contacts.
Personal protective equipment



“Gloves will be worn when it can be reasonably anticipated that the employee may have
hand contact with blood, other potentially infectious materials, mucous membranes, and nonintact skin; when performing vascular access procedures and when handling or touching
contaminated items or surfaces.”*
“Masks in combination with eye protection devices, such as goggles or glasses with solid
side shields, or chin-length face shields, shall be worn whenever splashes, spray, spatter or
droplets of blood or other potentially infectious materials may be generated and eye, nose, or
mouth contamination can be reasonable anticipated.”*
“Appropriate protective clothing such as, but not limited to, gowns, aprons, lab coats, clinic
jackets, or similar outer garments shall be worn in occupational exposure situations. The
type and characteristics will depend upon the task and degree of exposure anticipated.”*
Hand washing:
Hands will be cleaned with a waterless hand sanitizer at the scene of an alarm and washed in
water with antiseptic (e.g. Hibiclens®, pHisoHex) soap at the first opportunity.
Cleaning/disinfection:
“All equipment and environmental and working surfaces shall be cleaned and decontaminated
after contact with blood or other potentially infectious materials.”*


Inanimate surfaces are to be washed with a germicidal agent (quaternary ammonium
compound e.g. SaniMasterIII, Hi-Tor), a Phenolic compound (e.g. Matar, SaniMaster
Phenolic, Amphyl 2%,) or sodium hypochlorite (bleach) solution (mix every 24 hours)
following label directions.
Equipment coming into contact with the patient’s mucous membranes should be disinfected
according to label instructions with a glutaraldehyde (e.g. Cidex, Sonacide) or 70% isopropyl
alcohol and rinsed with water before using again.
Contaminated equipment/objects:
”Contaminated sharps shall be discarded immediately or as soon as feasible in containers that
are: closable, puncture resistant, leak-proof on sides and bottom and labeled or color
coded...”*
(next page)

Universal Precautions (cont.)


Recapping of contaminated needles should not be done if safe receptacle is immediately
available. If recapping at the scene must be done, it should be accomplished by placing the
needle cap on a surface and “scooping” the cap with the needle, keeping hands away from
the contaminated needle tip.
Clothing or linen contaminated with blood or body fluid (heavy enough saturation so the
fluid can be squeezed out, drip off, poured off or flaked off after drying) must be placed in a
leak-proof bags for transport to the point of decontamination.
Tuberculosis or Meningitis:

When emergency medical response personnel or others must transport, in a closed vehicle, an
individual with suspected or confirmed tuberculosis or meningitis, those personnel in the
patient compartment of the vehicle must wear a high efficiency particulate air (HEPA)
respirator. A simple face mask is not acceptable for EMS personnel but should be placed on
the patient if it does not compromise airway monitoring.
All suspected exposures to potentially communicable diseases must be reported to the
appropriate supervisor.
*CDC, MMWR, June 24, 1988, Vol 37, No 24: Update: Universal Precautions for Prevention of Transmission of Human
Immunodeficiency Virus, Hepatitis B Virus and Other Bloodborne Pathogens in Health-Care Settings.
END
GUIDELINE/STANDARD OF CARE
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 108
The following content will be considered the Guideline/Standard of care for the patient needing:
PHYSICAL AND CHEMICAL RESTRAINT













Protect patient, family, bystanders and EMS personnel from potential harm. Obtain
additional help as necessary.
Observe universal precautions (see guideline # 107)
Evaluate the situation to determine the need for police presence.
Do not approach an agitated and combative patient before law enforcement has gained control of the situation.
Assure clear airway, breathing and circulation.
Complete the history and physical assessment (see guideline # 103, 1001).
Assess the patient’s level of consciousness, level of activity, body language and affect.
Evaluate suicidal potential.
Attempt to rule out common physical causes for patient’s abnormal behavior.
 Hypoxia
 Hypoglycemia or other metabolic disorders
 Head trauma
 Alcohol intoxication
 Substance abuse
Maintain non-threatening attitude toward patient. Attempt verbal de-escalation if
appropriate.
Contact medical control for orders as needed.
Provide appropriate medical care as ordered.
Complete a patient care report, documenting all pertinent information received, procedures
ordered/completed, results of interventions and changes in the patient’s condition. (see guideline #
102)


Documentation must include:
 A description of the circumstances/behavior that precipitated the use of restraints (threat
to self or others).
 A statements that the patient’s significant others were informed of the reasons for the
restraints and that their application was for the safety of the patient/bystanders/personnel
and not as punishment for antisocial behavior.
 A statement that no other less restrictive measure appeared appropriate and/or other
measures were tried and failed.
 The time of applications of the restraint device and its removal, if appropriate.
 The position in which the patient was restrained and transported.
 The type of restraint used.
 Vital signs and/or observational status and condition of the patient every 5 minutes.
 Any medication that may have been used during the process.
Guidelines for application by EMS personnel include:
 BLS providers should consider paramedic response to scene or intercept
Physical restraints should be used as a method of last resort when verbal control is
ineffective.
 Restraint equipment applied by EMS personnel must be padded, soft restraints and allow
for quick release.
 Spider and 9-foot straps may be used to restrain a patient in addition to the padded soft
restraints as long as they do not restrict breathing efforts.
End page 1

Physical and chemical restraint (cont.)
 Restraints must be applied in such a manner that complete monitoring of vital signs is
possible.
 Restraints must not cause vascular, respiratory or neurological compromise.
 Any device used to prevent patient spitting must allow for clear visualization of the
airway (spit mask, mosquito netting, etc.)
 EMS personnel may NOT use:
 Hard plastic ties or any restraint device that requires a key to remove.
 Backboard or scoop stretcher to “sandwich” the patient.
 Restraints that secure the patient’s hands and feet behind the back (“hog-tie”).
 Any method or material applied in a manner that could cause vascular, respiratory or
neurological compromise
 For restraint devices applied by law enforcement officers:
 The restraints and position must provide sufficient slack in the device to allow the patient
to straighten the abdomen and chest to take full tidal volume in.
 An officer must be present with the patient AT ALL TIMES at the scene as well as in the
patient compartment of the ambulance during transport.
 Patients may NOT be transported in the prone position. A left lateral lying position should
be used whenever possible. The position of transport may not compromise respiratory or
circulatory systems and must not interfere with necessary medical treatment.
 Restrained extremities should be evaluated for pulse quality, capillary refill time, color, nerve
and motor function every 10-15 minutes. Restraints must be adjusted if compromise of any
those functions is discovered.
 Once restrained, the patient may never be left alone and unsupervised by medical personnel.
 For those patients requiring medical care, transport should be made to the closest, most
appropriate hospital.
Advanced EMT and Intermediate:
 Do not attempt IV until the patient is cooperative or effectively restrained to limit danger to
patient or rescuer
 Consider IV 0.9% NS at a KVO rate
 If signs of hyperthermia or hypovolemias are present, administer 1 liter of normal saline wide
open for adult patients. See pediatric IV guidelines if appropriate.
 Contact medical control if additional IV fluid is needed and consider second IV.
EMT Paramedic:
 Review symptoms of Excited Delirium (including but not limited to:)








Medication Administration (per local medical control)








Rapid onset of violent behavior, lack of clothing, breaking glass
Possible associated use of stimulant drugs (amphetamines, cocaine, etc.)
History of schizophrenia or bipolar disorder
Possible sudden withdrawal from psychiatric medications
Extremely diaphoretic or extremely hot and dry skin
“Superhuman strength”
“Insensitivity to pain”
Consider Geodon 10-20 mg IM (see drug profile 049)
Consider smaller dose for elderly patients or smaller individuals (less than120 pounds)
If absolutely necessary, it may be injected through clothing
Contact medical control if:

Any questions

If additional dose of Geodon is needed

If a benzodiazepine is also needed (i.e. Versed 5 mg IM)(see drug profile 023)
Consider lessening physical restraint if chemical restraint is effective
Obtain 12 lead ECG as soon as possible
Continue to monitor or over-sedation and medication complications per proper medication
guideline.
Document reasons for any deviation from the preceding guideline/standard.
END
GUIDELINE/STANDARD OF CARE
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 109
The following content will be considered the Guideline/Standard of care for any patient who is a
candidate to sign a release or refusal of treatment form:
REFUSAL OF CARE








Assure scene safety and observe universal precautions (see guideline # 107)
Complete the history and physical assessment (see guideline # 103, 1001).
Assess the patient’s level of consciousness, level of activity, body language and affect.
In order to sign a release or refuse care, the patient must be able to demonstrate decisionmaking capacity:
 Demonstrate the ability to communicate and understand information
 Demonstrate the ability to reason and deliberate
 Appreciate the current situation and its risks and consequences if treatment if refused
 Be logically consistent
 Not be homicidal or suicidal
For the patient who is refusing care and/or transport, ascertain:
 There is no history of or present altered level of consciousness.
 There is no significant or suspected head injury.
 The patient is presently oriented to time, place and person.
 There is no suspected alcohol or drug ingestion by exam or history.
 The patient can ambulate without difficulty.
There is an obligation to treat and transport, if possible, any patient who shows an altered
level of consciousness secondary to an injury, hypoxia, hypoglycemia, a mind-altering
substance or psychosis. These individuals should not be considered able to sign a release.
Only an adult patient (age 18 years or older), guardian, adult caregiver (relative, friend,
police officer or EMT), agent (durable power of attorney for health care), or legally
emancipated minor may sign a release form. The EMT must be comfortable with this
arrangement. If the EMT has reservations about the responsible party, law enforcement can
be notified to assist.
Information must be given to the person refusing care about the consequences, including
(they must receive discharge instructions):
 They have the right to refuse treatment and/or transport.
 They are aware of the potential consequences of refusal of care.
 Medical examination and/or treatment by a physician is highly recommended.
 Ambulance transport is strongly recommended.
 The condition may worsen or further injury may occur.
 Disability or death could occur from the illness or injury.
 Transport by means other than ambulance could be hazardous.
 If treatment or transport if refused but later desired, the patient should immediately call 91-1 and the EMS system will respond to render care and transport.

Contact should be made with medical control if there is any question about the patient’s
ability to understand the consequences of his/her decision.
Complete a patient care report, documenting all pertinent information given to the patient,
situation of the original response, information given to the patient (all patients must receive
discharge instructions), and conditions under which the patient was left. (see guideline # 102)


Two sets of vital signs are preferred to document a stable trend
A signature of the patient and witness(es) on a refusal of care form may be appropriate.

(next page)
Refusal of Care (cont.)
Special Circumstances
 Uninjured Minor – Adult guardian telephone approval for release is acceptable as long as there is a responsible
adult present to whom the minor can be released and both the patient’s guardian and the EMT feel comfortable
with the arrangement. If the patent’s adult guardian is not available, an adult caregiver may substitute.
 Uninjured adult with possible mind-altering substance – If the patient shows no altered level of consciousness,
has normal speech and stable gait and can demonstrate decision-making capacity (as above), they may be
signed out to a responsible adult who is not under the influence of a mind-altering substance. Often time, Law
enforcement is able to assist in convincing these patients to allow transport to the hospital.
END
xx Fire Department
xx Rd.
xx, WI xxxxx
I certify that I have been examined or been offered examination by the XX Fire Department Emergency Medical
Technicians (EMTs). The EMTs have informed me of their initial findings. I understand that there may be
injuries or illness not presently discovered and they can only be properly diagnosed and treated by a doctor at
a medical facility. I have been informed that I might have a condition or injury that could potentially result in
disfigurement, disability or death. I acknowledge I have been offered emergency medical care and
ambulance transport to a hospital emergency department. I voluntarily refuse medical treatment of
ambulance transport for myself or minor(s) who are my responsibility. I understand that, by refusing EMTs
services and by signing this document, I am releasing the EMTs and the XX Fire Department, its officers,
agents and employees from any and all liability for any and all injuries and/or damages. I acknowledge that I
am of sound mind and am not affected mentally by the injury or illness that resulted in the response by the
EMTs. This release is effected against all my assigns, heirs and personal representatives.
Signature _________________________ Witness
______________________________
E. PATIENTS WHO WILL ALLOW TRANSPORT BUT DECLINE SPECIFIC RECOMMENDED
THERAPY OR PRECAUTIONS:
I understand that by declining the following therapies, treatments, or precautions I may develop additional
injuries or a worsening of my condition:
List Items Declined: (spinal immobilization, Oxygen, heat monitoring, blood sugar evaluation, splint application,
etc. )
___________________________________________________________________
_____
Signature: ____________________________ Witness
___________________________
GUIDELINE/STANDARD OF CARE
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 110
The following content will be considered the Guideline/Standard for:
INTERACTION/CONTACT WITH MEDICAL CONTROL






The off-line medical control physician will be the authority for Emergency Medical
Technicians’ operations and medical care in the service to which they are licensed.
All Emergency Medical Technicians must be approved by the off-line medical control
physician
The on-line medical control physician will provide direction for patient care during and
medical emergency event.
Contact will be made with the on-line medical control physician for direction in patient
care as required by the policies and protocols of the EMS department.
EMTs will, at no time, perform duties/procedures beyond the scope of their practice or
outside the guidelines/standards of care of their EMS department off-line medical control
physician.
The off-line medical director will determine under what circumstances orders may be
accepted from on-scene physicians. Circumstances to be addressed include:

On-scene physician who is the patient’s personal physician:
EMTs may take orders from on-scene physicians if:
The orders are within the scope of practice
The EMT knows the orders are within the guidelines/standard of care for
the working assessment for that patient
The EMT should contact the on-line medical control physician if there are any
questions or concerns.

On-scene physician who is unknown to the patient or EMTs
The EMT should contact the on-line medical control physician before accepting
any orders from an individual on the scene who states he/she is a physician but
who is unknown to the EMT or the patient/family.

Telephone orders from a physician who is not the on-scene nor off-scene medical
control
EMTs will not take telephone orders from any individual other than the on-line
medical control physician. Any other individual/physician should be directed to
call on-line medical control and his/her orders should be evaluated and relayed
through standard on-line practices at the discretion of the on-line physician.
If technical difficulties prevent on-line communication, perform care as outlined in these
guidelines
END
GUIDELINE/STANDARD OF CARE
Initial Date:
1/15/03
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 111
The following content will be considered the Guideline/Standard for:
TRANSFER OF CARE
The following content will be considered the Guideline for Care for the patient who is seen and
evaluated by the Advanced Life Support (ALS) team and will be turned over to a Basic Life
Support (BLS) team for transport: (Note: For the purpose of this guideline, ALS will mean paramedic, intermediate and/or IV
technician.)










Assure scene safety and observe universal precautions. (see guideline #107).
Perform and document the history and physical assessment to determine that a lifethreatening or potentially life-threatening condition is not present (see guideline #103, 1001).
Complete documentation on the patient care report. All data that supports the decision to
transport the patient in the BLS mode and the agreement by BLS to accept responsibility for
the patient must appear on all copies. A copy of the patient care report and a copy of the
ECG (if applicable) must be given to the transporting unit. (see guideline #102)
A minimum of two (2) sets of vital signs including level of consciousness must be recorded,
one of which must have been obtained by the ALS team no more than 5 minutes prior to their
departure.
The decision to transport the patient by the BLS team must be unanimous among the ALS
team members.
At the point of transfer of care from the ALS to the BLS team, the team leader of the ALS
team will communicate directly with the BLS team, informing them of the physical condition
of the patient, the working assessment by the ALS team and a formal statement that, in the
judgment of the ALS team, the patient’s condition can be safely managed by the EMT during
transport. (e.g. “Our working assessment is…… Vital signs have been stable over 15
minutes. We do not feel the patient requires ALS intervention at this time and can be safely
transport by you. Do you have any questions or concerns about the patient?”)
The BLS team must formally accept/agree to assume responsibility for the care and transport
of the patient. If the BLS crew on the scene does not accept that responsibility, the patient
will be transported by the ALS team without further discussion.
The Medical Control physician should be contacted if there are any concerns regarding
transportation of a patient. If the dispatch information indicated an ALS response (chest
pain, unresponsive, etc., all new ALS services are required to contact medical control prior to
releasing a patient to a BLS unit. The medical director may waive this requirement when
evidence based on annual QA of this topic supports a sound practice pattern and good
medical decision-making.
The time of transfer of care to the BLS unit or to another ALS unit will be documented (e.g.
“1624 hours: responsibility for medical care transferred from ALS [or BLS] unit X to BLS
[or ALS] unit XX”).
Patients who have received ALS treatment by the ALS team or by other medical
professionals must be transported by the ALS team. ALS treatment includes but is not
limited to establishing or attempting to establish an IV, administration of medications and
any advanced airway placement.
 If an ALS provider is on the scene prior to the arrival of the BLS unit, the ALS provider will
perform duties allowed by their scope of practice and department operational guidelines. If
the call is BLS in nature, the ALS provider will return to previous duties when BLS
personnel arrive on scene and assume care. If, after assessment of the patient it is determined
that ALS care is needed, the ALS provider will continue to provide the care and activate the
proper departmental operational guidelines.
End page
Transfer of Care (cont.)

Patient who may not be turned down from an ALS to a BLS unit include, but are not limited
to:
 Individuals who have fallen a distance of 15 or more vertical feet
 Individuals in whom there is a high degree of suspicion of spinal cord injury
 Individuals involved in trauma which required prolonged or complicated
extrication
 Individuals with a complaint that includes chest pain or probable/possible cardiac
origin or difficulty breathing
 Tricyclic overdoses
 Penetrating injuries of the head, neck, torso or groin
 Diabetics with blood glucose levels greater than 400 mg%
 Patient with medical or traumatic conditions which could potentially benefit from
ALS monitoring or care.
Note: When BLS responds alone to the above instances, ALS mutual aid/intercept should be considered.)

Document any reasons for deviations from the above Guideline/Standard of Care.
END
GUIDELINE/STANDARD OF CARE
Initial Date: 1/1/05
Last Review/Revision: 12/18/08
Guideline Number: 112
Service Director’s
Signature
Medical Director’s
Signature
The following content will be considered the Guideline/Standard of care for the patient in pain:
ANALGESIA

Observe universal precautions (see guideline #107).

Assure patent airway. (see guideline # 101,201).















Allow the patient to assume the position of comfort.
Administer supplemental oxygen (see guideline # 105, 2001) with a device and at a rate appropriate
for the condition of the patient if appropriate.
Complete the history and focused physical assessment (see guideline # 103, 1001)
Any “discomfort” including pain, muscle spasm, dyspnea or anxiety should be addressed.
An age-appropriate pain scale (number scale, smiley face, etc.) should be used.
Consider prompt treatment of pain rated at a 4 or above. Clinical judgment regarding
patient’s level of distress, apparent injury and reported pain scale number must be used
before categorizing and treating patient as Mild, Moderate or Severe pain.
The goal is to reduce pain or discomfort while monitoring hemodynamic and respiratory side
effects.
The intravenous route is preferred. IM or subcutaneous routes may have delayed peak effect.
Intravenous medications for pain should be given over 2 to 3 minutes.
Vital signs must be monitored within 5 minutes prior to and after each dose.
Airway and ventilation equipment should be immediately accessible.
Naloxone (Narcan) should be immediately available. (see drug profile # 014)
Recognize contraindications and limitations of all medications available.
Short acting narcotics are preferred over long acting narcotics in the prehospital
setting.
Conditions for which analgesia is frequently needed include:










Ischemic chest pain
Left congestive heart failure
Kidney stones
Cancer pain
Extremity trauma
Burns (without inhalation injuries)
Back pain, spasms
Abdominal pain not associated with pregnancy
Medical control should be contacted for pain associated with other conditions than those
listed above.
Contraindications to prehospital analgesia include:











Known allergy to medication
Pregnancy (relative contraindication)
Imminent obstetrical delivery
Respiratory distress with fatigue
Signs of elevated intracranial pressure
Intake of other central nervous system depressant(s)
Hypotension/hypoperfusion
Hypoventilation
Altered mental status
Acute bronchospasm
Major trauma and the presence of shock





Pediatric patients who weigh more than 50 kg usually need adult doses. All pediatric
maximum doses are the adult equivalent.
Reassess and document the patient’s respiratory and cardiovascular systems frequently.
Complete a patient care report (see guideline #102) documenting all pertinent information received,
procedures ordered/completed, results of interventions and changes in the patient’s condition.
Transport to the closest, most appropriate hospital.
Document reasons for any deviation from the preceding Guideline/Standard of care.
End 1st page
Analgesia guideline
Page 2
DRUG
Adult
MILD PAIN
(Pain scale 1-3)
2 mg
MODERATE PAIN
(Pain scale 4-7)
5 mg
Pediatric
Not recommended
0.05 mg/kg
Adult
0.5 mg
1 mg
Pediatric
Not recommended
Recommend
morphine
Adult
25-50 mcg
50-100 mcg
Pediatric
Not recommended
1 mcg/kg
Adult
25 mg
50 mg
Pediatric
Not recommended
Recommend
morphine
Nalbuphine
(Nubain)
Adult
2 mg
5 mg
Repeat moderate
dose q 5-10 min
Butorphanol
(Stadol)
Adult
0.5 mg
1 mg
2 mg
Ketorolac
(Toradol) –
contraindicated in
potential surgical
patients
Adult
15 mg IV
30 mg IM
30 mg IV
60 mg IM
30 mg IV
60 mg IM
Geriatric or
known renal
failure
Pediatrics
15 mg IV
30 mg IM
15 mg IV
30 mg IM
15 mg IV
30 mg IM
Not recommended
0.5 mg/kg not to exceed adult dose
Morphine
Hydromorphone
(Dilaudid)
Fentanyl
Meperidine
(Demerol)
PATIENT
SEVERE PAIN
(Pain scale 8-10)
Repeat moderate
dose q 5-10 min
Repeat moderate
dose q 5-10 min
Repeat moderate
dose q 5-10 min
Recommend
morphine
Repeat moderate
dose q 5-10 min
Repeat moderate
dose q 5-10 min
Repeat moderate
dose q 5-10 min
Recommend
morphine
Nitrous oxide in preset delivery mix (50:50% with oxygen) with mask to be controlled voluntarily by the
patient. Do not strap the mask onto the patient’s face. Contraindicated in small bowel obstruction and
pneumothorax
Oral medications (Potential surgical patients should not be given anything to eat or drink, including
medications.)
DRUG
PATIENT
MILD PAIN
MODERATE PAIN
SEVERE PAIN
(Pain scale 1-3)
(Pain scale 4-7)
(Pain scale 8-10)
Ibuprofen (oral)
Adult
600-800 mg
600-800 mg
Use other options
Pediatrics
Not recommended
10 mg/kg
Use other options
Acetaminophen
END
Adult
Pediatrics
650-1000 mg
Not recommended
650-1000 mg
15 mg/kg
Use other options
Use other options
GUIDELINE/STANDARD OF CARE
Initial Date: 1/1/05
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 113
(Note: Medical director should indicate which of the medications below are acceptable in his/her service by initialing the box in front
of the medication table)
The following content will be considered the Guideline/Standard of care for the patient in need
of:
SEDATION (Paramedic only)

Observe universal precautions (see guideline #107).

Assure patent airway. (see guideline # 101,201).

Allow the patient to assume the position of comfort.
Administer supplemental oxygen (see guideline # 105, 2001) with a device and at a rate appropriate
for the condition of the patient if appropriate.
Complete the history and focused physical assessment (see guideline # 103, 1001)



Sedation may be indicated for:
 Premedication prior to cardioversion (Example: the patient is about to undergo synchronized cardioversion
with symptomatic supraventricular tachycardia who has failed treatment with adenosine and is in danger of
hemodynamic decompensation. The patient has no contraindication (see below) to sedation.)
Premedication prior to intubation (Example: Sedation to facilitate intubation in a
conscious patient with progressive respiratory failure requiring immediate intubation.)
Contraindications to sedation:
 Known allergy to the medication
 Hypotension/hypoperfusion
 Major trauma with impending shock
Pediatric patients who weight more than 50 kg usually need adult doses. All pediatric
maximum doses are the adult equivalent.



MEDICATION
Diazepam
(Valium)
Midazolam (Versed)
Lorazepam (Ativan)
Etomidate (Amidate)
Propofol (Diprivan)
PATIENT
USUAL INITIAL DOSE
Adult
2-5 mg
Pediatric
0.05 mg/kg
Adult
Pediatric
2-5 mg
0.05-0.1 mg/kg for intubation
0.05 mg/kg
Consider repeating sedation
dose if need greater effect
Consider repeating if need
greater effect
Adult
0.5-2 mg
Pediatric
0.05 mg/kg
Consider repeating if need
greater effect
Consider repeating if need
greater effect
Adult
0.2-0.3 mg/kg IV bolus
Pediatric
Not recommended
Adult
5 micrograms/kg/min for 5
minutes until peak effect
reached
Not recommended
Pediatric
Consider repeating if need
greater effect
Consider repeating if need
greater effect
Consider repeating if need
greater effect
Interfacility services only
Note: Amount of drug (e.g. 2 mg) is not equivalent from drug to drug. 2 mg of Valium is
NOT equivalent to 2 mg of Versed.
END
GUIDELINE/STANDARD OF CARE
Initial Date:
6/22/07
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 114
The following content will be considered the Guideline/Standard of care for the patient in need
of:
Hospital Destination / Transport / Bypass

Selecting a transport destination should be based on the following factors:








The presence of a medical condition where the loss of life or limb is imminent (ie..
inability to effectively ventilate a failed airway)
Patient hospital preference
Proximity to hospitals
Specialty medical care available (ie.. Trauma care based on trauma level designation,
Stroke center, Advanced cardiac care – cardiac cath lab, Burn management, Neonatal
intensive care, Pediatric intensive care, Hyperbaric therapy)
Current available bed status at hospital or emergency department (diversionary status)
Available resources at area hospitals affected by other transports from current emergency
or mass casualty
Local rules or policies limiting destination choices
Current level of service (scope of practice) on scene or available

Patient preference is typically the leading factor in determining a hospital destination for
patients in Waukesha County. EMTs should assist patients in making this decision based on
consideration of the above factors.

An emergency department should not be bypassed if an EMT is unable to affectively
ventilate a patient or if a patient has a critically low blood pressure that is not responding to
all available treatments.
o Additional options include ALS intercept before approaching the closest hospital or
utilizing aeromedical services.

An emergency department should not be bypassed if an EMT is concerned that a patient’s
condition will significantly worsen during the delay caused by driving to the alternate
facility.

Exceptions:
o Upon occasion, patients, or their legal representatives, will insist on being transported to
a facility that is not the closest most appropriate facility when in the opinion of the EMT,
the closest most appropriate facility is medically indicated. Under such circumstances, it
is advisable to discuss the situation with medical control and have the patient or their
legal representative sign an appropriate waver indicating their desire to deviate from the
medical plan of care proposed.
Contact on-line medical control with any questions.
END

GUIDELINE/STANDARD OF CARE
Initial Date:
4/17/08
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 7/25/08
Guideline Number: 115
The following content will be considered the Guideline/Standard of care for the patient in need
of:
Hospital Diversion

Objective:
o To transport patients to the most accessible medical facility which is staffed, equipped,
and prepared to administer emergency care appropriate to the needs of the patient.
o To have a mechanism where hospitals can have ambulance patients diverted away from
their emergency departments when it has been determined that the hospital is not staffed,
equipped, and/or prepared to provide emergency care for additional patients.
o Provide a means of communicating hospital status and capabilities to EMS providers.

Eligibility:
o A condition exists where the emergency department is unable to safely care for additional
patients and the hospital has already implemented its own internal procedures for
activating backup staff and resources.
o A condition exists where the hospital inpatient status or ICU is full (and the hospital has
already implemented its own internal procedures for expanding capacity) – preventing
additional admissions to the hospital through the emergency department or direct
admissions from ambulance services

Notification:
o Emergency Departments changing status should contact area dispatch centers by phone
as well as update WITRAC.
o “WITRAC” internet posting is the location for official hospital status posting

Hospital Status will be listed as one of the following in WITRAC:
o Open : Open to all patients
o Divert : Not accepting patients
 Comments (qualifiers are not limited to)
 Open to OB
 Open to Trauma
 Open to ECG confirmed AMI (Acute Myocardial Infarction)
 Open to Burn
 Open to TPA candidate CVA (Cerebral Vascular Accident)
 Diverting Psychiatric only
o If the Emergency Department (ED) is completely closed due to plant failure (ie, power,
fire, etc.. .) The Emergency Department can accept no patients under any circumstances.
This will be listed in the comments section of WITRAC and the status will be set at
Divert. Hospitals closed for this reason can not be “forced open”.

Diversion Reason (hospitals will choose a reason) and list in WITRAC:
o Diagnostic services unavailable (CT scanner down, Cath Lab down, etc..)
o No ED Beds / ED at capacity
o No Inpatient Beds : Critical Care (the hospital has no critical care beds)
o No Inpatient Beds : Telemetry/Floor (the hospital has no general medical beds)
o No Inpatient Beds : Other (explain)
o Physical Plant Problems : (ie. Power outage)

Forced Open : Hospital can be forced open once all Waukesha County Emergency
Departments are diverted
o Control of “forced open” status is linked to communication and cooperation between
hospital administrators
o Once 2 Waukesha County Hospitals have diverted, hospital administrators from each
hospital will immediately review area resources and discuss options to open facilities.
o If all hospitals in Waukesha County are diverting, all hospitals will be opened using the
above process.

Procedure:
o When a hospital is diverting patients, ambulances transporting the type of patient being
diverted, will bypass that hospital and transport to an “open” facility.
o If in a EMTs judgment, the patient has not been stabilized to the extent that the extra
transport time would be life or limb threatening, they should transport to the diverting
hospital (override diversion). The EMT must also consider the delay that may occur
once the patient has arrived at an already overwhelmed facility.
 Some possible examples (not limited to) :
 PNB
 Failed airway
 Symptomatic hypotension resistant to pre-hospital treatment (BPs <
90mmHg & symptomatic)
 Severe trauma where the diverting hospital is the preferred and proper
facility based on area trauma triage criteria.
 Status Epilepticus (continuous seizure activity lasting longer then 30 min.
resistant to treatment)
 Pregnant patients in active labor
 Cerebral Vascular Accident who is a TPA candidate
 EKG documented Acute Myocardial Infarction
o All cases where hospital diversion has been overridden will be reviewed by the service
medical director for quality assurance.
o A hospital may not change their status while in the midst of receiving an ambulance radio
report. “In-Route” diversions are not acceptable.
o If a patient demands transport to a diverting facility, the patient may still be transported to
that facility however the EMT must explain to the patient all of the possible delays and
dangers associated with entering an overwhelmed emergency department and discourage
this destination choice. The EMT should document this carefully. EMTs must
understand that they could incur liability regarding their destination choice if a patient is
released to a knowingly overwhelmed facility unless they stay in attendance with the
patient until an equal or greater level of care can be provided at that facility.
o A diverting hospital may not refuse a patient who has presented to them.
o In cases of Mass Casualty incidents, each hospital should be in communication with
incident command on scene to give active capacity updates allowing fluid transport
decisions. These communications may supersede the above process.
o Field triage must be considered where incidents involve multiple victims. Avoid
overwhelming any one facility and transport the most appropriate patient to the closest
most appropriate hospital.
o The above policy may not apply to direct admission patients if the admission has been
arranged before the diversion status. Agencies transporting direct admission patients
should clarify the destination if needed before starting the transfer.
END
GUIDELINE/STANDARD OF CARE
Initial Date:
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 116
The following content will be considered the Guideline/Standard of care for
SPECIAL OPERATIONS
Care in a Tactical/Disaster Environment
Purpose
The purpose of this guideline is to outline care that should be rendered while involved in a
tactical environment. Keeping in mind “tactical” may mean involvement with Law
Enforcement, but could also reflect care in an austere/disaster type situation. The basis of this
guideline is in-line with the tenants of TCCC (tactical combat casualty care) as outlined in the 6th
edition of PHTLS. The three phases of care are as follows:
 Care Under Fire: where the hostile act or disaster is still in progress,
 Tactical Field Care: care rendered while the hostile act or disaster is in a lull, but keep in
mind this is dynamic and may revert back to care under fire.
 Tactical Evacuation: this is care rendered while transporting the injured to definitive care.
The expectation is that a higher level of care is given in this phase and may include
ALS providers.

Care Under Fire: (EMT, AEMT, I and P) Safety of the EMS provider is paramount, if
gunfire is being exchanged, seek cover and do not attempt medical intervention unless
escorted by armed law enforcement personnel. Equipment should be kept to a minimum
as to ensure rapid movement and extrication of the patient from the point of wounding.
1. Address massive extremity hemorrhage with the use of an approved commercial
tourniquet. (See guideline 5013) Apply as high on the extremity as possible and
tighten till bleeding stops. For hemorrhages not amenable to a tourniquet the
wound should be packed with an approved Hemostatic agent, direct pressure
should be applied over the Hemostatic agent for 2-5 minutes. (See guideline
5014) Bleeding control should be confirmed before applying a pressure dressing
over the wound. Frequent re-assessment should be done to check for re-bleeding.
2. Penetrating Torso Trauma should rapidly be addressed. Shortness of Breath in
the presence of penetrating trauma is the indication for immediate chest needle
decompression (per guideline # 2015 with the addition of using a 3.25 inch 14
gauge needle). If your scope of practice allows for needle decompression,
remember to apply a full occlusive dressing(s) to entrance and exit wounds. If
your scope of practice does not allow for needle decompression, apply an
occlusive dressing that is not taped on all sides. Check patient for improvement
of respiratory effort. EMT and AEMT should apply and occlusive dressing that
allows the wound to vent one-way (Asherman Chest Seal®, Bolin Chest Seal®)
or apply a 3-sided occlusive dressing that may be “burped” to relieve any tension.
Immediate ALS intervention is needed to facilitate a chest needle decompression.
3. Airway compromise: Any patient found with airway compromise should be
placed in position that best maintains airway i.e. sitting and leaning forward to
allow secretions to drain. Insert Nasal Pharyngeal Airway (per guideline #2007) if
likelihood of patient becoming unconscious. To decrease equipment load, use 28fr
nasopharyngeal airway as standard size.


Tactical Field Care: (EMT, AEMT, I and P) Keeping in mind this phase may be
dynamic, the environment in which the EMS provider is working must constantly be
reassessed for unstable changes and safety concerns.
1. Wounds that have been addressed with tourniquets should be reassessed and if
bleeding continues a 2nd tourniquet should be applied 2-3 inches above the point
of wounding. Once applied and bleeding controlled, the 1st tourniquet can be
slowly removed. If Hemostatic agent was used, continue to reassess the wound,
re-apply additional pressure dressing and direct pressure.
2. If airway compromise continues, consider definitive airway per scope of practice
(i.e. Non-Visualized Airway (per guideline #2008) or Endotracheal Intubation
(per guideline #2009). Assist ventilations as needed and continue to reassess.
With massive facial injury and associated airway insult, consider Surgical Airway
(per guideline # 2016).
3. If penetrating torso injury and shortness of breath was addressed with occlusive
dressing(s) and chest needle decompression, reassess breathing. If patient’s
respiratory effort does not improve, consider 2nd needle decompression right next
to the first needle insertion.
4. Initiate at least one large bore IV 18-16 gauge (per guideline #3002) and infuse
boluses of 250-500cc of 0.9% NS not to exceed 2000 ml if possible. Attempt to
keep systolic BP around 90mmHg. (Key Point…Bleeding must be identified and
stopped. Over hydration of IV fluids reduces the remaining blood volume’s ability
to carry O2 and clot).
5. Prevent heat loss. Cover patient even in warmer months to help prevent
complications associated with clotting abnormalities.
6. Address pain control with short-acting narcotics (drug profile # 035, guideline
112)
Tactical Evacuation: (EMT, AEMT, I and P) This Phase of TCCC is much like mainstream
EMS transportation. The expectation is that an ambulance would be able to provide oxygen,
cardiac monitoring, pulse oximetry, vital signs, and protection from the elements (i.e. warmth
and light.)
1. Constantly monitor for bleeding. Ensure tourniquet is tight and has not become loose
during patient movement (there should be an absence of distal pulse in the extremity
that has a tourniquet applied). Bandage all wounds as appropriate.
2. Monitor Vital Signs, frequently assess for oxygenation and perfusion.
3. Provide psychological support for the patient
4. Complete documentation of events and rational for use of Tourniquets and
Hemostatics MUST be explicitly detailed.
5. Patient must be transported to appropriate medical center. Consider use of AeroMedical Services, but DO NOT delay transport.
6. Contact medical control from scene to ensure early notification and appropriate
trauma activations.
END
GUIDELINE/STANDARD OF CARE
Initial Date:
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/09
Guideline Number: 117
The following content will be considered the Guideline/Standard of care for
Recommendations for the Appropriate Use of:
Lights and Siren During Patient Transport
POLICY RECOMMENDATION
Setting the tone for operational safety in EMS is the responsibility of organizational leaders, but
ultimately, the emergency medical services (EMS) crew is responsible for the safe operation of an
ambulance. There is a documented risk of crashes involving emergency vehicles resulting in excess
injury and death to emergency personnel, patients, and bystanders. Because of this increased risk, it is
recommended that the use of emergency lights and siren during transport should be minimized. Use of
lights and siren transport should be reserved for unstable medical conditions when it is reasonable to
believe that the use of lights and siren will lead to a clinically relevant time saving to deliver definitive
care.
PATIENT CARE GOALS
•
Identify patients for whom safe use of emergency lights and siren during transport can
potentially reduce patient morbidity and mortality.
• Eliminate unnecessary use of emergency lights and siren during transport to improve
patient comfort, reduce anxiety, and enhance safety for the patient, the team and the
community.
PROCEDURE
1. Lights and Siren transport does not necessitate exceeding posted speed limits or violating
other traffic laws.
2. Road type, traffic conditions, and weather conditions all must be considered when using lights
and siren. (For example, when driving on a highway, it may be safer to drive with the flow
of traffic at normal highway speeds without lights and siren, instead of stimulating possibly
erratic lane changes by using lights and siren.)
3. When using lights and siren extreme caution must be taken when approaching an intersection
even if a priority light control system is being used. It is recommended that the ambulance
come to a complete stop before proceeding through an intersection when there is a possibility
that cross traffic may have the right-of-way (ie. “Stop” sign, “yield” sign, yellow traffic light,
red traffic light, uncontrolled intersection, or round-about).
4. When using lights and siren
a.
Never pass another vehicle while in a “no passing zone” unless the vehicle moves to the
right shoulder and comes to a complete stop.
b.
Come to a complete stop 100 feet from the front or rear of a school bus displaying
flashing red lights and/or a “stop” sign.
c.
Never force the right of way or assume the right of way. Emergency vehicles only have
the right of way when the other vehicle yields to you.
d.
Never tailgate another vehicle, even if they have not moved to the right shoulder of the
road and come to a complete stop.
5. At the discretion of the ambulance crew, driving with lights and siren may be considered if
the following clinical conditions or circumstances exist:
a.
Difficulty in sustaining the ABC's including (but not limited to):

Inability to establish an adequate airway or ventilation

Severe respiratory distress or respiratory injury not responsive to available field
treatment.

Acute coronary syndrome with one or more of the following:
ST elevation in 2 or more contiguous leads, acute congestive heart failure (CHF),
hypotension, bradycardia, wide complex tachycardia, or other signs of impending
deterioration.

Cardiac dysrhythmia accompanied by signs of potential or actual instability
(hypotension, acute CHF, altered level of consciousness, syncope, angina,
resuscitated cardiac arrest) which is unresponsive to available field treatment.

Severe uncontrolled hemorrhage

Shock, unresponsive to available treatment
b.
c.
Severe trauma including (but not limited to):

Penetrating wounds to head, neck, and torso.

Two or more proximal long bone fractures.

Major amputations (proximal to wrist or ankle)

Neurovascular compromise of an extremity

Multi-system trauma
Severe neurological conditions including (but not limited to):

Status epilepticus

Substantial or rapidly deteriorating level of consciousness

For a suspected Stroke where a significant reduction of time to receive thrombolytic
therapy can be achieved and the patient meets treatment inclusion criteria.
d.
Obstetrical emergencies including (but not limited to):

Labor complications that threaten survival of the mother or fetus
Such as : (Prolapsed cord, breech presentation, arrested delivery
{inability to complete delivery of a baby that is partially born}, or
suspected ruptured ectopic pregnancy.
6.
For any transport, where reducing time to definitive care is clinically indicated, consider
options other than emergent driving. In these cases, an alternative mode of transportation or
higher level of care (such as ALS intercept, air-medical, or critical care transfer) should be
considered, if available, appropriate, and if it will not delay the arrival of the patient.
7.
Critical-care level inter-facility patient transports should not automatically be handled as
lights and siren events. Clinical judgment and the patient criteria listed above should be
applied on transfers to determine the level of urgency and transport mode.
8.
When a physician or nurse attempts to order lights and siren transport for a patient, when
it is believed by the crew to be contraindicated , attempt to resolve the issue with the
ordering physician/nurse. If necessary, contact medical control to assist in resolving the
issue.
9.
Transport with lights and siren should be avoided in the following circumstances:
a.
Patients who present with a written and valid “Do Not Resuscitate” (DNR or DNAR)
order, confirmed by the patient’s wishes and/or medical authority orders to withhold
treatment.
b.
Inter-facility transfers when the patient is being transported to a lower level of care.
c.
Transport of human organs, blood, or organ transplant teams. The possible exception
would be a long distance inter-city transport of an organ or organ recipient, where the
time frame for successful reimplantation is in jeopardy, and use of lights and siren would
save a significant amount of time.
d.
Transport of an unsalvageable patient (including cardio-pulmonary arrests) even if
treatment procedures are continued en route.
e. Situations where the crew is requested to respond to another call while currently
transporting a patient who does not warrant emergent transport.
10. For any lights and siren transport, specifically document in the narrative the patient's
condition, case circumstances, and the rationale for choosing emergent transport.
REFERENCE:
Use of Warning Lights and Siren in Emergency Medical Vehicle Response and Patient Transport
(http://www.naemsp.org/documents/usewarnlightssirens.pdf)
GUIDELINE/STANDARD OF CARE
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 201
The following content will be considered the Guideline/Standard of care for the patient with a
provider impression of:




AIRWAY OBSTRUCTION
Assure scene safety and observe universal precautions (see guideline #107).
Evaluate airway.
If the patient is conscious and can speak/cough, encourage efforts but do not interfere.
If the patient is conscious but cannot speak or cough, complete the obstructed airway procedures
of the American Heart Association:
VICTIM 1 YEAR OF
AGE OR OLDER
Abdominal thrusts
INFANT
5 Back blows, 5 chest
thrusts
Repeat until airway clear
or patient becomes
unconscious
Repeat until airway clear
or patient becomes
unconscious


If the foreign body is successfully dislodged:
 Administer supplemental oxygen (see guideline #105, 2001) with a device and at a rate appropriate for
the condition of the patient.
 Reassess breath sounds. If wheezing or stridor is present, contact medical control for additional
orders prior to transport.
If the patient is unconscious, perform direct laryngoscopy and attempt to visualize the remove the
foreign body with the Magill forceps (see guideline # 2005). If equipment is not immediately available,
continue with the obstructed airway procedures of the American Heart Association.
VICTIM 1 YEAR OF
AGE OR OLDER
Open the airway
End page
INFANT
.
Open the airway
Remove the object if
visible
Remove the object if
visible
Begin CPR
Begin CPR
Visually check airway
before each breath.
Remove the object if
visible
Visually check airway
before each breath.
Remove the object if
visible
Airway Obstruction (cont.)

If unable to remove the foreign body with the Magill forceps, perform the abdominal thrust
maneuver and repeat the laryngoscopy.
 If the airway is cleared, reassess respirations and neurologic status. If the patient continues
to have an altered level of consciousness or if wheezing or stridor is present, contact medical
control.
 If unable to clear the airway, continue attempts to remove/ventilate and begin immediate
transport to the closest emergency department (overrule diversions).
 Administer supplemental oxygen (see guideline # 105, 2001) and attempt to ventilate between
attempts at removal en route.
 Consider advanced airway. (See guideline #2008, 2009, 2010).
 Assess for adequate circulation to perfuse the vital organs. Begin CPR as appropriate.
 Complete the history and focused physical assessment (see guideline # 103, 1001).
 Obtain initial vital signs (see guideline #1002) and repeat at a minimum of 15-minute intervals.
Critical patients may need more frequent monitoring.
 Consider intravenous access (see guideline # 3002-3004).
 Consider electrocardiograph monitoring (see guideline #3009). See appropriate dysrhythmia
guidelines.
 Consider 12-lead electrocardiogram (see guideline #3008).
 Contact medical control for orders as necessary.
 Reassess and document the patient’s respiratory and cardiovascular systems frequently.
 Complete a patient care report (see guideline #102) documenting all pertinent information received,
procedures ordered/completed, results of interventions and changes in the patient’s condition.
 Transport to the closest, most appropriate hospital.
 Document reasons for any deviation from the preceding Guideline/Standard of care.
END
GUIDELINE/STANDARD OF CARE
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 202
The following content will be considered the Guideline/Standard of care for the patient with a
provider impression of:
BRONCHIAL ASTHMA

Assure scene safety and observe universal precautions (see guideline #107).


Assure patent airway.
Assure adequate respiratory exchange, ventilate with supplemental oxygen in those patients with
inadequate or absent respirations, consider advanced airway (see guideline # 2002-2009).


Determine the degree of respiratory distress (mild/moderate/severe).
Allow the patient to assume the position of comfort unless contraindicated by medical
condition.
 Administer supplemental oxygen (see guideline # 105, 2001) with a device and at a rate appropriate
for the condition of the patient.
 Assess for adequate circulation to perfuse the vital organs. Begin CPR as appropriate.
 Complete the history and focused physical assessment (see guideline # 103, 1001).
 Obtain initial vital signs (see guideline #1002) and repeat at a minimum of 15-minute intervals.
Critical patients may need more frequent monitoring.
 Consider intravenous access (see guideline # 3002-3004)).
 Consider electrocardiograph monitoring (see guideline #3009). See appropriate dysrhythmia
guidelines.
 Monitor oxygen saturation.
 Consider drug therapy:
 Albuterol by nebulized inhalation (see drug profile # 002).
 Consider epinephrine (see drug profile # 009) intramuscular for the patient in severe distress
who does not respond to albuterol.
 Consider Atrovent (See drug profile # 019)
 Consider 12-lead electrocardiogram (see guideline #3008).
 Consider CPAP (see guideline #2018).
 Consider alternative causes for bronchospasm and follow appropriate guide, e.g. anaphylaxis,
COPD, CHF, foreign body aspiration.
 Contact medical control for orders as necessary.
 Reassess and document the patient’s respiratory and cardiovascular systems frequently.
 Complete a patient care report (see guideline #102) documenting all pertinent information received,
procedures ordered/completed, results of interventions and changes in the patient’s condition.
 Transport to the closest, most appropriate hospital.
 Document reasons for any deviation from the preceding Guideline/Standard of care.
END
GUIDELINE/STANDARD OF CARE
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 203
The following content will be considered the Guideline/Standard of care for the patient with a
provider impression of:
CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Assure scene safety and observe universal precautions (see guideline #107).


Assure patent airway. (see guideline # 101,201)
Assure adequate respiratory exchange, ventilate with supplemental oxygen in those patients with
inadequate or absent respirations, consider advanced airway (see guideline # 2002-2009).


Determine the degree of respiratory distress (mild/moderate/severe).
Allow the patient to assume the position of comfort unless contraindicated by medical
condition.
 Administer supplemental oxygen (see guideline # 105, 2001) with a device and at a rate appropriate
for the condition of the patient. Consider oxygen sensitive patient and monitor respiratory
effectiveness. As a general guideline, administer oxygen 2 liters higher than the patient is
usually receiving.
 The bag-valve-mask will be kept immediately available to all patients with a provider
assessment of chronic obstructive pulmonary disease who are in moderate/severe respiratory
distress.
 Assess for adequate circulation to perfuse the vital organs. Begin CPR as appropriate.
 Complete the history and focused physical assessment (see guideline #103, 1001).
 Obtain initial vital signs (see guideline #1002) and repeat at a minimum of 15-minute intervals.
Critical patients may need more frequent monitoring.
 Consider intravenous access (see guideline # 3002-3004).
 Consider electrocardiograph monitoring (see guideline #3009). See appropriate dysrhythmia
guidelines.
 Consider drug therapy.
 Albuterol (see drug profile # 002) by nebulized inhalation.
 Atrovent (See drug profile # 019)
 Consider 12-lead electrocardiogram (see guideline #3008).
 Consider CPAP (see guideline #2018).
 Contact medical control for orders as necessary.
 Reassess and document the patient’s respiratory and cardiovascular systems frequently.
 Complete a patient care report (see guideline #102) documenting all pertinent information received,
procedures ordered/completed, results of interventions and changes in the patient’s condition.
 Transport to the closest, most appropriate hospital.
 Document reasons for any deviation from the preceding Guideline/Standard of care.
END
GUIDELINE/STANDARD OF CARE
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 204
The following content will be considered the Guideline/Standard of care for the patient with a
provider impression of:
INHALATION INJURY

Assure scene safety and observe universal precautions (see guideline #107).

Assure patent airway. Consider potential cervical spine injury during airway maneuver (see guideline #
101,201).
Assure adequate respiratory exchange, ventilate with supplemental oxygen in those patients with
inadequate or absent respirations, consider advanced airway (see guideline # 2002-2009).

















Determine the degree of respiratory distress (mild/moderate/severe). Document the potential
for inhalation injury as evidenced by the history, burns of the face, chest or mouth,
carbonaceous sputum, singed nasal hair, dyspnea, decreased level of consciousness or stridor.
Allow the patient to assume the position of comfort unless contraindicated by medical
condition.
Administer supplemental oxygen (see guideline # 105, 2001) at 100% with a device appropriate for
the condition of the patient. Consider humidified oxygen.
Assess for adequate circulation to perfuse the vital organs. Begin CPR as appropriate.
Complete the history and focused physical assessment (see guideline #103, 1001).
Obtain initial vital signs (see guideline #1002) and repeat at a minimum of 15-minute intervals.
Critical patients may need more frequent monitoring.
Consider concurrent trauma, medication overdose, or toxic exposure (see guidelines #412, 506)
Consider intravenous access (see guideline # 3002-3004).
Consider electrocardiograph monitoring (see guideline #3009). See appropriate dysrhythmia
guidelines.
Consider drug therapy.
 Albuterol (see drug profile # 002)
 Atrovent (see drug profile #019)
Consider Positive End Expiratory Pressure (PEEP) (see guideline # 2011).
Consider 12-lead electrocardiogram (see guideline #3008).
For patients with suspected carbon monoxide poisoning:
 Rescue safely.
 Administer high flow oxygen via nonrebreather mask.
 Provide appropriate medical care based on patient assessment.
 Consider transport to facility with hyperbaric capabilities.
Contact medical control for orders as necessary.
Reassess and document the patient’s respiratory, cardiovascular and nervous systems
frequently.
Complete a patient care report (see guideline #102) documenting all pertinent information received,
procedures ordered/completed, results of interventions and changes in the patient’s condition.

Document the time of removal from the toxic environment, the circumstances and duration of
exposure, and the time started on oxygen.
 Document the history of loss of consciousness.
 Transport to the closest, most appropriate hospital.
 Document reasons for any deviation from the preceding Guideline/Standard of care.
END
GUIDELINE/STANDARD OF CARE
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 205
The following content will be considered the Guideline/Standard of care for the patient with a
provider impression of:

RESPIRATORY ARREST
Assure scene safety and observe universal precautions (see guideline #107).

Assure patent airway. Utilize airway obstruction maneuvers as appropriate (see guideline # 101,201).

Assure adequate respiratory exchange, ventilate with supplemental oxygen, consider
advanced airway. (see guideline # 2002-2009)
 Assess for adequate circulation to perfuse the vital organs. Begin CPR as appropriate.
 Complete the history and focused physical assessment (see guideline #103, 1001).
 Obtain initial vital signs (see guideline #1002) and repeat at a minimum of 15-minute intervals.
Critical patients may need more frequent monitoring.
 Consider causes for respiratory arrest and treat with the appropriate guidelines.
 Consider intravenous access (see guideline # 3002-3004).
 Consider electrocardiograph monitoring (see guideline #3009). See appropriate dysrhythmia
guidelines.
 Consider 12-lead electrocardiogram (see guideline #3008).
 Contact medical control for orders as necessary.
 Reassess and document the patient’s respiratory and cardiovascular systems frequently.
 Complete a patient care report (see guideline #102) documenting all pertinent information received,
procedures ordered/completed, results of interventions and changes in the patient’s condition.
 Transport to the closest, most appropriate hospital.
 Document reasons for any deviation from the preceding Guideline/Standard of care.
END
GUIDELINE/STANDARD OF CARE
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 206
The following content will be considered the Guideline/Standard of care for the patient with a
provider impression of:
RESPIRATORY DISTRESS

Assure scene safety and observe universal precautions (see guideline #107).

Assure patent airway. Consider potential for cervical spine injury during airway maneuvers. (see
guideline # 101,201).
Assure adequate respiratory exchange, ventilate with supplemental oxygen in those patients with
inadequate or absent respirations, consider advanced airway (see guideline # 2002-2009).



Determine the degree of respiratory distress (mild/moderate/severe).
Allow the patient to assume the position of comfort unless contraindicated by medical
condition.
 Administer supplemental oxygen (see guideline # 105, 2001) with a device and at a rate appropriate
for the condition of the patient.
 The bag-valve-mask will be kept immediately available to all patients with a provider
assessment of respiratory distress who are in moderate or severe respiratory distress.
 Assess for adequate circulation to perfuse the vital organs. Begin CPR as appropriate.
 Complete the history and focused physical assessment (see guideline #103, 1001). Consider both
medical and traumatic causes of respiratory distress. Follow appropriate treatment guideline.
 Obtain initial vital signs (see guideline #1002) and repeat at a minimum of 15-minute intervals.
Critical patients may need more frequent monitoring.
 Consider intravenous access (see guideline # 3002-3004).
 Consider electrocardiograph monitoring (see guideline #3009). See appropriate dysrhythmia
guidelines.
 Consider CPAP (see guideline #2017)
 Consider drug therapy.
 Albuterol (asthma, COPD) (see drug profile # 002).
 Atrovent (asthma, COPD)(See drug profile # 019)
 Epinephrine (anaphylaxis) (see drug profile # 009)
 Nitroglycerin (CHF) (see drug profile # 015)
 Consider 12-lead electrocardiogram (see guideline #3008).
 Contact medical control for orders as necessary.
 Reassess and document the patient’s respiratory and cardiovascular systems frequently.
 Complete a patient care report (see guideline #102) documenting all pertinent information received,
procedures ordered/completed, results of interventions and changes in the patient’s condition.
 Transport to the closest, most appropriate hospital.
 Document reasons for any deviation from the preceding Guideline/Standard of care.
END
Blank
GUIDELINE/STANDARD OF CARE
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 1/1/05
Guideline Number: 301
The following content will be considered the Guideline/Standard of care for the patient with a
provider impression of:
CARDIAC DYSRHYTHMIA

Assure scene safety and observe universal precautions (see guideline #107).


Assure patent airway (see guideline # 101,201).
Assure adequate respiratory exchange, ventilate with supplemental oxygen in those patients with
inadequate or absent respirations, consider advanced airway (see guideline # 2002-2009).








Determine the degree of respiratory distress (mild/moderate/severe).
Allow the patient to assume the position of comfort unless contraindicated by medical
condition.
Administer supplemental oxygen (see guideline # 105, 2001) with a device and at a rate appropriate
for the condition of the patient.
Assess for adequate circulation to perfuse the vital organs. Begin CPR as appropriate.
Complete the history and focused physical assessment (see guideline #103, 1001).
Obtain initial vital signs (see guideline #1002) and repeat at a minimum of 15-minute intervals.
Critical patients may need more frequent monitoring.
Consider intravenous access (see guideline # 3002-3004).
Consider electrocardiograph monitoring (see guideline #3009). See appropriate dysrhythmia
guidelines.
SYMPTOMATIC
NARROW COMPLEX
WIDE COMPLEX
BRADYCARDIA
TACHYCARDIA
TACHYCARDIA
Rhythm without heart block:
Atrial fibrillation or flutter
Cardioversion (guideline 3007)
Atropine (guideline 005)
with rapid ventricular rate
Procainamide (guideline 016)
Pace (guideline 3010)
(greater than 160), consider
Amiodarone (guideline 003)
Dopamine (guideline 024)
Diltiazem (see guideline #033)
Adenosine (guideline 001)
Epinephrine (guideline 009) Contact medical control as
necessary.
Know Ventricular
Rhythm with heart block
Tachycardia – Lidocaine (see
Pace (guideline 3010)
Other supraventricular
guideline #012) is an option.
tachycardias with inadequate
perfusion:
Vagal maneuvers
Adenosine (guideline 001)
Cardioversion (guideline
3007)




Consider 12-lead electrocardiogram (see guideline #3008). (Basic requires Operational Plan approval)
Contact medical control for orders as necessary.
Reassess and document the patient’s respiratory and cardiovascular systems frequently.
Complete a patient care report (see guideline #102) documenting all pertinent information received,
procedures ordered/completed, results of interventions and changes in the patient’s condition.
 Transport to the closest, most appropriate hospital.
 Document reasons for any deviation from the preceding Guideline/Standard of care.
END
GUIDELINE/STANDARD OF CARE
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 5/30/08
Guideline Number: 302
The following content will be considered the Guideline/Standard of care for the patient with a
provider impression of:
CARDIOPULMONARY ARREST




Assure scene safety and observe universal precautions (see guideline #107).
Assess for unresponsiveness and signs of life.
Basic life support (CPR) will be started on all patients in cardiopulmonary arrest with the
exception of victims with:
 Decapitation or other trauma incompatible with life
 Rigor mortis
 Evidence of tissue decomposition
 Extreme dependent lividity
 Present of valid Do-Not-Resuscitate Order (see guideline 305)
 The on-line medical control physician is to be consulted on all questionable resuscitation
cases. CPR and Advanced Life Support procedures will neither be withheld nor delayed
while the decision regarding resuscitation is made.
If ALS is available, assure that they have been dispatched to the scene.

Assure patent airway. Consider the potential for cervical spine injury during airway maneuvers. (see


guideline # 101,201)
Assure adequate respiratory exchange, ventilate with supplemental oxygen, consider
advanced airway (see guideline # 2002-2009). Defibrillation should not be delayed to insert an advanced airway.
Monitor the ECG.
VENTRICULAR FIBRILLATION,
PULSELESS VENTRICULAR
TACHYCARDIA
Defibrillate (guideline 3006)
Epinephrine (Vasopressin)
(guidelines 009, 020)
Defibrillate
Antiarrhythmic
Defibrillate
ASYSTOLE
Epinephrine (Vasopressin)
(guideline 009, 020)
Atropine (guideline 005)
PULSELESS ELECTRICAL ACTIVITY
Attempt to establish and treat cause:
Hypovolemia (fluids)
Hypoxia (hyperventilate)
Acidosis (hypervent, buffers)
Electrolyte imbalance
Overdose (antidote?)
Cardiac tamponade
Tension pneumothorax
Pulmonary embolism
Hypothermia
Hypoglycemia
Acute coronary syndrome
Epinephrine (Vasopressin)
(guideline 009, 020)
Slow rate = atropine
(guideline 005)
Consider fluids
End page
Cardiopulmonary Arrest (cont.)
 Complete the history and focused physical assessment (see guideline #103, 1001). Attempt to
determine the cause of the cardiac arrest.

AED with pediatric capabilities may be used on children ages 12 months and older. Adult biphasic
AED may be used on children ages 12 months and older but should not be considered preferred
equipment for EMS agencies servicing pediatric populations. Adult monophasic AEDs may be used
on pediatric patients greater than 8 years of age and over 55 pounds who are also less than 12 years
of age. However, energy levels should be set for no more than 200 J for the first two (2)
shocks and no more than 300 J for the third.
 When indicated, manual defibrillation of patients less than 8 years of age and/or less than 55
pounds by advanced life support personnel is done is accordance with AHA guidelines (see
guideline #3006)
 Consider intravenous access (see guideline # 3002-3004).
 Contact medical control for orders as necessary.
 Reassess and document the patient’s condition frequently.
 Complete a patient care report (see guideline # 102) documenting all pertinent information received,
procedures ordered/completed, results of interventions and changes in the patient’s condition.
 Transport to the closest, most appropriate hospital.
 Document reasons for any deviation from the preceding Guideline/Standard of care.
 For situations in which resuscitation attempts are not started, see DNR guideline #305.
Modification of the attached protocol when the victim is apparently pulseless and non-breathing
AND probably significantly hypothermic based on circumstances:
 Secure the airway and ventilate with 100% oxygen. (see guideline #2002, 2004, 105)
 Evaluate the patient, using a minimum of one minute to check carotid and apical pulse.
 Simultaneous with pulse evaluation, monitor (and record if possible) the ECG rhythm.
o For the suspected hypothermic patient in ventricular fibrillation (or the AED
recommends shock), defibrillate (see guideline 3006) one (1) time only. If no
conversion
 Begin Chest compressions
 If ALS, give 1 dose epinephrine/vasopressin)
 Continue with ventilation
 Transport to the closest, most appropriate medical facility
o For the suspected hypothermic patient in asystole or pulseless electrical
activity (PEA) (or no shock advised by AED),
 Continue ventilation
 Begin chest compressions
 If ALS, give 1 dose of epinephrine/vasopressin
 Transport to the closest, most appropriate medical facility.
When the victim is apparently pulseless and non-breathing AND involved in major/multiple trauma, see
guideline #507.
For the resuscitation attempt that is terminated in the field: (Note: permission to terminate
resuscitation efforts can only be obtained from medical control.)
 Complete documentation of the events of the resuscitation on the patient care report.
 Document final evaluation of patient including absence of heart tones, pulses, respiratory effort, final
ECG rhythm (in 3 leads) and the time of cessation of efforts.
 Notify the County Medical Examiner.
 Notify the appropriate law enforcement agency.
 Notify (or document inability to notify) relatives of the patient.
 Insure support and assistance to family/significant others until role is assumed by others.

Arrange appropriate transport of the body or document agency assuming responsibility for the body.
If transport has been initiated, continue transport to the appropriate emergency department and follow
medical control direction to stop resuscitation.
END
GUIDELINE/STANDARD OF CARE
Initial Date:
3/24/08
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/4/08
Guideline Number: 302a
{To use this protocol, a training plan and quality improvement process must be submitted to the
state}
The following content will be considered the Guideline/Standard of care for the patient with a
provider impression of:
Cardiopulmonary Arrest : CARDIOCEREBRAL RESUSCIATION (CCR)

The new CCR guideline is being updated prior to its release. The
new guideline will be distributed after the changes have been made
END
GUIDELINE/STANDARD OF CARE
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 3/28/07
Guideline Number: 303
The following content will be considered the Guideline/Standard of care for the patient with a
provider impression of:
CHEST PAIN/DISCOMFORT
of ischemic cardiac
disease, e.g. chest pressure, radiation pattern to shoulders, arm, diaphoresis, nausea, dyspnea and
in whom the pain is not reproduced by deep breathing or coughing
The guideline/standard should be applied to patients with chest pain and/or other symptoms suggestive













Assure scene safety and observe universal precautions (see guideline #107).
Assure patent airway (see guideline # 101,201).
Assure adequate respiratory exchange, ventilate with supplemental oxygen in those patients with
inadequate or absent respirations, consider advanced airway (see guideline # 2002-2009).
Determine the degree of respiratory distress (mild/moderate/severe).
Allow the patient to assume the position of comfort unless contraindicated by medical
condition.
Administer supplemental oxygen (see guideline # 105, 2001) with a device and at a rate appropriate
for the condition of the patient.
Assess for adequate circulation to perfuse the vital organs. Begin CPR as appropriate.
Complete the history and focused physical assessment (see guideline #103, 1001).
Obtain initial vital signs (see guideline #1002) and repeat at a minimum of 15-minute intervals.
Critical patients may need more frequent monitoring.
Assess for typical signs/symptoms of ischemic cardiac disease including:
 Crushing chest pain, pressure
 Radiation pattern to arm(s), neck, back, jaw
 Pain unchanged/not reproduced by deep breathing, palpation
 Nausea
 Diaphoresis
 Epigastric pain
Consider other causes of chest pain:
 Pulmonary
 Spontaneous pneumothorax
 Pulmonary emboli
 Infectious process (pneumonia, pleurisy)
 Musculoskeletal
 Gastrointestinal
 Hiatal hernia
 Esophageal reflux
 Vascular
 Aneurysm
Assess for other descriptions of chest pain including pleuritic, sharp, stabbing, etc.
Consider intravenous access (see guideline # 3002-3004).


Consider electrocardiograph monitoring (see guideline #3009). See appropriate dysrhythmia
guidelines.
Consider drug therapy.
 In the patient with normal or elevated blood pressure and who has his/her own
nitroglycerine, the EMT may assist the patient in taking his/her medications (see drug profile
#015). In patients with no prior experience with nitroglycerin, an IV line should be started
prior to administration of nitroglycerin.
End page
Chest pain, discomfort (cont.)
If not contraindicated, administer aspirin (see drug profile #004).
 For patients with moderate to severe pain unrelieved by nitroglycerine, administer
morphine IV (see drug profile #013).
 For patient with moderate to severe pain unrelieved by at least three nitroglycerin doses,
consider Nitroglycerin drip (see drug profile 047)
 In patients with ST elevation Myocardial Infarction consider contacting medical control
for Metropolol (see drug profile #051)
 Consider 12-lead electrocardiogram (see guideline #3008). Do not delay nitroglycerin
administration. (EMT requires Operational Plan approval)
 Contact medical control for orders as necessary.
 Reassess and document the patient’s respiratory and cardiovascular systems frequently.
 Complete a patient care report (see guideline #102) documenting all pertinent information received,
procedures ordered/completed, results of interventions and changes in the patient’s condition.
 Transport to the closest, most appropriate hospital.
 Document reasons for any deviation from the preceding Guideline/Standard of care.
END

GUIDELINE/STANDARD OF CARE
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 01/05/09
Guideline Number: 304
The following content will be considered the Guideline/Standard of care for the patient with a
provider impression of:
CONGESTIVE HEART FAILURE

Assure scene safety and observe universal precautions (see guideline #107).

Assure adequate respiratory exchange, ventilate with supplemental oxygen in those patients with
inadequate or absent respirations, consider advanced airway (see guideline # 2002-2009).


Determine the degree of respiratory distress (mild/moderate/severe).
Allow the patient to assume the position of comfort unless contraindicated by medical
condition.
 Administer supplemental oxygen (see guideline # 105, 2001) with a device and at a rate appropriate
for the condition of the patient.
 Assess for adequate circulation to perfuse the vital organs. Begin CPR as appropriate.
 Complete the history and focused physical assessment (see guideline #103, 1001).
 Obtain initial vital signs (see guideline #1002) and repeat at a minimum of 15-minute intervals.
Critical patients may need more frequent monitoring.
 Consider intravenous access (see guideline # 3002-3004).
 Consider electrocardiograph monitoring (see guideline #3009). See appropriate dysrhythmia
guidelines.
 Consider the following therapies.
 In the patient with normal or elevated blood pressure and who has his/her own
nitroglycerine supply, the EMT may assist the patient in taking his/her medication (see drug
profile #015).
 For patient with moderate to severe signs/symptoms of respiratory distress:
 Nitroglycerin sublingually (see drug profile #015)
 Consider CPAP (see guideline #2018) (Basic level systems require Operational Plan Approval)
 Consider Nitroglycerin drip (see drug profile #047)
 Consider Vasotec (see drug profile # 053)
 Consider 12-lead electrocardiogram (see guideline #3008). (Basic level systems require Operational Plan Approval)
 Contact medical control for orders as necessary.
 Reassess and document the patient’s respiratory and cardiovascular systems frequently.
 Complete a patient care report (see guideline #102) documenting all pertinent information received,
procedures ordered/completed, results of interventions and changes in the patient’s condition.
 Transport to the closest, most appropriate hospital.
 Document reasons for any deviation from the preceding Guideline/Standard of care.
END
GUIDELINE/STANDARD OF CARE
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 1/1/05
Guideline Number: 305
The following content will be considered the Guideline/Standard of care for the patient with a
provider impression of:
DO NOT RESUSCITATE ORDERS (DNR) OR OBVIOUS DEATH



Assure scene safety and observe universal precautions (see guideline #107).
Complete the history and focused physical assessment (see guideline # 103, 1001) to establish that the
patient is not a candidate for attempted resuscitation:
 Trauma incompatible with life
 Dependent lividity
 Rigor mortis
 Tissue decomposition
 Valid Do-Not-Resuscitate order
A valid Do-Not-Resuscitate order must include:
 In a health care institution (hospital or nursing home):

A written order on the patient’s chart for “No-Code” or “Do-Not-Resuscitate” signed
and dated by the patient’s attending physician. Contact medical control for advice if
questions arise.





Outside a health care institution, the patient must be wearing a valid Wisconsin Do-NotResuscitate bracelet:

A plastic wrist band with a white insert containing the state seal and the words “Do-NotResuscitate” in blue, the patient’s name, the physician’s name, business telephone number
and signature.

A metal bracelet displaying the international recognized symbol Staff of Aesculapius (staff
and snake) on the front and the words “Wisconsin Do-Not-Resuscitate-EMS”. The patient’s
first and last name must be engraved on the back.

Note: A DNR order is only valid on persons 18 years of age or older and who are not
pregnant.
A DNR order may be revoked by the patient, patient’s guardian or health care agent by
expressing to EMS personnel that the patient should be resuscitated or by defacing, cutting,
removing or asking someone to remove the bracelet.
Contact medical control if there are any questions.
A Do-Not-Resuscitate order is only implemented if the patient does NOT have a pulse. If the
patient still has an obtainable pulse, respirations, pupil reaction or other obvious signs of life,
standard medical care, excluding manual CPR and the use of an advanced airway. Contact
medical control for advice on the use of other advanced pharmacologic support such as
vasopressors and antiarrhythmics.
Special Situations:
 If circumstances are unclear, start resuscitation and contact medical control.
 Placement of an advanced airway or surgical airway is considered heroic and should not
be done in the case of a valid DNR order. Airway positioning, suctioning and
laryngoscopy for foreign body removal are considered comfort measures and may be
performed.


CPAP is a noninvasive airway adjunct and decreases the work of breathing. It is
considered a comfort care measure.
Medical control reserves the right to honor any form of DNR identification including
local facility bracelets, medic alert tags, written physician orders, out-of-state bracelets,
tags and orders. Contact medical control when encountering such documents.
End page 1
DNR page 2

PEDIATRIC DO-NOT-RESUSCITATE
 Wisconsin law does not permit a DNR order on a patient under the age of 18.
 Terminally ill children may have a hospital-directed DNR order
 EMS personnel can only honor a hospital-directed DNR order on a child with prior
approval by the off-line system medical director or on-line medical control at the time of
the call. (Example: The EMS system has prior knowledge of a terminally ill child in their response area and the system medical
director has written a directive for them to honor the hospital-directed DNR if they should respond to the scene.)
Comfort measures for the child prior to death should be instituted as soon as possible.
 Complete a patient care report (see guideline #102) documenting all pertinent information received.
 Follow department policy regarding transport of the body to the appropriate facility.
 Document reasons for any deviation from the preceding Guideline/Standard of care.
END

GUIDELINE/STANDARD OF CARE
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 401
The following content will be considered the Guideline/Standard of care for the patient with a
provider impression of:
ABDOMINAL PAIN/PROBLEMS

Assure scene safety and observe universal precautions (see guideline #107).


Assure patent airway. (see guideline # 101,201).
Assure adequate respiratory exchange, ventilate with supplemental oxygen in those patients with
inadequate or absent respirations, consider advanced airway (see guideline # 2002-2009).

Allow the patient to assume the position of comfort unless contraindicated by medical
condition.
 Administer supplemental oxygen (see guideline # 105, 2001) with a device and at a rate appropriate
for the condition of the patient.
 Assess for adequate circulation to perfuse the vital organs. Begin CPR as appropriate.
 Complete the history and focused physical assessment (see guideline # 103, 1001)
 Document history of hematemesis (vomiting blood), melena (black, tarry stools) or bright red
rectal bleeding.
 Question pregnancy status if of child-bearing age. Consider content of OB/GYN guideline.
 Obtain initial vital signs (see guideline #1002) and repeat at a minimum of 15-minute intervals.
Critical patients may need more frequent monitoring.
 Consider intravenous access (see guideline # 3002-3004).
 Consider pain management, contact medical control as required (see guideline #112)
 Consider electrocardiograph monitoring (see guideline #3009). See appropriate dysrhythmia
guideline.
 The patient should have nothing to eat or drink.
 Consider 12-lead electrocardiogram (see guideline #3008).
 Contact medical control for orders as necessary.
 Reassess and document the patient’s respiratory and cardiovascular systems frequently.
 Complete a patient care report (see guideline #102) documenting all pertinent information received,
procedures ordered/completed, results of interventions and changes in the patient’s condition.
 Transport to the closest, most appropriate hospital.
 Document reasons for any deviation from the preceding Guideline/Standard of care.
END
GUIDELINE/STANDARD OF CARE
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 402
The following content will be considered the Guideline/Standard of care for the patient with a
provider impression of:
ALLERGIC REACTION


Assure scene safety and observe universal precautions (see guideline #107).
Allow the patient to assume the position of comfort unless contraindicated by medical
condition.

Assure adequate respiratory exchange, ventilate with supplemental oxygen in those patients with
inadequate or absent respirations, consider advanced airway (see guideline # 2002-2009).


Determine the degree of respiratory distress (mild/moderate/severe).
Administer supplemental oxygen (see guideline # 105, 2001) with a device and at a rate appropriate
for the condition of the patient.
 Assess for adequate circulation to perfuse the vital organs. Begin CPR as appropriate.
 Complete the history and focused physical assessment (see guideline # 103, 1001)
 Obtain initial vital signs (see guideline #1002) and repeat at a minimum of 15-minute intervals.
Critical patients may need more frequent monitoring.
 Attempt to identify the allergen and its route into the body.
 Consider intravenous access (see guideline # 3002-3004) for patients in moderate/severe respiratory
distress or hypotension.
 Consider electrocardiograph monitoring (see guideline #3009). See appropriate dysrhythmia
guidelines.
 Consider drug therapy.
 For patients with mild to moderate symptoms (e.g. itching, hives), consider IV or PO
diphenhydramine (Benadryl) (see drug profile # 008).
 For patients with moderate to severe signs/symptoms including respiratory distress and/or
hypotension:
 Epinephrine IM (see guideline # 009).
 Diphenhydramine (Benadryl) (see drug profile # 008).
 Solumedrol (see drug profile #027)
 Contact medical control for orders as necessary.
 Ice may be applied to the injection site with the exception of snake bites. Ice should be
wrapped to prevent direct contact with the patient’s skin.
 Reassess and document the patient’s respiratory and cardiovascular frequently.
 Complete a patient care report (see guideline #102) documenting all pertinent information received,
procedures ordered/completed, results of interventions and changes in the patient’s condition.
 Transport to the closest, most appropriate hospital.
 Document reasons for any deviation from the preceding Guideline/Standard of care.
END
GUIDELINE/STANDARD OF CARE
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 403
The following content will be considered the Guideline/Standard of care for the patient with a
provider impression of:
ALTERED LEVEL OF CONSCIOUSNESS

Assure scene safety and observe universal precautions (see guideline #107).


Assure patent airway. (See guideline # 101,201).
Assure adequate respiratory exchange, ventilate with supplemental oxygen in those patients with
inadequate or absent respirations, consider advanced airway (see guideline # 2002-2009).




















Determine the degree of respiratory distress (mild/moderate/severe).
Administer supplemental oxygen (see guideline # 105, 2001) with a device and at a rate appropriate
for the condition of the patient.
The bag-valve-mask will be kept immediately available to all patients with a provider
assessment of altered level of consciousness who are in moderate/severe respiratory distress.
Assess for adequate circulation to perfuse the vital organs. Begin CPR as appropriate.
Complete the history and focused physical assessment (see guideline # 103, 1001)
Obtain initial vital signs (see guideline #1002) and repeat at a minimum of 15-minute intervals.
Critical patients may need more frequent monitoring.
If the cause of the decreased level of consciousness is established (trauma, cardiac,
respiratory, diabetic, CVA, etc.) and the circumstances warrant physician intervention,
contact medical control for specific orders. Apply the appropriate standard of care.
Consider intravenous access (see guideline # 3002-3004).
Consider electrocardiograph monitoring (see guideline #3009). See appropriate dysrhythmia
guidelines.
Measure the blood glucose level (see guideline #4001).
Consider drug therapy if blood glucose is less than 60 mg% (See Dextrose/Glucagon guidelines #006, 011).
Three minutes after administration of dextrose, check the blood glucose level.
If the patient continues to have an altered level of consciousness and the blood glucose level
is still less than60 mg%, repeat the initial dextrose dose.
If the patient does not respond to dextrose or the initial blood sugar is greater than 60 mg%,
administer naloxone (see drug profile #014).
Assess and consider other causes of altered mental status including hypoxia and CVA.
(AEIOU TIPS V)
Consider 12-lead electrocardiogram (see guideline #3008).
Contact medical control for orders as necessary.
Reassess and document the patient’s respiratory, cardiovascular and nervous systems
frequently.
Complete a patient care report (see guideline #102) documenting all pertinent information received,
procedures ordered/completed, results of interventions and changes in the patient’s condition.
Transport to the closest, most appropriate hospital.

Document reasons for any deviation from the preceding Guideline/Standard of care.
END
GUIDELINE/STANDARD OF CARE
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 404
The following content will be considered the Guideline/Standard of care for the patient with a
provider impression of:
BEHAVIORAL/PSYCHIATRIC PROBLEMS


Consider personnel, family and bystander safety.
Observe universal precautions (see guideline #107).

Assure patent airway. (see guideline # 101,201).








Allow the patient to assume the position of comfort.
Administer supplemental oxygen (see guideline # 105, 2001) with a device and at a rate appropriate
for the condition of the patient if appropriate.
Complete the history and focused physical assessment (see guideline # 103, 1001)
Attempt to rule out common physical causes for patient’s abnormal behavior (hypoglycemia,
hypoxia, etc.). Consider concurrent trauma, medication overdose or toxic exposure (see guideline
#412, 506)
Minimize external stimulation if possible.
Evaluate suicidal potential.
Interview with open-ended questions.
Protect patient, family, bystanders and EMS personnel from potential harm. Obtain
additional help as necessary. Consider need for assistance from law enforcement officers.
 Consider the need for physical and/or chemical restraint (see guideline #108).
 Assess the patient’s level of consciousness, level of activity, body language and affect.
 Maintain non-threatening attitude toward patient.
 Obtain initial vital signs (see guideline #1002) and repeat at a minimum of 15-minute intervals.
 Contact medical control for orders as necessary.
 Reassess and document the patient’s respiratory and cardiovascular systems frequently.
 Complete a patient care report (see guideline #102) documenting all pertinent information received,
procedures ordered/completed, results of interventions and changes in the patient’s condition.
 Transport to the closest, most appropriate hospital.
 Document reasons for any deviation from the preceding Guideline/Standard of care.
END
GUIDELINE/STANDARD OF CARE
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 405
The following content will be considered the Guideline/Standard of care for the patient with a
provider impression of:
BITES AND STINGS

Assure scene safety and observe universal precautions (see guideline #107).


Assure patent airway. (see guideline # 101,201).
Assure adequate respiratory exchange, ventilate with supplemental oxygen in those patients with
inadequate or absent respirations, consider advanced airway (see guideline # 2002-2009).






Determine the degree of respiratory distress (mild/moderate/severe).
Allow the patient to assume the position of comfort unless contraindicated by medical
condition.
Administer supplemental oxygen (see guideline # 105, 2001) with a device and at a rate appropriate
for the condition of the patient.
Assess for adequate circulation to perfuse the vital organs. Begin CPR as appropriate.
Complete the history and focused physical assessment (see guideline # 103, 1001).
Evaluate for specific problems associated with envenomation:
HYMENOPTERA (BEES)
Localized pain
Wheal and flare reaction
Anaphylaxis (see guideline
#402)





SPIDERS
Muscle spasm, cramps, pain
Abdominal rigidity
Paresthesias
Headache, dizzy
Nausea, vomiting
Edema
SNAKES
Pit vipers (rattlesnake,
cottonmouth)
Bleeding disorders
Convulsions
Localized swelling,
Coral snakes
Slurred speech
Dilated pupils
Difficulty
swallowing
Respiratory paralysis
For bites from non-venomous animals, see trauma guidelines.
Obtain initial vital signs (see guideline #1002) and repeat at a minimum of 15-minute intervals.
Critical patients may need more frequent monitoring.
Consider intravenous access (see guideline # 3002-3004).
Consider electrocardiograph monitoring (see guideline #3009). See appropriate dysrhythmia
guidelines.
Provide specific emergency care.
HYMENOPTERA (BEES)
SPIDERS
SNAKES
Immobilize and elevate site
Apply dressing to site
Immobilize and keep site
Scrape/brush stinger out
Ice
lower than rest of body
Consider diphenhydramine
(Benadryl) (see drug profile
# 008).
Consider epinephrine (see
guideline # 009).
Consider solumedrol
guideline #027)

(see
Consider diazepam for
Keep patient at rest
muscle spasm (see drug
Expedite transport for
profile # 007)
antivenom
Consider opiate for pain (see
drug profile # 013)
Transport for antitoxin
Consider 12-lead electrocardiogram (see guideline #3008).
End page
Bites and Stings (cont.)




Contact medical control for orders as necessary.
Consider contact with Poison Center.
Reassess and document the patient’s respiratory and cardiovascular systems frequently.
Complete a patient care report (see guideline #102) documenting all pertinent information received,
procedures ordered/completed, results of interventions and changes in the patient’s condition.
 Transport to the closest, most appropriate hospital.
 Document reasons for any deviation from the preceding Guideline/Standard of care.
END
GUIDELINE/STANDARD OF CARE
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 406
The following content will be considered the Guideline/Standard of care for the patient with a
provider impression of:
DIABETES MELLITUS

Assure scene safety and observe universal precautions (see guideline #107).


Assure patent airway. (see guideline # 101,201).
Assure adequate respiratory exchange, ventilate with supplemental oxygen in those patients with
inadequate or absent respirations, consider advanced airway (see guideline # 2002-2009).

Administer supplemental oxygen (see guideline # 105, 2001) with a device and at a rate appropriate
for the condition of the patient.
 Assess for adequate circulation to perfuse the vital organs. Begin CPR as appropriate.
 Complete the history and focused physical assessment (see guideline # 103, 1001).
 Obtain initial vital signs (see guideline #1002) and repeat at a minimum of 15-minute intervals.
Critical patients may need more frequent monitoring.
 Consider intravenous access (see guideline # 3002-3004).
 Consider electrocardiograph monitoring (see guideline #3009). See appropriate dysrhythmia
guidelines.
 Monitor the blood glucose level (see guideline #4001).
 Consider drug therapy if blood glucose is less than60 mg%. (See Dextrose/Glucagon guidelines #006, 011)
 Three minutes after administration of dextrose, check the blood glucose level.
 If the patient continues to have an altered level of consciousness and the blood glucose level
is still less than60 mg%, repeat the initial dextrose dose.
 If the patient’s initial blood sugar is greater than 400 mg%, consider establishing an IV of
0.9% NS. If no history of CHF or renal failure, run IV at 250 ml/hr and transport patient.
 Consider 12-lead electrocardiogram (see guideline #3008).
 Contact medical control for orders as necessary.
 Reassess and document the patient’s respiratory, cardiovascular and nervous systems
frequently.
 Complete a patient care report (see guideline #102) documenting all pertinent information received,
procedures ordered/completed, results of interventions and changes in the patient’s condition.
 Transport to the closest, most appropriate hospital.
 Document reasons for any deviation from the preceding Guideline/Standard of care.
END
GUIDELINE/STANDARD OF CARE
Last Review/Revision: 12/18/08 Guideline Number: 407
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
The following content will be considered the Guideline/Standard of care for the patient with a
provider impression of:
HEADACHE

Assure scene safety and observe universal precautions (see guideline #107).



Assure patent airway. (see guideline # 101,201).
Consider trauma as a possible cause. (see guideline # 506)
Assure adequate respiratory exchange, ventilate with supplemental oxygen in those patients with
inadequate or absent respirations, consider advanced airway (see guideline # 2002-2009)
Consider toxin inhalation (e.g. carbon monoxide) as a possible cause. (see guideline # 204)







Allow the patient to assume the position of comfort unless contraindicated by medical
condition.
Administer supplemental oxygen (see guideline # 105, 2001) with a device and at a rate appropriate
for the condition of the patient.
Assess for adequate circulation to perfuse the vital organs. Begin CPR as appropriate.
Complete the history and focused physical assessment (see guideline # 103, 1001).
Obtain initial vital signs (see guideline #1002) and repeat at a minimum of 15-minute intervals.
Critical patients may need more frequent monitoring.
Evaluate for possible cause





Document potentially serious symptoms











Tension

Muscle contractions of face, neck, scalp

Dull, persistent, non-throbbing
Migraine

Constriction and dilation of cerebral blood vessels

May have aura (visual/GI)

Unilateral, throbbing pain, nausea, vomiting
Cluster

Related to release of histamine and dilated carotid arteries

Usually awakens from sleep

Severe pain in and around eye, nasal congestion, tearing
Sinus

Pain forehead, nasal area, eyes
Hypertension, bradycardia
Unequal pupils
Altered level of consciousness
Projectile vomiting
Posturing
Consider intravenous access (see guideline # 3002-3004).
Consider electrocardiograph monitoring (see guideline #3009). See appropriate dysrhythmia
guidelines.
Consider 12-lead electrocardiogram (see guideline #3008).
Contact medical control for orders as necessary.
Reassess and document the patient’s respiratory and cardiovascular systems frequently.
Complete a patient care report (see guideline #102) documenting all pertinent information received,
procedures ordered/completed, results of interventions and changes in the patient’s condition.


Transport to the closest, most appropriate hospital.
Document reasons for any deviation from the preceding Guideline/Standard of care.
END
GUIDELINE/STANDARD OF CARE
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 408
The following content will be considered the Guideline/Standard of care for the patient with a
provider impression of:
HYPERTENSION

Assure scene safety and observe universal precautions (see guideline #107).


Assure patent airway. (see guideline # 101,201).
Assure adequate respiratory exchange, ventilate with supplemental oxygen in those patients with
inadequate or absent respirations, consider advanced airway (see guideline # 2002-2009).














Allow the patient to assume the position of comfort unless contraindicated by medical
condition.
Administer supplemental oxygen (see guideline # 105, 2001) with a device and at a rate appropriate
for the condition of the patient.
Assess for adequate circulation to perfuse the vital organs. Begin CPR as appropriate.
Complete the history and focused physical assessment (see guideline # 103, 1001).
Document associated symptoms.
Obtain initial vital signs (see guideline #1002) and repeat at a minimum of 15-minute intervals.
Critical patients may need more frequent monitoring.
Consider intravenous access (see guideline # 3002-3004).
Consider electrocardiograph monitoring (see guideline #3009). See appropriate dysrhythmia
guidelines.
Consider 12-lead electrocardiogram (see guideline #3008).
Contact medical control for orders as necessary.
Reassess and document the patient’s respiratory and cardiovascular systems frequently.
Complete a patient care report (see guideline #102) documenting all pertinent information received,
procedures ordered/completed, results of interventions and changes in the patient’s condition.
Transport to the closest, most appropriate hospital.
Document reasons for any deviation from the preceding Guideline/Standard of care.
Note: Pre-hospital intervention is usually not indicated for hypertensive patients with a
working assessment of CVA. Contact medical control if in doubt.
END
GUIDELINE/STANDARD OF CARE
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 409
The following content will be considered the Guideline/Standard of care for the patient with a
provider impression of:
HYPERTHERMIA/FEVER

Assure scene safety and observe universal precautions (see guideline #107).


Assure patent airway. (see guideline # 101,201).
Assure adequate respiratory exchange, ventilate with supplemental oxygen in those patients with
inadequate or absent respirations, consider advanced airway (see guideline # 2002-2009).


Determine the degree of respiratory distress (mild/moderate/severe).
Administer supplemental oxygen (see guideline # 105, 2001) with a device and at a rate appropriate
for the condition of the patient.
 Assess for adequate circulation to perfuse the vital organs. Begin CPR as appropriate.
 Move the patient to a cool environment.
 Remove clothing.
 Complete the history and focused physical assessment (see guideline # 103, 1001).
 Obtain initial vital signs (see guideline #1002) and repeat at a minimum of 15-minute intervals.
Critical patients may need more frequent monitoring.
 Consider intravenous access (see guideline # 3002-3004)
 Consider electrocardiograph monitoring (see guideline #3009). See appropriate dysrhythmia
guidelines.
 Cool patient with misting spray/sprinkle and fan patient to promote evaporation.
 For patients with high core temperatures (as evidenced by altered mental status), attempt to
cool the core with ice applied to neck, axillae and femoral areas. Ice should be wrapped to
prevent injury due to direct contact with skin.
 Consider 12-lead electrocardiogram (see guideline #3008).
 Contact medical control for orders as necessary.
 Reassess and document the patient’s respiratory and cardiovascular systems frequently.
 Complete a patient care report (see guideline #102) documenting all pertinent information received,
procedures ordered/completed, results of interventions and changes in the patient’s condition.
 Transport to the closest, most appropriate hospital.
 Document reasons for any deviation from the preceding Guideline/Standard of care.
END
GUIDELINE/STANDARD OF CARE
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 410
The following content will be considered the Guideline/Standard of care for the patient with a
provider impression of:
HYPOTHERMIA

Assure scene safety and observe universal precautions (see guideline #107).

Assure patent airway. Consider the potential for cervical spine injury when performing airway
maneuvers. (see guideline # 101,201).
Assure adequate respiratory exchange, ventilate with warmed supplemental oxygen (if available) in
those patients with inadequate or absent respirations, consider advanced airway (see guideline # 2002-


2009).
Administer supplemental oxygen (see guideline # 105, 2001) with a device and at a rate appropriate
for the condition of the patient.
 Assess for adequate circulation to perfuse the vital organs. Additional time (35-45 seconds)
should be used to check for peripheral pulses in the hypothermic patient. Begin CPR as
appropriate.
 Hypothermic patients in cardiac arrest should be transported as soon as possible to a medical
facility for rewarming.
 Hypothermic patients in ventricular fibrillation should be defibrillated once to determine
response to electrical cardioversion, then transport. Further defibrillation attempts should be
deferred until the patient’s core temperature is greater than 30º C or 86º F. Focus on CPR.
 Depending on patient temperature, ACLS drugs may be ineffective. Contact medical control
prior to administration of second round of ACLS drugs.
 Remove wet clothing, move to a warm environment, minimize physical jostling of the
patient.
 Complete the history and focused physical assessment (see guideline # 103, 1001).
 Obtain initial vital signs (see guideline #1002) and repeat at a minimum of 15-minute intervals.
Critical patients may need more frequent monitoring.
 Consider intravenous access (see guideline # 3002-3004). ). Encourage warmed IV fluids if available.
 Consider electrocardiograph monitoring (see guideline #3009). See appropriate dysrhythmia
guidelines.
 Sinus bradycardia with a pulse may be physiologic and usually does not require specific
cardiac rate treatment.
 Avoid rubbing frost bitten extremities.
 Contact medical control for orders as necessary.
 Reassess and document the patient’s respiratory and cardiovascular systems frequently.
 Complete a patient care report (see guideline #102) documenting all pertinent information received,
procedures ordered/completed, results of interventions and changes in the patient’s condition.
 Transport to the closest, most appropriate hospital.
 Document reasons for any deviation from the preceding Guideline/Standard of care.
END
GUIDELINE/STANDARD OF CARE
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 411
The following content will be considered the Guideline/Standard of care for the patient with a
provider impression of:
INTOXICATION/SUBSTANCE ABUSE

Assure scene safety and observe universal precautions (see guideline #107). Consider the need for
law enforcement assistance.

Assure patent airway. Consider the potential for cervical spine injury during airway maneuvers. (see
guideline # 101,201).
Assure adequate respiratory exchange, ventilate with supplemental oxygen in those patients with
inadequate or absent respirations, consider advanced airway (see guideline # 2002-2009).


Allow the patient to assume the position of comfort unless contraindicated by medical
condition.
 Administer supplemental oxygen (see guideline # 105, 2001) with a device and at a rate appropriate
for the condition of the patient.
 Assess for adequate circulation to perfuse the vital organs. Begin CPR as appropriate.
 Complete the history and focused physical assessment (see guideline # 103, 1001). Attempt to identify
and document the type and quantity of substance(s) abused. Patients should be asked directly
if they used any substance(s) as opposed to assuming that they did. If the patient is unable or
unwilling to supply the information, seek and document the source of information from
family or bystanders.
 Attempt to identify specific health problems known to be related to the patient’s type of
substance abuse.
 Consider concurrent trauma, medication overdose or toxic exposure (see guidelines #412, 506).
 Obtain initial vital signs (see guideline #1002) and repeat at a minimum of 15-minute intervals.
Critical patients may need more frequent monitoring.
 Consider intravenous access (see guideline # 3002-3004).
 Measure blood sugar (see guideline 4001). If the patient is hypoglycemic, consider Thiamine (see drug
profile 022) prior to administration of Dextrose (see guideline 406).
 Consider electrocardiograph monitoring (see guideline #3009). See appropriate dysrhythmia
guideline
 Contact medical control for orders as necessary.
 Reassess and document the patient’s respiratory and cardiovascular systems frequently.
 Complete a patient care report (see guideline #102) documenting all pertinent information received,
procedures ordered/completed, results of interventions and changes in the patient’s condition.
 Transport to the closest, most appropriate hospital.
 Document reasons for any deviation from the preceding Guideline/Standard of care.
END
GUIDELINE/STANDARD OF CARE
Last Review/Revision: 12/18/08 Guideline Number: 412
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
The following content will be considered the Guideline/Standard of care for the patient with a
provider impression of:
POISONING, OVERDOSE OR TOXINS

Assure scene/environmental safety and observe universal precautions (see guideline #107).


Assure patent airway. (see guideline # 101,201).
Assure adequate respiratory exchange, ventilate with supplemental oxygen in those patients with
inadequate or absent respirations, consider advanced airway (see guideline # 2002-2009).



















Allow the patient to assume the position of comfort unless contraindicated by medical
condition.
Administer supplemental oxygen (see guideline # 105, 2001) with a device and at a rate appropriate
for the condition of the patient.
Assess for adequate circulation to perfuse the vital organs. Begin CPR as appropriate.
Complete the history and focused physical assessment (see guideline # 103, 1001).
Obtain initial vital signs (see guideline #1002) and repeat at a minimum of 15-minute intervals.
Critical patients may need more frequent monitoring.
Attempt to identify and document:
 Time of ingestion
 Amount of substance ingested, injected, inhaled or absorbed
 Substance(s) ingested, injected, inhaled or absorbed
Name and strength of medication
Name, active ingredients of toxic substances
For patients older than age 6, ask specifically why they ingested the substance(s). Document
the answer.
Closely supervise all patients who admit to or who appear to have ingested, injected or
inhaled a substance in an attempt at self-harm. Evaluate suicide potential. Consider need for
assistance from law enforcement.
If patient has mental status changes, rule out and treat hypoxia and hypoglycemia (see guideline
406, 4001) if present
Consider intravenous assess (see guideline # 3002-3004).
Consider electrocardiograph monitoring (see guideline #3009).
For situations involving envenomation (bites/stings), see appropriate guideline. (see guideline #405)
Consider 12-lead electrocardiogram (see guideline #3008).
Consider contact of Poison Center.
If vital signs are unstable and narcotic overdose is likely, consider Narcan (see drug profile
014).
If pure benzodiazepine overdose is suspected and the patient’s airway is compromised,
consider Romazicon with the approval of on-line medical control. (see drug profile 025).
Contact medical control for orders as necessary.




Reassess and document the patient’s respiratory, cardiovascular and nervous systems
frequently.
Complete a patient care report (see guideline #102) documenting all pertinent information received,
procedures ordered/completed, results of interventions and changes in the patient’s condition.
Transport to the closest, most appropriate hospital.
Transport all medications or other substances believed to have been taken by the patient to
the hospital with the patient.
Document reasons for any deviation from the preceding Guideline/Standard of care.

END
GUIDELINE/STANDARD OF CARE
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 413
The following content will be considered the Guideline/Standard of care for the patient with a
provider impression of:
SEIZURE

Assure scene safety and observe universal precautions (see guideline #107).

Assure patent airway. Consider the potential for cervical spine injury during airway maneuvers. (see
guideline # 101,201).
Assure adequate respiratory exchange, ventilate with supplemental oxygen in those patients with
inadequate or absent respirations, consider advanced airway (see guideline # 2002-2009).













Allow the patient to assume the position of comfort unless contraindicated by medical
condition.
Administer supplemental oxygen (see guideline # 105, 2001) with a device and at a rate appropriate
for the condition of the patient.
Assess for adequate circulation to perfuse the vital organs. Begin CPR as appropriate.
Protect patient from injury.
Complete the history and focused physical assessment (see guideline # 103, 1001).
Document:
 Description of the seizure activity
 Time of onset and length of seizure activity
Attempt to ascertain and document the probable cause of the seizure, e.g. hypoglycemia,
hypoxia, medication noncompliance, use of illicit drugs or alcohol. Consider concurrent
trauma, medication overdose or toxic exposure (see guidelines #412, 506).
Obtain initial vital signs (see guideline #1002) and repeat at a minimum of 15-minute intervals.
Critical patients may need more frequent monitoring.
Measure blood sugar level. (see guideline #4001). If hypoglycemic (See Dextrose/Glucagon guidelines #006.)
Consider intravenous access (see guideline # 3002-3004).
Consider electrocardiograph monitoring (see guideline #3009). See appropriate dysrhythmia
guidelines.
Consider drug therapy.
 Diazepam (Valium) (see drug profile #007)
 Lorazepam (Ativan) (see drug profile #038)
 Midazolam (Versed) (see drug profile #022)
 Dextrose (See drug profile # 006).
 Glucagon (see drug profile #011)
 Magnesium Sulfate for seizures associated with hypertension of pregnancy (see drug profile
#026)

Contact medical control for orders as necessary.
Reassess and document the patient’s respiratory, cardiovascular and nervous systems
frequently.
 Complete a patient care report (see guideline #102) documenting all pertinent information received,
procedures ordered/completed, results of interventions and changes in the patient’s condition.
 Transport to the closest, most appropriate hospital.
 Document reasons for any deviation from the preceding Guideline/Standard of care.
END

GUIDELINE/STANDARD OF CARE
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 414
The following content will be considered the Guideline/Standard of care for the patient with a
provider impression of:
STROKE/CEREBRAL VASCULAR ACCIDENT/TRANSIENT ISCHEMIC ATTACK

Assure scene safety and observe universal precautions (see guideline #107).


Assure patent airway. (see guideline # 101,201).
Assure adequate respiratory exchange, ventilate with supplemental oxygen in those patients with
inadequate or absent respirations, consider advanced airway (see guideline # 2002-2009).


















Allow the patient to assume the position of comfort unless contraindicated by medical
condition.
Administer supplemental oxygen (see guideline # 105, 2001) with a device and at a rate appropriate
for the condition of the patient.
Assess for adequate circulation to perfuse the vital organs. Begin CPR as appropriate.
Complete the history and focused physical assessment (see guideline # 103, 1001).
Complete Cincinnati Prehospital Stroke Scale
 Have patient smile or show teeth (Look for facial droop on one side.)
 Have patient close eyes and hold out both arms in front of him/her (Look for arm drift—
one arm doesn’t move or one arm drifts down compared with the other.)
 Have patient say a familiar phrase e.g. You can’t teach an old dog new tricks.” (Listen for
slurring of words, using inappropriate words or inability to speak.)
Obtain initial vital signs (see guideline #1002) and repeat at a minimum of 15-minute intervals.
Critical patients may need more frequent monitoring.
Attempt to ascertain the patient’s normal mental status and physical capabilities.
Assess for signs of trauma, including head and neck evaluation. Immobilize if indicated.
Obtain information as to exact time of onset of symptoms.
Notify receiving hospital as soon as possible allowing mobilization of hospital resources.
Take precautions to avoid accidental injury to paralyzed extremities during patient
movement.
Check blood sugar. (see guideline #4001). If hypoglycemic (Blood glucose less than60 mg%)
follow appropriate guideline. (see guideline # 403, 406).
Begin transport as soon as possible for evaluation and possible administration of
thrombolytic agents.
Consider intravenous access (see guideline # 3002-3004).
Consider electrocardiograph monitoring (see guideline #3009). See appropriate dysrhythmia
guidelines.
Consider 12-lead electrocardiogram (see guideline #3008).
Contact medical control for orders as necessary.
Reassess and document the patient’s respiratory, cardiovascular and nervous systems
frequently.



Complete a patient care report (see guideline #102) documenting all pertinent information received,
procedures ordered/completed, results of interventions and changes in the patient’s condition.
Transport to the closest, most appropriate hospital.
Document reasons for any deviation from the preceding Guideline/Standard of care.
Note: Pre-hospital intervention is usually not indicated for hypertensive patients with a
working assessment of CVA. Contact medical control if in doubt.
END
GUIDELINE/STANDARD OF CARE
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 415
The following content will be considered the Guideline/Standard of care for the patient with a
provider impression of:
SYNCOPE

Assure scene safety and observe universal precautions (see guideline #107).

Assure patent airway. Consider potential for cervical spine injury during airway maneuvers. (see
guideline # 101,201).
Assure adequate respiratory exchange, ventilate with supplemental oxygen in those patients with
inadequate or absent respirations, consider advanced airway (see guideline # 2002-2009).















Allow the patient to assume the position of comfort unless contraindicated by medical
condition.
Administer supplemental oxygen (see guideline # 105, 2001) with a device and at a rate appropriate
for the condition of the patient.
Assess for adequate circulation to perfuse the vital organs. Begin CPR as appropriate.
Complete the history and focused physical assessment (see guideline # 103, 1001).
Obtain initial vital signs (see guideline #1002) and repeat at a minimum of 15-minute intervals.
Critical patients may need more frequent monitoring.
Attempt to establish and document a reason for the syncopal episode e.g. cardiac, trauma,
metabolic, neurologic problems. See appropriate guideline.
Obtain a blood sugar measurement (see guideline #4001). If hypoglycemic, follow appropriate
guideline (see guideline # 403.406).
Consider intravenous access (see guideline # 3002-3004).
Consider electrocardiograph monitoring (see guideline #3009). See appropriate dysrhythmia
guidelines.
Obtain and document orthostatic vital signs, provided the patient is not hypotensive when
supine. Orthostatic hypotension will be defined as a drop in systolic blood pressure of 20
mmHg or more and/or pulse increase of 20 or more/min. For individuals with orthostatic
hypotension, follow appropriate guideline (see guideline # 505).
Consider 12-lead electrocardiogram (see guideline #3008).
Contact medical control for orders as necessary.
Reassess and document the patient’s respiratory, cardiovascular and nervous systems
frequently.
Complete a patient care report (see guideline #102) documenting all pertinent information received,
procedures ordered/completed, results of interventions and changes in the patient’s condition.
Transport to the closest, most appropriate hospital.
Document reasons for any deviation from the preceding Guideline/Standard of care.


END
GUIDELINE/STANDARD OF CARE
Initial Date:
1/05/09
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision:
Guideline Number: 416
The following content will be considered the Guideline/Standard of care for
Cyanide Poisoning


Cyanide poisoning may occur from inhalation, dermal exposure, or ingestion of cyanide
containing substances.
Smoke inhalation in the setting of burning plastics, nylon, other synthetic polymers, or
wool.
Occupational exposure to cyanide salts or inhalation of hydrocyanide gas.
Accidental, suicidal, or homicidal ingestions of cyanide containing substances or plants.
Cyanide is a cellular toxin that inhibits cellular utilization of oxygen.
Cyanide does not affect the transfer of oxygen by the lungs to blood cells. The oxygen
saturation (SPO2) will not be affected by cyanide poisoning. It may read normal; high in
the setting of simultaneous carbon monoxide poisoning; or low if there was a thermal or
other injury to the lungs.
Poisoned cells are asphyxiated. Even with adequate oxygenation of the blood, the cells
are prevented from utilizing oxygen and will die unless an antidote is administered to
remove the cyanide. Hyperbaric treatment is not effective in treating cyanide poisoning.
However, hyperbaric treatment can be effective if the patient also has carbon monoxide
poisoning.
Signs and Symptoms of Acute Cyanide Toxicity
Cardiovascular
Tachycardia (heart rate >100)
Mild
Hypertension (BP > 140/90)

Bradycardia (heart rate <60)

Hypotension (systolic BP <100)
Cardiovascular Collapse
Asystole


Severe
CNS
Headache
Drowsiness
Seizures
Coma
Mild


Severe
Pulmonary
Dyspnea
Tachypnea (adult resp rate >20)
Apnea
Mild

Severe
From: Emergency Medicine: A Comprehensive Study Guide, 6 th edition. Tintinalli, JE, et al, McGraw-Hill, 2004.
VI. Assure scene safety and observe universal precautions (see guideline #107).
VII. Assure patent airway. (see guideline # 101,201).
VIII. Assure adequate respiratory exchange, ventilate with supplemental oxygen in those patients with
inadequate or absent respirations, consider advanced airway (see guideline # 2002-2009).
IX. Determine the degree of respiratory distress (mild/moderate/severe). Evaluate for potential
for inhalation injury. (see guideline #204)
X. Administer supplemental oxygen (see guideline # 105, 2001) with a device appropriate for the
condition of the patient, and with the highest percent oxygen inspired (FIO2) possible.
XI. Assess for adequate circulation to perfuse the vital organs. Begin CPR as appropriate.
XII. Complete the history and focused physical assessment (see guideline # 103, 1001).
XIII. Obtain initial vital signs (see guideline #1002) and repeat at a minimum of 15-minute intervals.
Critical patients may need more frequent monitoring.
XIV. In patients in whom there is a high clinical suspicion of cyanide poisoning and with more
than mild signs or symptoms, contact medical control for consideration of
administration of Cyanokit cyanide antidote (see DRUG PROFILE Number: ).
XV. Example: 40 yo male found unconscious in an industrial fire with dense smoke present
with no evidence of trauma, a respiratory rate of 8, pulse of 50 and BP 86/50.
XVI. Cyanide toxicity as outlined in the table in this protocol can present with mild to severe
symptoms. There is no test in the field to determine if it is present. Many of the signs
and symptoms could also be caused by other conditions such as carbon monoxide
poisoning, trauma, cardiac events, overdoses, etc. Cyanide toxicity can of course also
occur at the same time as these other conditions and require simultaneous treatment.
The key is to keep this diagnosis in mind in the settings where someone may have been
exposed; most commonly this would be from smoke inhalation or industrial chemicals.
XVIII. In patients with more than mild signs and symptoms, consider possibility of carbon
monoxide poisoning in addition to cyanide toxicity, communicate with medical control
and consider direct transport (or flight) to appropriate hyperbaric center.
GUIDELINE/STANDARD OF CARE
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 10/30/02
Guideline Number: 501
The following content will be considered the Guideline/Standard of care for the patient with a
provider impression of:
ABUSE/ASSAULT

Assure scene safety and observe universal precautions (see guideline #107).


Assure patent airway. (see guideline # 101,201).
Assure adequate respiratory exchange, ventilate with supplemental oxygen in those patients with
inadequate or absent respirations, consider advanced airway (see guideline # 2002-2009).












Allow the patient to assume the position of comfort unless contraindicated by medical
condition.
Administer supplemental oxygen (see guideline # 105, 2001) with a device and at a rate appropriate
for the condition of the patient.
Assess for adequate circulation to perfuse the vital organs. Begin CPR as appropriate.
Complete the history and focused physical assessment (see guideline # 103, 1001).
Obtain initial vital signs (see guideline #1002) and repeat at a minimum of 15-minute intervals.
Critical patients may need more frequent monitoring.
Consider intravenous access (see guideline # 3002-3004).
Consider electrocardiograph monitoring (see guideline #3009). See appropriate dysrhythmia
guidelines.
For patients with suspected domestic violence:
 Ask directly if someone hurt them.
 Convey awareness that injuries may be due to their spouse/partner.
 Consider safety issues.
 Supply information on community resources and how to access them.
For patients with suspected elder abuse
 Assess for medical, social and economic stresses.
 Use direct questions as in domestic abuse.
 Involve law enforcement and social agencies as appropriate.
For patients with suspected child abuse
 Involve law enforcement and social agencies as appropriate
For patients with suspected sexual assault/abuse:
 Assess and treat physical injuries (see guideline # 504).
 Preserve evidence.
 Consider transport to Sexual Assault Treatment Center.
 Involve law enforcement as appropriate.
Consider 12-lead electrocardiogram (see guideline #3008).



Contact medical control for orders as necessary.
Reassess and document the patient’s respiratory and cardiovascular systems frequently.
Complete a patient care report (see guideline #102) documenting all pertinent information received,
procedures ordered/completed, results of interventions and changes in the patient’s condition.
 Transport to the closest, most appropriate hospital.
 Document reasons for any deviation from the preceding Guideline/Standard of care.
END
GUIDELINE/STANDARD OF CARE
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision:
12/06/2002
Guideline Number: 502
The following content will be considered the Guideline/Standard of care for the patient with a
provider impression of:
BURNS


Assure scene safety and observe universal precautions (see guideline #107).
Stop the burning process.


Assure patent airway. (see guideline # 101,201).
Assure adequate respiratory exchange, ventilate with supplemental oxygen in those patients with
inadequate or absent respirations, consider advanced airway (see guideline # 2002-2009).

Determine the degree of respiratory distress (mild/moderate/severe). Evaluate for potential
for inhalation injury. (see guideline #204)
 Consider toxic inhalation and follow appropriate guideline if indicated.
 Administer supplemental oxygen (see guideline # 105, 2001) with a device and at a rate appropriate
for the condition of the patient.
 Assess for adequate circulation to perfuse the vital organs. Begin CPR as appropriate.
 Complete the history and focused physical assessment (see guideline # 103, 1001).
 Obtain initial vital signs (see guideline #1002) and repeat at a minimum of 15-minute intervals.
Critical patients may need more frequent monitoring.
 Document causative agent of the burn injury.
 Calculate the extent of the burn injury using the Rule of 9’s or Rule of Palms.
 Consider intravenous access (see guideline # 3002-3004).
 Consider pain management (see guideline #112).
 Consider electrocardiograph monitoring (see guideline #3009). See appropriate dysrhythmia
guidelines.
 Remove nonadherent contaminated clothing
 Provide wound care for the burn injury.
 For burns less than25% of total body surface area, use wet dressings.
 For burns greater than 25% of total body surface area, use dry dressings.
 May use alternative clear plastic wrap (eg. Glad wrap) on thermal burns (noncircumferential application)
 Contact medical control for orders as necessary.
 Reassess and document the patient’s respiratory and cardiovascular systems frequently.
 Complete a patient care report (see guideline #102) documenting all pertinent information received,
procedures ordered/completed, results of interventions and changes in the patient’s condition.
 Transport to the closest, most appropriate hospital.
 Document reasons for any deviation from the preceding Guideline/Standard of care.
END
Note: Note: State of Wisconsin Standards and Procedures of Practical Skills Manual
(July 2008 Rev) is appended and contains step-by-step instructions for: Chemical burns,
electrical burns. See index for page numbers.
GUIDELINE/STANDARD OF CARE
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 10/30/02
Guideline Number: 503
The following content will be considered the Guideline/Standard of care for the patient with a
provider impression of:
DROWNING


Rescue safely.
Assure scene safety and observe universal precautions (see guideline #107).

Assure patent airway. Consider the potential for cervical spine injury during airway maneuvers. (see
guideline # 101,201).
Assure adequate respiratory exchange, ventilate with supplemental oxygen in those patients with
inadequate or absent respirations, consider advanced airway (see guideline # 2002-2009).


Determine the degree of respiratory distress (mild/moderate/severe), including prior vomiting
or aspiration.
 Administer supplemental oxygen (see guideline # 105, 2001) with a device and at a rate appropriate
for the condition of the patient.
 Assess for adequate circulation to perfuse the vital organs. Begin CPR as appropriate.
 Complete the history and focused physical assessment (see guideline # 103, 1001). Consider the
potential for hypothermia.
 Obtain initial vital signs (see guideline #1002) and repeat at a minimum of 15-minute intervals.
Critical patients may need more frequent monitoring.
 Consider intravenous access (see guideline # 3002-3004).
 Consider electrocardiograph monitoring (see guideline #3009). See appropriate dysrhythmia
guidelines.
 Document the estimated time of submersion.
 Attempt to ascertain why the incident occurred (child left unattended, seizure or other
medical emergency, head/neck injury, etc.)
 Document the type and temperature of the water.
 Minimize heat loss from the patient.
 Apply appropriate guideline/standard for associated trauma or medical condition.
 Consider 12-lead electrocardiogram (see guideline #3008).
 Contact medical control for orders as necessary.
 Consider Positive End Expiratory Pressure (PEEP). (see guideline # 2011)
 Reassess and document the patient’s respiratory, cardiovascular and nervous systems
frequently.
 Complete a patient care report (see guideline #102) documenting all pertinent information received,
procedures ordered/completed, results of interventions and changes in the patient’s condition.
 Transport to the closest, most appropriate hospital.
 Document reasons for any deviation from the preceding Guideline/Standard of care.
END
GUIDELINE/STANDARD OF CARE
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 10/30/02
Guideline Number: 504
The following content will be considered the Guideline/Standard of care for the patient with a
provider impression of:
ELECTROCUTION

Assure scene safety and observe universal precautions (see guideline #107).


Assure patent airway. Consider cervical spine during airway maneuvers. (see guideline # 101,201).
Assure adequate respiratory exchange, ventilate with supplemental oxygen in those patients with
inadequate or absent respirations, consider advanced airway (see guideline # 2002-2009).


Determine the degree of respiratory distress (mild/moderate/severe).
Allow the patient to assume the position of comfort unless contraindicated by medical
condition.
 Administer supplemental oxygen (see guideline # 105, 2001) with a device and at a rate appropriate
for the condition of the patient.
 Assess for adequate circulation to perfuse the vital organs. Begin CPR as appropriate.
 Complete the history and focused physical assessment (see guideline # 103, 1001).
 Obtain initial vital signs (see guideline #1002) and repeat at a minimum of 15-minute intervals.
Critical patients may need more frequent monitoring.
 Consider intravenous access (see guideline #3002).
 Consider electrocardiograph monitoring (see guideline #3009). See appropriate dysrhythmia
guidelines.
 Provide appropriate wound care. (see guideline # 5001).
 Evaluate for fractures and dislocations due to muscle contractions during electrical injury.
 Consider 12-lead electrocardiogram (see guideline #3008).
 Contact medical control for orders as necessary.
 Reassess and document the patient’s respiratory, nervous and cardiovascular systems
frequently.
 Complete a patient care report (see guideline #102) documenting all pertinent information received,
procedures ordered/completed, results of interventions and changes in the patient’s condition.
 Document type of current and duration of contact if known.
 Transport to the closest, most appropriate hospital.
 Document reasons for any deviation from the preceding Guideline/Standard of care.
END
GUIDELINE/STANDARD OF CARE
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 10/30/02
Guideline Number: 505
The following content will be considered the Guideline/Standard of care for the patient with a
provider impression of:
HYPOTENSION/SHOCK

Assure scene safety and observe universal precautions (see guideline #107).

Assure patent airway. Consider the potential for cervical injury during airway maneuvers. (see guideline
# 101,201).
Assure adequate respiratory exchange, ventilate with supplemental oxygen in those patients with
inadequate or absent respirations, consider advanced airway (see guideline # 2002-2009).






Administer supplemental oxygen (see guideline # 105, 2001) with a device and at a rate appropriate
for the condition of the patient.
Assess for adequate circulation to perfuse the vital organs. Begin CPR as appropriate.
Stop all obvious hemorrhage (see guideline # 5001). Splint major fractures. (see guideline # 5003-5010)
Complete the history and focused physical assessment (see guideline # 103, 1001)
Obtain initial vital signs (see guideline #1002) and repeat at a minimum of 15-minute intervals.
Critical patients may need more frequent monitoring. Document, if known, specific information about the
mechanism of injury.


If hypovolemia is not believed to be the cause of hypotension, consider Dopamine (see drug
profile 024).
Attempt to ascertain and document cause of hypotension and inadequate perfusion. If
nontraumatic etiology, follow appropriate guideline.
 Expedite transport of hypotensive trauma victims.
 The patient should have nothing to eat or drink.
 Consider intravenous access (see guideline # 3002-3004). For hypovolemia, one IV line with a
pressure bag should be started and a second attempted in route if possible.
 In trauma cases, administer IV fluids to maintain systolic blood pressure at 90 mmHg.
Additional IV fluid to elevate the blood pressure may cause unnecessary bleeding and
hemodilution when administered prior to surgical repair of bleeding site.
 Consider the use of the PASG. (see guideline # 5004)
 Consider electrocardiograph monitoring (see guideline #3009). See appropriate dysrhythmia
guidelines.
 Contact medical control for orders as necessary.
 Reassess and document the patient’s respiratory, cardiovascular and nervous systems
frequently.
 Complete a patient care report (see guideline #102) documenting all pertinent information received,
procedures ordered/completed, results of interventions and changes in the patient’s condition.
 Transport to the closest, most appropriate hospital.
 Document reasons for any deviation from the preceding Guideline/Standard of care.
END
GUIDELINE/STANDARD OF CARE
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/03/02
Guideline Number: 506
The following content will be considered the Guideline/Standard of care for the patient with a
provider impression of:
BLUNT, PENETRATING OR LACERATING TRAUMA

Assure scene safety and observe universal precautions (see guideline #107).

Assure patent airway. Consider the potential for cervical spine injury during airway maneuvers. (see
guideline # 101,201).
Assure adequate respiratory exchange, ventilate with supplemental oxygen in those patients with
inadequate or absent respirations, consider advanced airway (see guideline # 2002-2009).


Administer supplemental oxygen (see guideline # 105, 2001) with a device and at a rate appropriate
for the condition of the patient.
 Assess for adequate circulation to perfuse the vital organs. Begin CPR as appropriate.
 Stop all obvious hemorrhage (see guideline # 5001), splint major fractures (see guideline #5003-5010).
Dressings applied to the proximal wound (stump) in the case of traumatic amputations should
be dry.
 Complete the history and focused physical assessment (see guideline # 103, 1001).
 Obtain initial vital signs (see guideline #1002) and repeat at a minimum of 15-minute intervals.
Critical patients may need more frequent monitoring. If the patient is hypotensive, see
hypotension—shock. (see guideline # 505).
 Document, if known, specific information about the mechanism of injury.
 In the instance of traumatically amputated or avulsed tissue, that tissue should be enclosed in
a water-proof plastic bag and cooled. The tissue can be wrapped in dry dressings to prevent
cold injury before placing in water-proof bag. The patient and separated tissues should be
conveyed to a medical facility capable of attempting to reattach it.

Consider intravenous access (see guideline # 3002-3004). The number of intravenous lines and the
rate of administration are adjusted according to the clinical condition of the patient.
 Consider electrocardiograph monitoring (see guideline #3009). See appropriate dysrhythmia
guidelines.
 Contact medical control for orders as necessary.
 Reassess and document the patient’s respiratory, cardiovascular, nervous and
musculoskeletal systems frequently.
 Complete a patient care report (see guideline #102) documenting all pertinent information received,
procedures ordered/completed, results of interventions and changes in the patient’s condition.
Include computation of the Glasgow Coma Scale.
 Transport to the closest, most appropriate hospital. Expedite transport of unstable trauma
victims.
 Document reasons for any deviation from the preceding Guideline/Standard of care.
END
GUIDELINE/STANDARD OF CARE
Initial Date: 1/1/05
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 1/07/09
Guideline Number: 507
The following content will be considered the Guideline/Standard of care for
MAJOR/MULTIPLE TRAUMA
For the patient who sustains major or multiple blunt or penetrating trauma, the following
protocols shall be followed:
Assess scene safety and observe universal precautions (see guideline 107).
BLS service : If patient is pulseless and not breathing
 Determine if obvious death before proceeding with resuscitation (se guideline 302)
 Patients in ventricular tachycardia or ventricular fibrillation should be defibrillated once at
the appropriate setting prior to expedited transport.
EMT Intermediate & Paramedic service : If patient is pulseless and not breathing consider
the following before proceeding with resuscitation:


Multiple blunt trauma or penetrating trauma to the head or trunk OR
Partial/full thickness burns over at least 80% body surface area in the adult
(over age 16) with empirical evidence of inhalation injury
AND


The patient has no signs of life (e.g. respiratory effort, pupil reaction, etc.) AND
The patient has a rhythm of:
 Asystole or
 Agonal PEA at less then 30 per minute with a wide (aberrant) QRS

No resuscitation efforts are indicated



Give control of the scene/body to the appropriate law enforcement
agency.
Complete a standard EMS report documenting your findings.
Assure the medical examiner has been notified.
1. Resuscitation must be started on all patients with narrow (less than0.12 sec-3 small boxes) QRS
complexes regardless of the rate.
2. Patients in ventricular tachycardia or ventricular fibrillation should be defibrillated once at the
appropriate setting prior to expedited transport.
BLS and ALS services For Severe Trauma Patients with signs of life (e.g. respiratory effort,
pupil reaction, pulse, etc.)
1.
2.
3.
4.
5.
Administer oxygen
Control the airway as necessary
Stabilize the cervical spine
Begin CPR if patient becomes pulseless
Control all external hemorrhage
a. Direct pressure
b. Consider hemostatic agents (see guideline # 5014)
c. Consider tourniquet application for massive extremity trauma (see guideline # 5013)
6. Protect fracture sites and splint as indicated
7. Consider application of pelvic binder or application of and inflation of the pneumatic antishock
garment (PASG)(MAST) if appropriate: (see guideline # 5004)
a. Suspected pelvic fracture
b. Significant soft tissue injury in areas covered by the PASG
c. Suspected ruptured abdominal aortic aneurism
8. Transport the patient to the ambulance
9. Notify the receiving hospital of circumstances and estimated time of arrival.
10. Start one (1) IV of Normal Saline in a peripheral site. Do not delay transport if there is
difficulty starting the IV. A second IV may be attempted in transit.
11. Replace the volume as rapidly as possible if there is evidence of continued hypovolemic
shock.
a. Volume replacement in the patient equal to or greater than 16 years is at a “wide
open” rate (consider warmed IV fluids)
b. In patients less than 16 years old, volume replacement is given using a wide open
bolus of 20cc/kg. Reevaluate the circulatory status and repeat while in route to the
hospital if necessary
c. Pressure infusion cuffs can be applied to the IV bag to increase flow rate
12. See flow diagram below to assist with transport destination plan
13. Transport should be in progress within 10 minutes of the time EMS personnel have full
access to the patient
14. During the resuscitation attempt and transport of the pulseless non-breathing trauma victim, if
the ALS personnel has reason to suspect the presence of a tension pneumothorax as
evidenced by increasing difficulty in ventilating the patient and/or a tracheal shift away from
the affected side, the ALS personnel may, without base physician contact, decompress the
intrathoracic space by inserting a 14 gauge 3.25 inch IV cath in the 2nd intercostal space,
midclavicular line on the affected side.
15. In the instance of traumatically amputated or avulsed tissue, that tissue should be enclosed in
a water-proof plastic bag and cooled. The patient and separated tissues should be conveyed
to a medical facility capable of attempting to reattach it.
16. ALS personnel should follow the Analgesia guideline (see guideline 112) for pain relief in
conscious, non-hypotensive patients with:
a. Thermal burns
b. Isolated extremity injuries
c. Contact medical control for other situations
The following guidelines are NOT protocol but should be used as general guidelines:
General guidelines to follow for the ALS personnel unit to transfer the patient with
significant mechanism of injury to the regional trauma center. Physical assessment findings
which include:
Criteria List A (Definition of Major Trauma)
1. Glasgow Coma Scale of less than 14
2. Clinical signs of shock: pale, cold, weak pulses, prolonged capillary refill
3. Unstable blood pressure
a. Adult: Systolic blood pressure less than90 mmHg
b. Pediatric:
 Infant less than 6 months: BP less than60 mmHg
 Child 2 months-5 years: less than70 mmHg
 Child 6-12 years: less than80 mmHg
4. Respiratory rate (for all ages rate greater than 60)
a. Adult: Less than 10 or greater than 30 breaths per minute
b. Pediatrics under 12 years:
 Infants less than6 months: less than20 breaths per minute
 6 months-12 years: less than16 breaths per minute
5. Penetrating injury to head, neck, torso or proximal extremity
6. Flail chest
7. Trauma in a patient with burns to face or airway or with burns of 15% or
greater of the total body surface area
8. Distended, rigid abdomen
9. Two or more long-bone fractures (humerus, femur)
10. Depressed or open skull fracture
11. Major/multiple trauma (cont.)
12. Unstable pelvic fracture
13. New onset paralysis
14. Amputation above the wrist or ankle
ALS personnel evaluation and transport should be made to the closest, most appropriate
hospital for patients whose mechanism of injury include::
Criteria List B (Indicators of possible major trauma)
1. Accidents in which the patient was ejected from the vehicle
2. Accidents in which another occupant of the vehicle was killed
3. Extrication time in excess of 20 minutes
4. Falls of 20 feet or greater for adults, 10 feet or greater for children
5. Victim of a roll-over motor vehicle crash
6. Passenger compartment intrusion greater than 12 inches is present
7. Auto vs pedestrian or bicycle
8. Accidents involving a pedestrian, motorcyclist or bicyclist struck by a car with
significant impact.
9. Motorcycle crashes or similar vehicle crash greater then 20 mph
Criteria List C: Trauma patients whose injuries may be significantly impacted by other
factors
1. Whose age is less than 5 or greater than 55
2. Who have known cardiac or respiratory disease or
3. Who are pregnant
4. Who is immunosuppressed
5. Who has a with bleeding disorder
Blank
Field Trauma Triage Decision Tree for Waukesha County
Step One
Step Two
Access Airway – If unable to maintain airway, transport to closest emergency department. Consider field ALS options (ground vs. air
medical) and Estimated Time of Arrival (ETA) to hospital vs. ALS
Glasgow Coma Scale (GCS) {less then} < 14
Systolic Blood Pressure (BP s) < 90 mmHg or (< 6 mo < 60 mmHg; 6 mo to 5 yr < 70 mmHg; 6 to 12 yr < 80 mmHg)
Clinical Signs of Shock : pale, cold, weak pulse, prolonged capillary refill
Respiratory rate : < 10 or > 29 breaths/min (bpm) (< 1 yr < 20 bpm; 1 – 12 yr < 16 bpm; any age > 60 bpm)
Ineffective breathing, grunting or stridor
Any penetrating injury to head, neck, torso, or extremities proximal to elbows or knees
Flail chest
Two or more proximal long bone fractures
Crushed, degloved, or mangled extremity
Amputation proximal to wrist or ankle
Pelvic fractures
Open or depressed skull fracture
Paralysis (new onset)
Distended or rigid abdomen
Yes
Rapidly and safely transport to the highest level trauma center within a 30 min. radius of the scene. Consider air medical vs. ground
ALS transfer. Do not delay transport waiting for air medical or ALS but consider ground intercept site and/or fixed landing zone at
hospital. Consider traffic and weather implications. Air medical transport can be requested from scene to meet at interim hospital,
reducing total transport time to level 1 facility. If air medical not available, consider contacting medical control prior to leaving scene
for assistance with transport plan.
Mechanism of Injury
Step Three
Evidence of highenergy impact
No
Falls:

Adults: Greater then 20 feet (one story = 10 feet)

Children: Greater then 10 feet or 2-3 times the height of the child
High Risk auto crash:

Intrusion: > 12” occupant site; > 18” any site of patient compartment.

Ejection (partial or complete) from automobile

Death in same passenger compartment

Vehicle telemetry data consistent with high risk of injury
Auto vs. Pedestrian/bicyclist thrown, run over, or with significant ( > 20mph) impact
Motorcycle or other similar vehicle crash greater then 20 mph
Yes
Transport to the closest appropriate trauma center, which need not be the highest level trauma center. Consider contacting medical
control prior to leaving the scene for assistance with transport plan.
No
Age:
Special considerations
Step Four
Special needs patients


Older adults: Risk of injury/death increases after age 55
Children: Should be triaged preferentially to pediatric-capable trauma centers
Anticoagulation and bleeding disorders
Burns

Without other trauma mechanism: triage to burn facility

With trauma mechanism: triage to trauma center
Time sensitive extremity injury
End stage renal disease requiring dialysis
Pregnancy greater then 20 weeks
EMS provider judgment
Yes
Transport to closest appropriate trauma center based on special circumstances and patient needs, which does not have to be the
highest level trauma center. Consider contacting medical control prior to leaving the scene for assistance with transport plan.
No
Transport per local protocol
GUIDELINE/STANDARD OF CARE
Initial Date:
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision:
Guideline Number: 508
The following content will be considered the Guideline/Standard of care for the patient with a
provider impression of:
CRUSH SYNDROME
**A crush syndrome is a prolonged entrapment where the victim’s body tissue is crushed and
circulation to the tissue is restricted. Lactic acid builds up in affected tissue. When
circulation is restored (release of crushed tissue), acidic blood returns to the central
circulation which can result in cardiac arrhythmias and electrolyte imbalance.

Assure scene safety and observe universal precautions (see guideline #107).

Assure patent airway. Consider the potential for cervical spine injury during airway maneuvers. (see
guideline # 101,201).
Assure adequate respiratory exchange, ventilate with supplemental oxygen in those patients with
inadequate or absent respirations, consider advanced airway (see guideline # 2002-2009).









Administer supplemental oxygen (see guideline # 105, 2001) with a device and at a rate appropriate
for the condition of the patient.
Assess for adequate circulation to perfuse the vital organs. Begin CPR as appropriate.
Consider ALS intercept.
If possible, check core temperature, treat for hypothermia if indicated (see guideline #410)
Place tourniquet on affected extremities) proximal to and as close to the crushed tissue as
possible, tight enough to restrict arterial flow.
Complete the history and focused physical assessment (see guideline # 103, 1001).
Obtain initial vital signs (see guideline #1002) and repeat at a minimum of 15-minute intervals.
Critical patients may need more frequent monitoring. If the patient is hypotensive, see
hypotension—shock. (see guideline # 505).
Document, if known, specific information about the mechanism of injury.
For the EMT-Advanced or Intermediate:
 Initiate 2 large bore IV lines with Normal Saline. Administer fluids in 500 ml increments
to achieve and maintain a systolic blood pressure of 90 mmHg (see guidelines #3002-3004)
For EMT-Paramedics:
 Inject 50 mEq sodium bicarbonate into 1000 ml Normal Saline and administer at a
wide/open rate.
 Administer additional Normal Saline to maintain a systolic blood pressure of at least 100
mmHg.



Auscultate breath sounds, check for pulmonary edema.
Contact medical control for orders as necessary.
Reassess and document the patient’s respiratory, cardiovascular, nervous and
musculoskeletal systems frequently. Expect and monitor for sudden shifts in blood pressure and/or
cardiac arrhythmias. Trapped patients can become very unstable when debris is removed and toxins/acidotic
blood return to the central circulation.



Complete a patient care report (see guideline #102) documenting all pertinent information received,
procedures ordered/completed, results of interventions and changes in the patient’s condition.
Include computation of the Glasgow Coma Scale.
Transport to the closest, most appropriate hospital. Expedite transport of unstable trauma
victims.
Document reasons for any deviation from the preceding Guideline/Standard of care.
Blank

GUIDELINE/STANDARD OF CARE
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 601
The following content will be considered the Guideline/Standard of care for the patient with a
provider impression of:
OBSTETRICAL OR GYNECOLOGICAL COMPLAINT

Assure scene safety and observe universal precautions (see guideline #107).


Assure patent airway. (see guideline # 101,201).
Assure adequate respiratory exchange, ventilate with supplemental oxygen in those patients with
inadequate or absent respirations, consider advanced airway (see guideline # 2002-2009).



















Allow the patient to assume the position of comfort unless contraindicated by medical
condition. Pregnant women should be transported lying on their left side.
Administer supplemental oxygen (see guideline # 105, 2001) with a device and at a rate appropriate
for the condition of the patient.
Assess for adequate circulation to perfuse the vital organs. Begin CPR as appropriate.
Complete the history and focused physical assessment (see guideline # 103, 1001) including:
Length of pregnancy, due date
Problems with pregnancy, prenatal care
Previous obstetrical history
Obtain initial vital signs (see guideline #1002) and repeat at a minimum of 15-minute intervals.
Critical patients may need more frequent monitoring.
Evaluate the progress of labor, frequency and intensity of contractions.
Document the amount and duration of any vaginal bleeding.
If the patient appears to be straining, pushing, or states she feels as if she has to move her
bowels, inspect the perineum for crowning.
Consider intravenous access (see guideline # 3002-3004).
Consider electrocardiograph monitoring (see guideline #3009).
For women in active labor, assist as necessary (see guideline #6001, 6002)
Contact medical control for orders as necessary.
Reassess and document the patient’s respiratory and cardiovascular systems frequently.
Complete a patient care report (see guideline #102) documenting all pertinent information received,
procedures ordered/completed, results of interventions and changes in the patient’s condition.
Transport to the closest, most appropriate hospital. For the patient who delivers in the field,
the mother and newborn should be kept together and transported to the same hospital,
preferably where prenatal care was obtained.
The stable newborn should be transported in a rear-facing car seat with a cap in place (for
warmth, to minimize heat loss) while taking appropriate warming considerations.

The temperature in the ambulance should be raised (“light perspiration temperature range
for an adult”).
 The newborn should have been dried and wrapped in dry, warm blankets as soon as the
initial assessments are complete.
 Warm packs should be placed outside the blankets but inside the car seat.
End page 1
OB-GYN cont.

Consider transporting Newborn infants in distress to a Level III Neonatal Intensive Care Unit
(Children’s Hospital, St. Joseph’s-Milwaukee, St. Mary’s—Milwaukee, Aurora Sinai,
Waukesha Memorial) (see guideline # 6003)
 Document reasons for any deviation from the preceding Guideline/Standard of care.
END
GUIDELINE/STANDARD OF CARE
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 1001
The following content will be considered the Guideline/Standard of care for:
PHYSICAL ASSESSMENT
Approved for use
by:
EMT
Advanced EMT
XX
XX
EMTIntermediate
XX
EMTParamedic
XX
PURPOSE
To complete a initial and focused assessment of a patient
To identify life threatening or potentially life-threatening conditions
To establish a working assessment
To prioritize treatment
EQUIPMENT
Stethoscope
Blood pressure cuff of appropriate size for patient
Light source (e.g. pen light)
Medical equipment necessary to treat conditions identified by the assessment
Personal protective equipment to prevent exposure to blood/body fluids
PROCEDURE
1. Assure scene safety and observe universal precautions (see guideline #107).
2. Survey the scene as you approach for information and potential hazards to rescuers:

Hazards

Potential number of patients

Need for additional or specialized equipment, manpower

Environment (mechanism of injury, nature of illness, living conditions, etc.).

Evaluate Mechanism of Injury (MOI), Nature of Illness (NOI), potential for C-spine
injury

Delay entry until the scene is safe if necessary
3. Make patient contact; establish patient’s normal and current level of consciousness.

Use AVPU scale to describe

Identify self; explain role if time and patient condition permits.

Attempt to determine nature of illness or mechanism of injury
4. Assess the airway: (see guideline # 101,201).

Consider the need for cervical spine stabilization.

Monitor for patency of airway, need for adjuncts to control airway.

Open airway of unresponsive patients (chin lift or jaw thrust).
5. Assess breathing: (see guideline # 2002-2009).

Look for chest movement.

Listen and feel for air exchange.



End page 1
Ventilate with pocket mask or bag-valve device if patient is not breathing or
exchange is not adequate.
Suction as necessary.
Start supplemental oxygen as soon as possible at rate and with device appropriate
for patient’s condition. (see guideline # 105, 2001).
Physical assessment (cont)
6. Assess circulatory status.

Check central and peripheral pulses.

Look for signs of hemorrhage, apply direct pressure, hemostatic agents, or
tourniquet to bleeding wounds.

Evaluate capillary refill.

Evaluate skin color, temperature and condition. Look for cyanosis, diaphoresis.

Begin CPR as needed.

Establish peripheral IV line as soon as possible if condition warrants it.
7. Consider need for ALS if not already dispatched or on-scene.
8. Perform cursory body survey to identify “Load and Go” situations.

Immediate transport is indicated in a limited number of situations (unstable trauma,
complicated obstetrical, etc.).
9. Obtain baseline vital signs. (see guideline # 1002).

Blood pressure including both systolic and diastolic readings

Pulse, counted peripheral or centrally

Respiratory rate and effort

Reassess level of consciousness (AVPU)

Alert

Verbal stimuli response

Painful stimuli response

Unresponsive
10. Obtain history of the present problem: (OPQRST)

Chief complaint

Onset, origin

Provokes

Quality

Region/priority

Severity

Time

Associated symptoms
11. Obtain pertinent past medical history: (SAMPLE)

Signs, symptoms

Allergies

Medications

Past medical history

Last meal or oral intake

Events before the emergency
Focused physical assessment as appropriate:
12. Assess head and face:

Re-evaluate the airway

Signs of trauma – DCAP-BTLS

Blood or discharge from ears or nose

Pupil size and reaction

Presence of identifiable odors
13. Assess neck:

Signs of trauma – DCAP-BTLS

Carotid pulses



End page 2
Position of trachea in the midline
Jugular vein distention
Subcutaneous emphysema
Physical Assessment (cont.)
14. Assess chest:

Signs of trauma – DCAP-BTLS

Pain

Subcutaneous emphysema

Listen to breath sounds
15. Assess abdomen:

Signs of trauma – DCAP-BTLS

Pain

Distention

Pregnancy

Rigidity
16. Assess spine and back:

Signs of trauma/deformity – DCAP-BTLS

Pain
17. Assess pelvis and buttocks:

Signs of trauma/deformity – DCAP-BTLS

Signs of bleeding (melena, blood)

Presence of secretions (e.g. amniotic fluid)

Pain
18. Assess upper and lower extremities:

Signs of trauma/deformity – DCAP-BTLS

Pain

Pitting edema

Circulation, sensation, movement
19. Establish working assessment.
20. Prioritize interventions.
21. Obtain necessary medical control orders.
END
GUIDELINE/STANDARD OF CARE
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 1002
The following content will be considered the Guideline/Standard of care for:
MEASUREMENT OF SYSTOLIC AND DIASTOLIC BLOOD PRESSURE
Approved for use
by:
EMT
Advanced EMT
XX
XX
EMTIntermediate
XX
EMTParamedic
XX
PURPOSE
To accurately measure and monitor the systolic and diastolic blood pressure
EQUIPMENT
Blood pressure cuff of appropriate size for the patient
Stethoscope
Personal protective equipment to prevent exposure to blood/body fluids
PROCEDURE
Blood pressure measurement, auscultation method
1. Assure scene safety and observe universal precautions (see guideline #107).
2. Position the patient with the arm to be used at the level of the heart.
3. Select a blood pressure cuff that covers 2/3 of the distance between the axilla and
antecubital fossa of the patient, long enough to securely wrap around the arm.
4. Wrap the cuff around the arm, positioning the bladder over the anterior aspect of the arm
with the lower edge at least 1 inch above the antecubital space.
5. Place stethoscope earpieces in rescuer’s ears with tips pointing forward; check that the
appropriate head of the stethoscope is in the open position.
6. Palpate the brachial artery while inflating the cuff approximately 30 mmHg above loss
of pulse.
7. Place head of stethoscope firmly over the brachial artery and listen while slowly
deflating the cuff pressure, watching the pressure gauge as the cuff deflates.
8. Record the pressure when sound is first heard as the systolic pressure.
9. Record the pressure when the sound disappears as the diastolic pressure.
10. Document procedure and results, including any unusual circumstances and/or difficulties
encountered.
Blood pressure measurement, palpation method
Note: The palpation method is used to monitor the blood pressure only when environmental
noise or conditions make it difficult to hear through the stethoscope
1. Observe universal precautions.
2. Position the patient with the arm to be used at the level of the heart.
End page 1
Blood pressure (cont.)
3. Select a blood pressure cuff that covers 2/3 of the distance between the axilla and
antecubital fossa of the patient, long enough to securely wrap around the arm.
4. Wrap the cuff around the arm, positioning the bladder over the anterior aspect of the arm
with the lower edge at least 1 inch above the antecubital space.
5. Palpate the radial or brachial artery while inflating the cuff approximately 30 mmHg
above loss of pulse.
6. Deflate the cuff slowly, watching the pressure gauge.
7. Record the pressure when the pulse returns as the systolic pressure/palpated.
8. Document procedure and results, including any unusual circumstances and/or difficulties
encountered.
ORTHOSTATIC VITAL SIGNS
Orthostatic (postural) hypotension is a drop in both systolic and diastolic blood pressure with a
change from supine to sitting or standing position. It is generally accompanied by dizziness,
blurring of vision and/or syncope.
1. Assure scene safety and observe universal precautions (see guideline #107).
2. Take and record the blood pressure (both systolic and diastolic) and pulse rate with the
patient supine.
3. Have the patient stand, assisting as necessary. Observe carefully for associated signs
and symptoms. Protect the patient from falling.
4. After 30 seconds, repeat the blood pressure and pulse reading. A drop of systolic
pressure of 20 mmHg or increase in pulse of 20/min or presence of clinical
signs/symptoms is significant.
5. Document procedure and results, including any unusual circumstances and/or difficulties
encountered.
Note: If the cuff is too wide, the measured blood pressure will be lower than the true
pressure. If the cuff is too narrow, the measured blood pressure will be higher than the
true pressure.
END
Blank
GUIDELINE FOR PRACTICAL SKILL
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 10/30/02
Guideline Number: 2001
The following content will be considered the Guideline/Standard for:
OXYGEN EQUIPMENT PREPARATION
Approved for use
by:
EMT
Advanced EMT
XX
XX
EMTIntermediate
XX
EMTParamedic
XX
PURPOSE
To increase the partial pressure of oxygen in the lungs increasing diffusion across the
alveolar and capillary membranes into the blood, providing additional oxygen to the tissues
of the body
EQUIPMENT
Oxygen source with connecting tubing
Nasal cannula (25-40%)
Non-rebreathing face mask (90+%)
Bag-valve-mask device with reservoir bag (100%)
Personal protective equipment to prevent exposure to blood/body fluids
PROCEDURE
To apply oxygen
1. Assure scene safety and observe universal precautions (see guideline #107).
2. Assemble regulatory/flow meter and oxygen source:
a.
Remove protective cap or tape.
b.
Open and close cylinder valve to crack
c.
Attach regulator and flowmeter with leak-proof seal
d.
Turn on tank; check that pressure gauge registered in the safe (green) range.
3. Select administration device which will meet patient’s needs:
a.
Nasal cannula delivers 25-40% oxygen content at 1-6 L/min flow from the source
(4%
increase for each one liter flow rate)
b.
Non-rebreather face mask delivers 90+% at 12-15L/min flow rate
c.
Bag-valve device delivers nearly 100% oxygen content when used with the
oxygen
reservoir attachment and maximum (15+ L/min) flow rate from the source
d.
Nebulizer chamber for aerosol medications is run at 6-8 L/min flow rate.
4. Attach delivery device to oxygen source.
5. Monitor and evaluate patient’s response to oxygen therapy.
6. Document procedure and results, including any unusual circumstances and/or difficulties
encountered.
To discontinue oxygen
1. Remove the device from the patient.
2. Shut off the cylinder.
3. Bleed the regulator.
4. Return the flow meter control to the “off” position
End page
Oxygen equipment preparation (cont)
Recognize/verbalize advantages of oxygen therapy:

Increasing the partial pressure of oxygen in the blood stream increases the availability of oxygen to the tissue,
minimizing the effects of hypoxia and anaerobic metabolism on the cells.
Recognize/verbalize hazards of oxygen therapy:


Oxygen is stored under pressure. Damage to the tank or valve can turn the cylinder into a projectile.
Oxygen supports combustion. There is an increased fire risk when oxygen is in use.
Recognize/verbalize complications of oxygen administration:



Oxygen can suppress the respiratory drive of a patient with chronic obstructive pulmonary disease.
Prolonged administration of high pressures of oxygen can cause lung damage in susceptible individuals. (Oxygen
toxicity)
Prolonged administration of high pressures of oxygen can cause retina damage in premature infants.
Recognize/verbalize contraindication to oxygen administration:

END
None
GUIDELINE FOR PRACTICAL SKILL
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision:
12/06/2002
Guideline Number: 2002
The following content will be considered the Guideline/Standard for:
SUCTIONING
Approved for use
by:
EMT
Advanced EMT
XX
XX
EMTIntermediate
XX
EMT-Paramedic
XX
PURPOSE
To remove mucus or foreign material from the upper airway or endotracheal tube
EQUIPMENT
Suction machine with connecting tubing and reservoir
Flexible suction catheters 8, 10, 14 and 18 French
Yankauer suction tip
DeLee Mucous Trap with bulb
Bulb syringe
Meconium aspirator
Water/saline as necessary to flush the tubing
Personal protective equipment to prevent exposure to blood/body fluids
PROCEDURE
1. Assure scene safety and observe universal precautions (see guideline #107).
2. Protect the airway prior to suctioning by turning the patient to the side if possible.
3. Select flexible suction catheter for suctioning the nasal pharynx, endotracheal tube or
stoma.
4. Suctioning the mouth and pharynx:

Measure suction catheter from the corner of the mouth to the ipsilateral (same side)
earlobe.

Open the mouth using the cross-finger technique.

Insert catheter tip into the area of the mouth/pharynx to be suctioned.

Apply suction as the catheter is withdrawn from the mouth.

Flush tubing and catheter with water as necessary.

Repeat as necessary to remove foreign material/liquids from the airway.

Limit each suctioning episode to 15 seconds or less.

Oxygenate the patient with 5-6 breaths with supplemental oxygen after each
suctioning episode.
5. Suctioning the endotracheal tube/tracheostomy:

Use sterile suction catheter and as sterile technique as possible.

Use a new sterile suction catheter for each suctioning event.

Oxygenate the patient with 5-6 breaths with supplemental oxygen before and after
each suctioning episode.




End page 1
Insert the suction catheter down the endotracheal tube or into the stoma opening until
it reaches the area where secretions/foreign matter are present.
Apply suction to the catheter as it is withdrawn from the tube/stoma.
If thick material is present, Normal Saline (2.5-5 ml) may be instilled into the
endotracheal tube or stoma prior to suctioning to help liquefy the secretions.
If an intubated patient needs to be extubated, suction the oral pharynx and around the
exterior of the tube above the inflated cuff before the cuff is deflated.
Suctioning, cont.
6. Rigid suction catheter

Open the mouth, using the cross finger technique.

Watch the tip of the Yankauer as it is inserted into the area to be suctioned.

Apply suction as the tip is moved across the area when material is to be removed.

Limit suctioning to no more than 15 seconds at a time.

Oxygenate the patient with 5-6 breaths with supplemental oxygen after each
suctioning episode.
Note: The rigid tip can cause oral or pharyngeal trauma and it is never used to suction an
individual who is in a moving vehicle.
7. Document procedure and results, including any unusual circumstances and/or difficulties
encountered.
DeLee Mucous Trap suctioning (newborn, infant)
1. Observe universal precautions. (see guideline # 107)
2. Hold the mucous trap upright with suction bulb compressed while inserting the
suction catheter tip into the infant’s mouth.
3. Keep the collection bottle in a vertical position.
4. Slowly release the compressed bulb while moving the suction tip across the infant’s
pharynx.
5. Suction for a maximum of 15 seconds at a time.
6. Oxygenate with supplemental oxygen for 5-6 breaths after each suctioning event.
7. Assess the infant’s respiratory status after each suctioning procedure.
8. Document procedure and results, including any unusual circumstances and/or
difficulties encountered.
Bulb Syringe suctioning (newborn, infant)
1. Observe universal precautions (see guideline # 107)
2. Squeeze air from the bulb before insertion.
3. Suction the mouth first, then each nostril.
4. Release pressure on the bulb gradually while removing the bulb tip from the mouth
or nose.
5. Expel contents (suctioned material) out of the bulb before next suctioning attempt.
6. Document procedure and results, including any unusual circumstances and/or
difficulties encountered.
Meconium aspirator – Approved for intermediate and paramedic only
1. Intubate the trachea of the newborn with an appropriate-sized uncuffed endotracheal
tube.
2. Attach the meconium aspirator to the top of the endotracheal tube.
3. Attach the suction tubing to the small end of the meconium aspirator.
4. Decrease the suction power on the machine to an appropriate pediatric setting.
5. Cover the finger hole of the meconium aspirator, applying suction as the
endotracheal tube is removed.
6. Evaluate the airway and respirations.
7. Repeat as needed until the airway is clear.
Recognize/verbalize advantages of suctioning:

Clears foreign material and liquids from the airway.
Recognize/verbalize disadvantages of suctioning:
Removes air as well as foreign matter.
Can introduce bacteria into the airway.
End page 2


Suctioning, cont.
Recognize/verbalize complications of suctioning:



Hypoxia
Oral trauma
May stimulate vomiting
Recognize/verbalize contraindication to suctioning:
 None
Notes:
Suctioning removes air as well as secretions. Oxygenate with supplemental oxygen after each
procedure.
During suctioning, the ECG monitor (or pulse rate if not on monitor) should be observed to
quickly identify if bradycardia--an indicator of hypoxia--occurs.
END
GUIDELINE FOR PRACTICAL SKILL
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 10/30/02
Guideline Number: 2003
The following content will be considered the Guideline/Standard for:
VENTILATION WITH POCKET MASK
Approved for use
by:
EMT
Advanced EMT
XX
XX
EMTIntermediate
XX
EMTParamedic
XX
PURPOSE
To ventilate patient when the bag-valve-mask device is not available
To administer supplemental oxygen
To reduce exposure to the patient’s upper respiratory secretions
EQUIPMENT
Pocket mask with oxygen port and one-way valve
Oxygen source and delivery tubing
Oral or nasopharyngeal airway of size appropriate for patient
Oral airway size selection includes 40-100 mm
Nasopharyngeal airway size (French) selections include 12 through 34.
Suction machine and catheters
PROCEDURE
1. Assure scene safety and observe universal precautions (see guideline #107).
2. Select and insert an oral or nasopharyngeal airway. (see guideline # 2006, 2007)
3. Suction as necessary. (see guideline # 2002)
4. Attach one-way valve to the pocket mask at the top opening.
5. Attach the oxygen source with tubing to oxygen port of the pocket mask and adjust liter
flow to 8-15 liters/min.
6. Position self at the top of the head of the patient.
7. Seal the mask over the patient’s face, maintaining an open airway. Consider potential cspine injury.
8. Hold mask in place on the patient’s face with one hand on each side of the mask,
maintaining an open airway by lifting the chin up and forward. Observe C-spine
precautions, avoiding a head tilt.
9. Ventilate the patient by blowing into the top of the one-way valve with sufficient force
to attain an observable chest rise.
10. If resistance is felt, reassess the airway, taking such measures as are necessary to obtain
and maintain an open airway.
11. Remove mouth from the pocket mask, allowing patient to exhale while holding the mask
firmly on the face.
12. Repeat ventilations at AHA guideline rates.
13. Document procedure and results, including any unusual circumstances and/or difficulties
encountered.
End page
Pocket mask ventilation (cont.)
Recognize/verbalize advantages of pocket mask ventilation:
 Barrier device to provide mouth-to-mouth ventilation without direct contact with
secretions
 Provides supplemental oxygen
 Easier to obtain a face seal by using 2 hands to seal the face mask
Recognize/verbalize disadvantages of pocket mask ventilation:
 Does not prevent aspiration
Recognize/verbalize complications of the pocket mask ventilation:
 Gastric distention with air
Recognize/verbalize contraindication to pocket mask ventilation:
 Facial or upper airway trauma
END
GUIDELINE FOR PRACTICAL SKILL
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision:
12/06/2002
Guideline Number: 2004
The following content will be considered the Guideline/Standard for:
BAG-VALVE MASK VENTILATION
Approved for use
by:
EMT
Advanced EMT
XX
XX
EMTIntermediate
XX
EMTParamedic
XX
PURPOSE:
To assist respirations in a patient whose respiratory effort is absent or inadequate
To oxygenate a patient
To assist ventilations in an intubated patient
EQUIPMENT
Self-inflating bag with valve assembly and oxygen reservoir, (adult, child or infant)
Transparent face masks, sizes 0 to 4
Oral airways Available sizes 40, 50, 60, 80, 90, 100 mm
Nasopharyngeal airways Available sizes 12 through 34 French
Oxygen source with connecting tubing
Suction machine and catheters
Personal protective equipment to prevent exposure to blood/body fluids
PROCEDURE
1. Assure scene safety and observe universal precautions (see guideline #107).
2. Select size of bag-valve-mask appropriate for patient (adult, child, infant).
3. Suction as necessary. (see guideline # 2002)
4. Connect the bag-valve-mask with oxygen reservoir to the oxygen source with the tubing
and open source to deliver 15 L/min. (see guideline # 2001)
5. Select an appropriate size transparent face mask to cover the area between the bridge of
the patient’s nose and the indentation beneath the patient’s lower lip.
6. Select an appropriate size oral airway. (see guideline # 2006)
7. Position self at the top of the head of the patient.
8. Open the airway using the cross-finger technique and place an oral airway in the
patient’s mouth. A nasopharyngeal airway may be substituted for an oral airway. (see
guideline # 2006, 2007)
9. If no cervical injury is suspected, tilt the patient’s head back. For patients with a
potential cervical injury, use the jaw thrust to open the airway.
10. Grasp the patient’s mandible with your left hand and lift the jaw anteriorly.
11. Place the nose end of the face mask over the ridge of the patient’s nose and then place
the chin end over the patient’s lower lip.
12. Using one hand, firmly press the face mask against the patient’s face while continuing to
lift the jaw anteriorly.
13. Compress the bag-mask with the other hand with enough speed and force to deliver 400600 cc of air (to an adult) through the valve into the mask over a 2 second period. For
children and infants, ventilate with a volume sufficient to produce an adequate chest rise.
14. Monitor the patient’s chest rise with each compression of the bag. The chest should fall
when the pressure on the bag is released and the patient exhales.
End page
Bag-valve-mask ventilation, (cont.)
15. Continue to ventilate the adult patient at AHA guideline rates, adjusted for the patient’s
individual needs.
16. If adequate chest is not achieved with compression of the bag, reevaluate the airway
(reposition, check for obstruction, etc.) and repeat the sequence.
17. Document procedure and results, including any unusual circumstances and/or difficulties
encountered.
Note: If 2 rescuers are available, one should maintain the airway and face seal of the
mask and the second squeezes the bag.
Recognize/verbalize advantages of bag-valve-mask ventilation:
 Provides for ventilation with supplemental oxygen
 Reduces exposure to upper airway secretions
Recognize/verbalize disadvantages of bag-valve-mask ventilation:
 Requires special equipment, training and continued practice
 Can be difficult to maintain a face seal
 Does not prevent aspiration
Recognize/verbalize complications of bag-valve-mask ventilation:
 Gastric inflation
Recognize/verbalize contraindication to bag-valve-mask ventilation:
 Facial trauma with disruption of the boney framework of the face and jaw
END
Note: State of Wisconsin Standards and Procedures of Practical Skills Manual (July
2008 Rev) is appended and contains step-by-step instructions for: Flow-restricted
oxygen-powered ventilation device. See index for page numbers.
GUIDELINE FOR PRACTICAL SKILL
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 10/30/02
Guideline Number: 2005
The following content will be considered the Guideline/Standard for:
USE OF LARYNGOSCOPE AND MAGILL FORCEPS TO REMOVE AN
OBSTRUCTION FROM THE UPPER AIRWAY
Approved for use
by:
EMT
Advanced EMT
XX
XX
EMTIntermediate
XX
EMTParamedic
XX
PURPOSE
To remove a foreign body from the upper airway
EQUIPMENT
Laryngoscope with functioning batteries
Laryngoscope blade of appropriate size for the patient with functioning light bulb
Magill forceps of appropriate size for the patient (Adult and pediatric size available)
Suction machine and catheters
Bag-Valve-Mask device with oxygen reservoir
Oxygen source with connecting tubing
Personal protective equipment to prevent exposure to blood/body fluids
PROCEDURE
1. Assure scene safety and observe universal precautions (see guideline #107).
2. Assemble the laryngoscope and blade, checking the battery and the security of the light
bulb in the blade.
3. Position self at the top of the head of the patient.
4. Place the patient’s head in a slightly extended (“sniffing”) position if no cervical injury
is suspected. For patients with potential for cervical injury, in-line stabilization with the
head in neutral position must be maintained by another individual.
5. Holding the laryngoscope in the left hand, insert the blade into the right side of the
patient’s mouth and move it gently toward the left, moving the tongue to the left and out
of the way.
6. Place the tip of the curved blade in the vallecula and the tip of the straight blade over the
epiglottis.
7. Lift up and anterior with the laryngoscope and blade to expose the posterior pharynx and
the epiglottis without prying on teeth or gums.
8. Visualize the vocal cords. Avoid any leverage on the laryngoscope blade or the teeth.
9. Suction as necessary. (see guideline # 2002)
10. Locate the foreign body.
11. Holding the Magill forceps in the right hand, insert the tip into the patient’s mouth, grasp
and remove the obstruction.
12. Visualize the airway for further obstruction before removing laryngoscope blade.
End page
Magill forceps (cont.)
13. Ventilate the patient for 5-6 breaths with supplemental oxygen.
14. Document procedure and results, including any unusual circumstances and/or difficulties
encountered.
Recognize/verbalize advantages of foreign body removal with Magill forceps:
 Provides rapid removal of visualized object
 Avoids potential trauma of abdominal thrusts
Recognize/verbalize disadvantages of foreign body removal with Magill forceps:
 Requires specialized equipment and training
 Must be able to visualize the object (must be superior to the vocal cords)
Recognize/verbalize complications of foreign body removal with Magill forceps:
 Oral or pharyngeal trauma
Recognize/verbalize contraindication to foreign body removal with Magill forceps:
 Foreign body is below the level of the vocal cords
END
GUIDELINE FOR PRACTICAL SKILL
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 10/30/02
Guideline Number: 2006
The following content will be considered the Guideline/Standard for:
INSERTION OF ORAL AIRWAY
Approved for use
by:
EMT
Advanced EMT
XX
XX
EMTIntermediate
XX
EMTParamedic
XX
PURPOSE
To maintain a patent airway by holding the tongue anteriorly off the posterior pharynx in
unresponsive patients without a gag reflex.
EQUIPMENT
Oral airway of size appropriate for patient
Size selection includes 40-100 mm
Tongue blade
Personal protective equipment to prevent exposure to blood/body fluids
PROCEDURE
1. Assure scene safety and observe universal precautions (see guideline #107).
2. Select appropriate sized airway by measuring from the earlobe to the ipsilateral (same
side) corner of the patient’s mouth or angle of the jaw.
3. Open the patient’s mouth using the cross-finger technique. (Place the thumb on the
lower teeth and the index finger on the upper teeth. Push the lower jaw down while
pushing up on the upper jaw).
4. Insert the airway with the tip pointing toward the roof of the patient’s mouth (for an
adult); Follow normal curvature of mouth/pharynx for pediatric patients.
Note: When placing airway following normal curvature, use tongue blade to
displace
tongue forward and down.
5. Advance airway posteriorly, taking care not to push the tongue back or scrape the roof of
the mouth until the tip reaches the soft palette.
6. Rotate the airway 180º into position with the flange resting against the patient’s lips or
teeth.
7. Do NOT tape the airway in place.
8. Suction patient as necessary to remove secretions. (see guideline # 2002)
9. Document procedure and results, including any unusual circumstances and/or difficulties
encountered.
Recognize/verbalize advantages of the oral airway
 Maintains patent airway by holding the tongue anteriorly off the posterior pharynx
 Easy to use with minimal training necessary
 Prevents the patient from biting down on objects in the mouth (e.g. endotracheal tube).
Recognize/verbalize disadvantages of the oral airway
 Does not prevent aspiration
Position may stimulate the gag reflex.
 Cannot be used in the awake patient.
Recognize/verbalize complications of the oral airway
 Oral trauma during insertion
 Vomiting with possible aspiration as the level of consciousness increases.
Recognize/verbalize contraindication of the oral airway
 Any individual with a gag reflex

END
GUIDELINE FOR PRACTICAL SKILL
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 10/30/02
Guideline Number: 2007
The following content will be considered the Guideline/Standard for:
INSERTION OF NASOPHARYNGEAL AIRWAY
Approved for use
by:
EMT
Advanced EMT
XX
XX
EMTIntermediate
XX
EMTParamedic
XX
PURPOSE:
To maintain a patient airway by holding the tongue anteriorly off the posterior pharynx in a
patient with a decreased level of consciousness
EQUIPMENT:
Nasopharyngeal airway of appropriate size for the patient
Size selections include sizes 12 through 34 (French).
Water soluble lubricant
Personal protective equipment to prevent exposure to blood/body fluids
PROCEDURE:
1. Assure scene safety and observe universal precautions (see guideline #107).
2. Select airway slightly smaller in diameter than the patient’s nostril, equal in length to the
distance from the nostril to ipsilateral (same side) earlobe or angle of the jaw.
3. Lubricate exterior of airway with water soluble lubricant.
4. Insert airway into nares with bevel facing the nasal septum.
5. Direct airway straight back along the floor of the nasal passage until the flange end
touches the external nares.
6. Suction as necessary to clear secretions. (see guideline # 2002)
7. Document procedure and results, including any unusual circumstances and/or difficulties
encountered.
Recognize/verbalize advantages of the nasopharyngeal airway:
 Better tolerated than rigid oral airways
 Less likely to stimulate gag reflex as patient regains consciousness
 Can be inserted without having to open mouth.
Recognize/verbalize disadvantages of the nasopharyngeal airway:
 Does not prevent aspiration
Recognize/verbalize complications of the nasopharyngeal airway:
 Insertion may cause epistaxis
 Pharyngeal stimulation may cause gagging or vomiting.
Recognize/verbalize contraindication to the nasopharyngeal airway:

END
Should not be inserted in patients with suspected basilar skull fractures or severe facial
trauma.
GUIDELINE FOR PRACTICAL SKILL
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/08/06
Guideline Number: 2008
The following content will be considered the Guideline/Standard for:
COMBI-TUBE AIRWAY (ESOPHAGEAL-TRACHEAL COMBI-TUBE) / KING LTS-D
Approved for use
by:
EMT
XX *
Advanced EMT
EMTIntermediate
XX
XX
*Requires Operational Plan
EMTParamedic
XX
PURPOSE:
To prevent regurgitation of stomach contents into the airway
To facilitate ventilation of the lungs with a bag-valve device
To provide a more secure airway when endotracheal intubation is not feasible
INDICATIONS:
Cardiopulmonary arrest
Respiratory arrest in the patient without a gag reflex
Unresponsive patient with inadequate respirations without a gag reflex
EQUIPMENT:
Combi-tube airway
140 cc syringe
20 cc syringe
Water soluble lubricant
Suction machine and catheters
Bag-valve device with oxygen reservoir
Oxygen source with connecting tubing
Stethoscope
Personal protective equipment to prevent exposure to blood/body fluids
PROCEDURE: INSERTION
1. Assure scene safety and observe universal precautions (see guideline #107).
2. For patients with a pulse, assure the patient is adequately pre-oxygenated while preparing
equipment (~ 6 breaths with BVM). For patient with no pulse, follow AHA CPR
guidelines and place Combi-tube while minimizing interruption of chest compressions.
(pre-oxygenation is not needed.)
3. Attach syringe and inflate the cuffs of the tube with air, check for leaks in the cuff,
deflate.
4. Remove dentures if possible.
5. Lubricate the exterior of the Combi-tube with water-soluble lubricant.
6. With the patient’s head in neutral position, place left thumb inside the patient’s mouth
between the teeth and the cheek, fingers under the mandible and protract the patient’s
lower jaw. Consider the necessity of c-spine stabilization during insertion.
7. Gently insert the tube into the patient’s mouth, advancing the tube to follow the curvature
of the posterior pharynx until the printed ring is aligned with the teeth. Do not use force.
If the airway does not slide in easily, withdraw and attempt again to insert.
8. Inflate pilot tube #1 (blue) with 100 cc of air using the 140 cc syringe. Assess for leaks,
add 5-10 cc of additional air if leaking around cuff
9. Inflate pilot tube #2 (white) with 15 cc of air.
10. Attach bag-valve device to #1 (blue) tube and ventilate.
11. Assess respiratory effect (breath sounds, epigastric sounds, chest rise, color improvement,
etc.).
End page
Combi-tube, cont.
12. If chest rise and breath sounds indicate placement of the tube is in the esophagus,
continue ventilation through blue tube. If breath sounds are absent, attach bag valve
device to the #2 (white) port and ventilate.
13. Assess respiratory effect (breath sounds, chest rise, color improvement, etc.).
14. If chest rise and breath sounds indicate placement of the tube in the trachea, continue
ventilation through the white port.
15. If position is uncertain, deflate both cuffs, withdraw ½ inch, re-inflate both cuffs and
reevaluate.
16. If unable to ventilate adequately through either port, remove the Combitube and
reattempt placement (steps 6-14). No more than 30 seconds should elapse for each
attempt. If 3 attempts are unsuccessful, an alternate airway adjunct should be used. Reoxygenate for 30 seconds between attempts for patient with pulse. For patients without a
pulse, continue AHA-SPR between attempts.
17. Once placement is successful in a patient with pulses, hyperventilate for 30 seconds and
the continue ventilation of the patient according to AHA guidelines. For the patient
without a pulse, skip the hyperventilation step.
18. Reassess tube placement and ventilatory status frequently.
19. Document procedure and results, including any unusual circumstances and/or difficulties
encountered.
PROCEDURE: REMOVAL OF THE COMBI-TUBE (per medical direction)
1. Assure suction is immediately available.
2. Turn patient on side unless contraindicated (e.g. C-spine)
3. Deflate both cuffs and gently but quickly remove.
4. Anticipate regurgitation and suction as necessary.
5. Reassess respiratory status.
6. Provide supplemental oxygen.
List advantages of the Combi-tube:
 Ease of insertion, cannot be improperly placed
 Requires minimal skill and training
 Requires minimal spinal manipulation
 Provides for ease of suctioning
List disadvantages of the Combi-tube:
 Can only be used if unconscious without gag reflex
 Not tolerated by semiconscious or awake individual
 Must identify where tube is located (esophagus or trachea)
 May need to be removed before endotracheal intubation is possible
List complications of the Combi-tube:
 Possible esophageal damage from inflation of the cuff
List contraindications to insertion of the Combi-tube:
 Individuals less than 5 feet in height or taller than 7 feet**
 Known esophageal disease or trauma
 Known foreign body obstruction of larynx or trachea
 Intact gag reflex
 Caustic ingestion
 Use with caution in patients with facial trauma, broken teeth/dentures
Note: If unsuccessful after three (3) attempts (no more than 30 seconds per attempt), use
alternate airway adjunct.
**Note: A small adult Combitube is available for individuals greater than 4 ft and less
than 5 feet in height. Inflate the blue pilot tube with 85 cc of air and the white with 12 cc.
Prior to use, you must submit an educational plan to the state for approval and update
your operational plan.
KING LTS-D ADVANCED AIRWAY
1. INSERTION
a. Reconfirm assessment of absent or inadequate
breathing without a gag reflex
b. Determine correct size airway based on patient’s
height
c. Determine cuff integrity
1) Inflate cuffs
2) Disconnect syringes
3) Carefully inspect pharyngeal and distal cuff
4) Carefully inspect valve and pilot cuff
5) Deflate cuffs
d. Prepare all necessary accessories
1) Preset inflation syringe to correct amount for
device size
2) Bag-valve-mask with supplemental oxygen
3) Water soluble lubricant
4) Suction device
5) Stethoscope
A chin lift or laryngoscope
e. Suction as necessary; inspect patient’s airway for
and tongue depressor can be
obstructions, broken teeth, dentures, dental
used to lift the tongue
appliances, tongue piercings or other items that
anteriorly to allow easy
could damage cuffs
advancement
f. Ventilate for a minimum of thirty (30) seconds
g. Lubricate airway with water soluble lubricant as
necessary
h. Position the patient supine with head in the
Obese patient may need
neutral or sniffing position. Do not hyperextend
padding under shoulders
the patient’s head
and upper back
2. Normal Insertion
a. Hold the King LTS-D at the connector with
Important that the tip of the
dominant hand
device be maintained at
b. With non-dominant hand, hold mouth open and
midline to assure that the
apply chin lift unless contraindicated by C-spine
distal tip is properly placed
precautions or patient position
in the hypopharynx/upper
c. Using a lateral approach, introduce the tip into the
esophagus
corner of the mouth
d. Advance the tip behind the base of the tongue
During insertion, if tip is
while rotating the tube back to midline so that the
placed or deflected
blue orientation line faces the chin of the patient
laterally, it may enter the
e. Without exerting excessive force, advance tube
periform fossa and will
until base of connector is aligned with teeth or
appear to bounce back upon
gums
full insertion and release.
f. Deeper placement and subsequent retraction is
preferred
Insertion can be
g. When the King LTS-D is positioned
accomplished via a midline
1) Inflate cuffs to volume sufficient to seal the
approach by applying a chin
airway
lift and sliding the distal tip
2) Attach ventilation device to the connector of
along the palate and into
the King LTS-D
3) At the same time, gently bag the patient and
withdraw the King LTS-D until ventilation is
easy and free flowing
4) Readjust cuff inflation to “just seal” volume
5) Check breath sounds, epigastric sounds and
chest rise and fall
3. Secure the airway
a. Disconnect the ventilation device
b. Aggressively tape the King LTS-D in the midline
to the maxilla
c. Avoid taping over gastric access lumen
d. Reattach the ventilation device
4. Removal
a. Remove the King LTS-D when protective reflexes
have returned
b. Contact medical control (local protocol)
c. Prepare suction and emesis collection devices –
suction as indicated
d. Position patient in lateral recumbent position
when feasible, observing appropriate C-spine
precautions for trauma patients
e. Deflate cuffs
f. Immediately withdraw airway with a smooth and
steady motion while maintaining normal
curvature of the pharynx
g. Monitor the patient’s airway and breathing closely
h. Provide high-flow oxygen via non-rebreather
mask
i. Consider nasopharyngeal airway and assist
ventilations as necessary
END
position in the hypopharynx
– head extension may be
helpful
GUIDELINE FOR PRACTICAL SKILL
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/08/06
Guideline Number: 2009
The following content will be considered the Guideline/Standard for:
ENDOTRACHEAL INTUBATION
Approved for use
by:
EMT
Advanced EMT
With added module
EMTIntermediate
XX
EMTParamedic
XX
PURPOSE
To provide positive control of an airway
To facilitate assisted ventilation in a patient with inadequate respirations
To prevent aspiration in a patient with decreased reflexes
EQUIPMENT
Laryngoscope handle with functioning batteries
Curved or straight laryngoscope blade of appropriate length with functioning light bulb
Endotracheal (ET) tube of appropriate size for the patient
Available sizes include adult 6.0 through 9.0 mm; pediatric (uncuffed) 2.5 through 5.5
Water soluble lubricant
Syringe to inflate cuff
Tape or commercial endotracheal tube holder
Stethoscope
Bag-valve-mask device with oxygen reservoir
Oxygen source with connecting tubing
Stylette
Magill forceps
Suction machine and catheters
Oral airway of appropriate size for the patient (sizes 50-100 mm available)
Personal protective equipment to prevent exposure to blood/body fluids
Fiberoptic assisted intubation equipment may be used per manufacturer recommendation
PROCEDURE
1. Assure scene safety and observe universal precautions (see guideline #107).
2. Assure adequate ventilation and oxygenation of patient prior to attempting procedure.
3. Assemble laryngoscope and blade, checking the battery and the security of the light
bulb in the blade.
4. Select an appropriate size endotracheal tube with an exterior diameter approximately
equal to the diameter of the distal joint of the patient’s little finger.
5. Attach the syringe to the endotracheal tube, inflate the cuff with 6-8 cc of air and check
cuff of tube for leaks, deflate the cuff.
6. Lubricate distal end of the endotracheal (ET) tube with water soluble gel.
7. If stylette is to be used, insert into the lumen of the ET tube until the tip of the stylet is
just distal to the cuff. Assure that it does not protrude beyond the tip of the tube by
bending the looped
end of the stylet down over the connector at the top of the ET tube.
End page
Endotracheal intubation, (cont.)
8. If the patient has a pulse, pre-oxygenate with at least 6 breaths with BVM prior to
intubation attempt. If the patient is pulseless, follow AHA-CPR guidelines, minimizing
compression interruptions.
9. (Paramedic only) Consider sedation with Versed (see drug profile 023, guideline 113) or Rapid
Sequence Intubation (see guideline 2018) as approved by your scope and medical director.
10. Place the patient’s head in a slightly extended “sniffing”) position if no cervical injury is
suspected. For patients with potential for cervical injury, in-line stabilization with the
head in neutral position must be maintained by another individual.
11. Holding the laryngoscope in the left hand, insert the blade into the right side of the
patient’s mouth and move it gently toward the left, moving the tongue to the left and out
of the way.
12. Place the tip of the curved blade in the vallecula and the tip of the straight blade over the
epiglottis.
13. Lift up and anterior with the laryngoscope and blade to expose the posterior pharynx and
the epiglottis. An assistant may apply cricoid pressure (Sellick’s Maneuver) as
appropriate.
14. Visualize the vocal cords. Avoid any leverage on the laryngoscope blade.
15. Suction as necessary. (see guideline # 2002)
16. Limit intubation attempts to no longer than 20 seconds. Abort the attempt at that time
and ventilate the patient. Repeat the attempt.
17. Insert the ET tube into the right side of the patient’s mouth. Do not obstruct the view of
the cords.
18. Pass the tube through the vocal cords until the cuff has passed approximately 1 cm
below the level of the cords.
19. Holding the ET tube firmly in place, remove the laryngoscope blade.
20. With the tube properly placed in the trachea, inflate the cuff with 6-8 cc of air.
21. Ventilate the patient through the ET tube using the bag-valve assembly and auscultate
over the stomach to confirm the tube is not in the esophagus. Auscultate breath sounds
to confirm proper placement. Observe chest rise with ventilation.
22. At least 2 methods to confirm tube placement in the tracheal must be made. Methods
include: visualization of the tube passing between the vocal cords, auscultation of breath
sounds, observation of chest rise with ventilation, end-tidal CO2 readings, esophageal
intubation detector (syringe type).
23. If the endotracheal tube has been misplaced in the esophagus, immediately remove the
tube, ventilate the patient and repeat the sequence above.
a.
If successful intubation has not been established after 3 attempts, an alternate
airway adjunct should be considered.
b.
Ventilate the patient for at least 30 seconds between attempts.
24. Secure the tube with tape or ET tube holder. Document marking on tube at the corner of
the mouth.
25. Select and insert an oral airway. (see guideline # 2006)
26. Ventilate patient with 100% oxygen via bag-valve device. Continue to ventilate patient
while intubated.
27. Frequently reassess breath sounds and respiratory status to confirm tube placement,
especially after moving patient.
28. Document position of the tube and quality of breath sounds upon arrival at the hospital.
29. Document procedure and results, including any unusual circumstances and/or difficulties
encountered.
End page
Endotracheal intubation (cont.)
Recognize/verbalize advantages of endotracheal intubation
 Positive control of the airway
 Prevents aspiration when cuff is inflated
 Provides for easy ventilation
 Provides route for administration of selected medications
 Permits easier suctioning of secretions from the airway
Recognize/verbalize disadvantage of endotracheal intubation
 Requires special training and equipment
 May be difficult to avoid cervical spine movement
Recognize/verbalize complications of endotracheal intubation
 Unrecognized misplacement of the tube can result in acute gastric dilation and rupture
 Injury to the tracheal wall by the balloon cuff
 Failure to recognize esophageal intubation results in hypoxia
 Improper position of the tube (e.g. into mainstem bronchus)
 Trauma to the upper airway during insertion
 Potential for barotrauma (pneumothorax, tension pneumothorax) to the lungs with
ventilations
Recognize/verbalize contraindication to endotracheal intubation:
 Laryngospasm
END
GUIDELINE FOR PRACTICAL SKILL
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision:
10/30/02
Guideline Number: 2010
The following content will be considered the Guideline/Standard for:
NASOTRACHEAL INTUBATION
Approved for use
by:
EMT
Advanced EMT
EMTIntermediate
EMTParamedic
XX
PURPOSE
To provide positive control of an airway, especially in those adult patients who have some
respiratory effort, who have suspected cervical injury, who have an intact gag reflex or
whose mouth cannot be opened.
To facilitate assisted ventilation in an adult patient with inadequate respirations
EQUIPMENT
Endotracheal tube of appropriate size for patient
Available sizes include adult 6.0 through 9.0 mm
Water soluble lubricant
Syringe to inflate cuff
Tape or commercial endotracheal tube holder
Stethoscope
Bag-valve-mask device with oxygen reservoir
Oxygen source with connecting tubing
Suction machine and catheters
Personal protective equipment to prevent exposure to blood/body fluids
PROCEDURE
1. Assure scene safety and observe universal precautions (see guideline #107).
2. Assure adequate ventilation and oxygenation of patient prior to attempting procedure.
3. Select an appropriate size endotracheal tube, one size smaller that would be selected for
oral intubation (Oral size = an exterior diameter approximately equal to the diameter of
the distal joint of the patient’s little finger.)
4. Attach the syringe to the endotracheal tube, inflate the cuff with 6-8 cc of air and check
cuff of tube for leaks, deflate the cuff.
5. Lubricate distal end of the endotracheal (ET) tube with water soluble gel.
6. Maintain head in neutral position and ventilate the patient with at least 6 breaths prior to
intubation attempt
7. Advance ET tube gently through the nostril (bevel toward septum) straight back along
the floor of the nasal passage until the tip of the tube reaches a level slightly above the
patient’s vocal cords. Air will be heard moving through the tube. If resistance is met,
repeat the attempt in the other nostril.
8. When the patient next inhales, advance the tube through the cords.
9. Advance the tube approximately 1 cm until the cuff clears the cords.
End page
Nasotracheal intubation, (cont.)
10. Limit intubation attempts to no longer than 20 seconds. Abort the attempt at that time
and ventilate the patient. Repeat the attempt.
11. Ventilate the patient through the ET tube using the bag-valve assembly and auscultate
breath sounds over the axillae to confirm proper placement. Auscultate over the
stomach to confirm the tube is not in the esophagus. Observe chest rise with ventilation.
12. At least 2 methods to confirm tube placement in the tracheal must be made. Methods
include: visualization of the tube passing between the vocal cords, auscultation of breath
sounds, observation of chest rise with ventilation, end-tidal CO2 readings, esophageal
intubation detector (syringe type).
13. If the endotracheal tube has been misplaced in the esophagus, immediately remove the
tube, ventilate the patient and repeat the sequence above.
a.
If successful intubation has not been established after 3 attempts, an alternate
airway
adjunct should be considered.
b.
Ventilate the patient for at least 30 seconds between attempts.
14. Inflate the cuff with 6-8 cc of air. Secure the tube with tape or with a commercial
endotracheal tube holder.
15. Ventilate patient with 100% oxygen via bag-valve device. Continue to ventilate patient
while intubated.
16. Frequently reassess breath sounds and respiratory status to confirm tube placement,
especially after moving patient.
17. Document position of the tube and quality of breath sounds upon arrival at the hospital.
18. Document procedure and results, including any unusual circumstances and/or difficulties
encountered.
Recognize/verbalize advantages of nasotracheal intubation:
 Positive control of the airway
 Prevents aspiration when cuff is inflated
 Provides for easy ventilation
 Provides route for administration of selected medications
 Permits easier suctioning of secretions from the airway
 Manipulation of cervical spine not needed
 Better tolerated by a conscious patient
 Do not need to open mouth of patient
Recognize/verbalize disadvantage of nasotracheal intubation:
 Requires special training and equipment
 Cannot be used on pediatric patients because of the anatomy of the airway
Recognize/verbalize complications of nasotracheal intubation:
 Unrecognized misplacement of the tube can result in acute gastric dilation and rupture
 Injury to the tracheal wall by the balloon cuff
 Failure to recognize esophageal intubation results in hypoxia
 Improper position of the tube (e.g. into the mainstem bronchus)
 Epistaxis
 Potential for barotrauma to the lungs with ventilations
Recognize/verbalize contraindication to nasotracheal intubation:
 Laryngospasm
 Suspected facial or basilar skull fractures
END
GUIDELINE FOR PRACTICAL SKILL
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 1/1/09
Guideline Number: 2011
The following content will be considered the Guideline/Standard for:
APPLICATION OF POSITIVE END EXPIRATORY PRESSURE (PEEP) VALVE
Approved for use
by:
EMT
Advanced EMT
EMTIntermediate
EMTParamedic
XX
PURPOSE
To increase back pressure in the airway during exhalation to help hold the alveoli and
terminal bronchioles open, facilitating removal of carbon dioxide
EQUIPMENT
Positive End Expiratory Pressure (PEEP) valve
Bag-valve-mask device with oxygen reservoir
Oxygen source with connecting tubing
Exhalation diverter cap (if needed)
Personal protective equipment to prevent exposure to blood/body fluid
PROCEDURE
1. Assure scene safety and observe universal precautions (see guideline #107).
2. Confirm medical control order for a specific setting of the PEEP valve.
3. Attach the exhalation diverter cap to the valve of the bag-valve-mask device if
necessary.
4. Attach the PEEP valve to the exhalation (diverter) cap.
5. Dial the specified setting on the PEEP valve.
6. Ventilate the patient with bag-valve device with 100% oxygen.
7. Evaluate and monitor the patient response to treatment.
8. Document procedure and results, including any unusual circumstances and/or difficulties
encountered.
Note: The PEEP valve is most efficient when used in conjunction with an endotracheal tube.
Unless a CPAP mask with straps is used, it is almost impossible to maintain PEEP with a face
mask.
Recognize/verbalize the indications of the PEEP valve:
The PEEP valve may be beneficial In patients with a working assessment of:
 Pulmonary edema
 Inhalation injury
 Aspiration
 Near-drowning
Recognize/verbalize advantages of positive end expiratory pressure:
 Increase in the partial pressure of oxygen in the alveoli improves oxygen transfer into
the blood stream.
 Maintains open alveoli to facilitate gas exchange
End page
PEEP, (cont.)
Recognize/verbalize disadvantages of positive end expiratory pressure:

Can increase the pressure in the airway enough to cause damage/rupture of airway
structures.
Recognize/verbalize the complications which may occur as a result of using a PEEP valve when
ventilating a patient;



Simple pneumothorax
Tension pneumothorax
Hypotension
Recognize/verbalize contraindication to positive end expiratory pressure:


END
Presence of simple or tension pneumothorax
Use with caution in patient with chronic obstructive or other restrictive lung disease (e.g.
asthma, emphysema)
GUIDELINE FOR PRACTICAL SKILL
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 1/1/09
Guideline Number: 2012
The following content will be considered the Guideline/Standard for:
EXTUBATION
Approved for use
by:
EMT
Advanced EMT
With added module
EMTIntermediate
XX
EMTParamedic
XX
PURPOSE
To safely remove an indwelling endotracheal tube (oral or nasal) from the trachea
EQUIPMENT
Bag-valve device with oxygen reservoir
Oxygen source with connecting tubing
Suction machine and flexible catheters
Syringe to deflate cuff
Non-rebreathing mask
Intubation equipment
Personal protective equipment to prevent exposure to blood/body fluids
PROCEDURE
1. Assure scene safety and observe universal precautions (see guideline #107).
2. Perform per local medical direction.
3. Evaluate and document the patient’s level of consciousness and ability to follow
commands prior to extubation.
4. Explain the procedure to the patient.
5. Ventilate the patient for approximately 12 breaths with 100% oxygen.
6. Suction out the mouth and oropharynx, using a soft tip suction catheter to remove all
secretions that may be above the cuff of the endotracheal tube.
7. Instruct the patient to take in a deep breath.
8. Attach the syringe, deflate the cuff of the endotracheal tube and have the patent cough as
the tube is gently removed from the airway.
9. Instruct the patient to cough and to take deep breaths.
10. Supplement the patient with high flow oxygen via a non-rebreathing mask for the
duration of the prehospital care.
11. Report the completion of the procedure and condition of the patient to medical control.
12. Monitor the patient carefully for respiratory distress, prepared to intubate if necessary.
13. Document procedure and results, including any unusual circumstances and/or difficulties
encountered.
Recognize/verbalize advantages of extubation:
Removes focus of discomfort and agitation from an alert patient who has an intact gag
reflex and is ventilating adequately on his/her own.
End page

Extubation (cont.)
Recognize/verbalize disadvantages of extubation:
 May precipitate laryngospasm
 Loss of positive airway control
Recognize/verbalize complications of extubation:
 Aspiration
 Laryngospasm
Recognize/verbalize contraindication to extubation:
 Any patient unable to adequately ventilate or protect his/her own airway
END
GUIDELINE FOR PRACTICAL SKILL
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 1/1/09
Guideline Number: 2013
The following content will be considered the Guideline/Standard for:
NASOGASTRIC OR OROGASTRIC TUBE PLACEMENT
Approved for use
by:
EMT
Advanced EMT
EMTIntermediate
EMTParamedic
XX
PURPOSE
To decompress gastric dilatation following placement of an endotracheal tube
EQUIPMENT
Nasogastric tube
Water soluble lubricant
60 ml syringe
Stethoscope
Tape
Laryngoscope with functioning batteries
Laryngoscope blade of appropriate size for the patient with functioning light bulb
Magill forceps of appropriate size for the patient (Adult and pediatric sizes available)
Personal protective equipment to prevent exposure to blood/body fluids
PROCEDURE
1. Assure scene safety and observe universal precautions (see guideline #107).
2. Approximate the length of the nasogastric tube needed by measuring from the ear lobe to
the tip of the nose and then to the umbilicus of the patient.
3. Lubricate the tube with water-soluble lubricant.
4. For the patient with an endotracheal tube in place, insert the nasogastric tube into the
patient’s nostril, directing the advancement straight back along the floor of the nasal
passage.
5. For patients with suspected facial or basilar skull fracture, the tube should be inserted
orally rather than nasally.
6. Advance the tube until:
a. The measured length of the tube has been reached or
b. Gastric contents appear in the tube or
c. Gastric distention has been relieved.
7. Check the posterior pharynx to be sure the tube is not curled up in the back of the mouth.
If found curled in the pharynx, withdraw and reinsert the tube, advancing it if necessary
with Magill forceps under direct visualization with a laryngoscope and blade.
8. Inject approximately 30 ml of air into the nasogastric tube while listening over the
stomach with the stethoscope to confirm placement.
9. Secure placement of the tube with tape.
10. Document procedure and results, including any unusual circumstances and/or difficulties
encountered
Recognize/verbalize advantages to insertion of a gastric tube:
Decompresses the stomach, reducing the chance of regurgitation and aspiration
Allows freer downward movement of the diaphragm, making ventilation easier
End page


Nasogastric/orogastric tube (cont.)
Recognize/verbalize disadvantages to insertion of a gastric tube:

May stimulate vomiting
Recognize/verbalize complications of the insertion of a gastric tube:


Epistaxis
Accidental passage into the trachea may stimulate coughing
Recognize/verbalize contraindication to the insertion of a gastric tube
 Facial or basilar skull fracture
 Unprotected airway in the patient with an altered level of consciousness
END
GUIDELINE FOR PRACTICAL SKILLS
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 1/1/09
Guideline Number: 2014
The following content will be considered the Guideline/Standard for:
TRACHEOSTOMY CARE
Approved for use
by:
EMT
Advanced EMT
EMTIntermediate
XX
EMTParamedic
XX
PURPOSE
To maintain a patent airway and adequate oxygenation of the patient with a temporary or
permanent tracheostomy
To remove or replace a temporary tracheostomy tube
EQUIPMENT
Suction machine and catheters
Normal Saline
Temporary tracheostomy tube with inner and outer tubes and placement obturator
Tracheostomy ties
(patient at home with tracheostomy should have spare tubes and ties available)
Endotracheal tube of appropriate size for neck opening
Available sizes include adult 6.0 through 9.0 mm; pediatric (uncuffed) 2.5 through 5.5
Bag-valve-mask device with reservoir bag
Oxygen source with connecting tubing
Personal protective equipment to prevent exposure to blood/body fluids
PROCEDURE - TEMPORARY TRACHEOSTOMY
1. Assure scene safety and observe universal precautions (see guideline #107).
2. Evaluate respiratory status of the patient.
3. Suction through the inner tube. 2.5-5 cc of Normal Saline may be installed into the tube
and then suctioned out if secretions are very thick.
4. The inner tube can be removed and the suctioning repeated.
5. If the outer tube has been displaced or is blocked, remove it and replace it with the spare
kept at home by the patient or with an endotracheal tube.
6. To ventilate through a tracheostomy tube, attach the bag-valve directly to the
tracheostomy tube. An adapter off an endotracheal tube may be needed to make the
connection.
7. Intubation is also usually possible through the upper airway structures. The cuff of the
tube must extend below the opening in the neck.
8. If ventilating from above, block the neck opening. If ventilating through the neck
opening with an uncuffed tube, block the upper airway.
9. Monitor the patient’s respiratory status.
10. Document procedure and results, including any unusual circumstances and/or difficulties
encountered.
Note: Temporary tracheostomy bypasses the upper airway. A metal or plastic tube is
inserted through the soft tissue of the anterior neck into the trachea and is held in place with
ties circling the neck.
End page
Tracheostomy care, (cont.)
Temporary tubes are rarely cuffed unless used in conjunction with a ventilator and
aspiration is possible from above or from gastric contents.
Suctioning removes air as well as secretions. Ventilate with supplemental oxygen after
each procedure.
PROCEDURE - PERMANENT TRACHEOSTOMY
1. Assure scene safety and observe universal precautions (see guideline #107).
2. Evaluate the respiratory status of the patient.
3. Suction through the opening in the neck. The upper airway is surgically absent and
aspiration from above or of gastric contents is not possible. (see guideline # 2002)
4. 2.5-5 cc of Normal Saline can be installed into the stoma and then suctioned out if
secretions are very thick.
5. Intubation and ventilation must occur through the stoma in the neck.
6. Monitor the patient’s respiratory status.
7. Document procedure and results, including any unusual circumstances and/or difficulties
encountered.
Note: A permanent tracheostomy is created when the upper airway structures are surgically
removed. An opening called a stoma is created in the anterior neck and the trachea
surgically attached to the opening.
Suctioning removes air as well as secretions. Ventilate with supplemental oxygen after each
procedure.
INTUBATION THROUGH A STOMA:
1.
2.
3.
4.
5.
6.
Assure scene safety and observe universal precautions (see guideline #107).
If a tracheostomy tube is present, remove it.
Suction as necessary. (see guideline # 2002)
Insert the endotracheal tube through the opening until the cuff is past the opening.
Inflate the endotracheal tube cuff with 6-8 cc air.
Ventilate the patient with 100% oxygen via bag-valve device. If the patient has a
temporary tracheostomy, the upper airway must be blocked unless a cuffed tube is in
place.
7. Auscultate breath sounds over the axillae to confirm proper placement. Special care is
needed for the patient with a temporary tracheostomy to assure the endotracheal tube has
entered the tracheal lumen and is not lodged in the soft tissue of the neck.
8. Secure the endotracheal tube with tape.
9. The endotracheal tube can only be shortened to the point where the cuff inflation line
separates from the tube.
10. Frequently reassess breath sounds and respiratory status to confirm tube placement,
especially after moving the patient.
11. Document the position of the tube and quality of breath sounds upon arrival at the
hospital.
12. Continue to ventilate the patient while intubated.
13. Document procedure and results, including any unusual circumstances and/or difficulties
encountered.
Recognize/verbalize advantages of endotracheal intubation through a tracheostomy/stoma:
 Positive control of the airway
 Prevents aspiration when cuff of endotracheal tube is inflated
End page
Tracheostomy care, (cont.)



Provides for easy ventilation
Provides route for administration of selected medications
Permits easier suctioning of secretions from the airway
Recognize/verbalize disadvantage of endotracheal intubation through a
tracheostomy/stoma:
 Requires special training and equipment
Recognize/verbalize complications of endotracheal intubation through a
tracheostomy/stoma:
 Unrecognized misplacement of the tube can result in acute subcutaneous emphysema if
the end of the tube is in the soft tissue space between the anterior neck and the trachea
 Failure to recognize misplacement of the tube results in hypoxia



Improper position of the tube (very easy to advance the tube too far and enter the
mainstem bronchus)
Trauma to the soft tissue of the neck or the trachea during insertion
Potential for barotrauma to the lungs with ventilations
Recognize/verbalize contraindication to endotracheal intubation through a
tracheostomy/stoma:
 None
END
GUIDELINE FOR PRACTICAL SKILL
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 1/1/09
Guideline Number: 2015
The following content will be considered the Guideline/Standard for:
THORACENTESIS (THORACIC DECOMPRESSION)
Approved for use
by:
EMT
Advanced EMT
EMTIntermediate
XX
EMTParamedic
XX
PURPOSE
To provide an open vent into the pleural space to decompress a suspected tension
pneumothorax
EQUIPMENT
14 gauge 3.25 inch IV catheter
Alcohol prep
Tape
Stethoscope
Personal protective equipment to prevent exposure to blood/body fluids
PROCEDURE
1. Assure scene safety and observe universal precautions (see guideline #107).
2. Confirm the order with medical control.
3. Determine which side of the chest has a tension pneumothorax.
4. Locate the suprasternal notch, move laterally to the midclavicular line and locate the
second and third rib on the side of the pneumothorax.
5. Remove the protective sheath and confirm the IV catheter is in place on the 14 gauge
needle.
6. Cleanse the insertion site with alcohol.
7. Insert the needle and extracatheter at a 90º angle directly over the 3rd rib. When the tip
of the needle has passed through the chest skin and touches the 3rd rib, alter the angle
and “walk” the needle over the 3rd rib, advancing it into the pleural cavity.
Note: Alternative site 5th intercostal space, midaxillary line
8. Listen for escape of air to confirm placement of the catheter.
9. Withdraw the needle and tape the catheter in place.
10. Dispose of contaminated materials in the appropriate receptacle.
11. Reassess the patient’s condition and vital signs.
12. Document procedure and results, including any unusual circumstances and/or difficulties
encountered.
Recognize/verbalize signs/symptoms of a tension pneumothorax

Restless/agitated
Increased resistance to ventilation
 Jugular vein distention
 Decreased or absent breath sounds on the affected side
 Mechanism of injury, nature of illness, iatrogenic interventions
End page

Thoracic decompression (cont.)
Recognize/verbalize indications that the diagnosis was correct and the procedure
successful:





Increase in blood pressure
Loss of jugular vein distention
Decreased dyspnea
Easier to ventilate patient
Improved color
Recognize/verbalize complications of thoracic decompression:


Intercostal artery injury
Iatrogenic pneumothorax if original diagnosis is incorrect
Recognize/verbalize contraindication to thoracic decompression:
 None if the patient meets the clinical criteria
END
GUIDELINE FOR PRACTICAL SKILL
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 1/1/09
Guideline Number: 2016
The following content will be considered the Guideline/Standard for:
Cricothyroidotomy and Needle cricothyroidotomy
Approved for use
by:
EMT
Advanced EMT
EMTIntermediate
EMTParamedic
XX
PURPOSE
To provide an airway in a patient where other airway techniques have failed or are not
indicated.
EQUIPMENT
#12 and #14 gauge over the needle catheters (8.5 cm in length)
Antiseptic swabs
3.0 mm endotracheal tube adapter or 3 cc syringe and 7.0 endotracheal tube adapter
Syringes ranging between 5 cc and 12 cc
Scalpel #10
Hemostats and small rake retractors
Twill-tape or umbilical tape
Personal protective equipment to prevent exposure to blood/body fluids
Jet insufflator or BVM assembly
5.0 or 7.0 endotracheal tube or tracheostomy tube
PROCEDURE (Needle)
1.
2.
3.
4.
5.
6.
7.
8.
9.
Assure scene safety and observe universal precautions (see guideline #107).
Confirm the order with medical control.
Place patient in the supine position
Palpate the cricothyroid membrane
Prep the area with antiseptic swabs
Assemble #12 or #14 over the needle catheter to a 5-12 ml syringe.
Puncture the skin midline and directly over the cricothyroid membrane.
Direct the needle at a 45 degree angle caudally.
Carefully advance the needle through the cricothyroid membrane with constant
aspiration (aspiration of air indicates entry into the tracheal lumen.
10. Withdraw the stylet while gently advancing the catheter.
11. Attach the needle to either a 3 mm ET tube adapter or combine a 3cc syringe and a 7mm
ET tube adapter.
12. Connect to Jet insufflator or BVM assembly. (Jet insufflator is used with an I:E ratio of
1:2).
13. Secure the apparatus to the patient’s neck.
14. Dispose of contaminated equipment in the appropriate receptacle.
15. Report completion and results of the procedure to medical control.
16. Reassess the patient’s condition.
17. Document procedure and results, including any unusual circumstances and/or difficulties
encountered.
End page
PROCEDURE (surgical) (not recommended for patients less then 12 yrs old)
1. Place patient in the supine position
2. Palpate thyroid notch, cricoid cartilage, and sternal notch for orientation.
3. Prep the area with antiseptic swabs.
4. Stabilize the thyroid cartilage.
5. Make a skin incision with a #10 scalpel.
6. Make a second incision through the cricothyroid membrane.
7. Spread the edges with rakes or the scalpel handle
8. Insert an appropriately sized cuffed ETT or tracheostomy tube directing it distally.
9. Inflate the cuff and ventilate the patient with a BVM.
10. Auscultate the lung fields
11. Secure the endotracheal or tracheostomy tube by tying around neck.
18. Dispose of contaminated equipment in the appropriate receptacle.
19. Report completion and results of the procedure to medical control.
20. Reassess the patient’s condition.
21. Document procedure and results, including any unusual circumstances and/or difficulties
encountered.
Contraindications and Complications












END
Surgical technique not indicated if trachea is likely disrupted or fractured
Asphyxia
Aspiration
Cellulitis
Creation of false tissue passage
Subglottic stenosis/edema
Laryngeal stenosis
Hemorrhage or hematoma formation
Laceration of the esophagus
Laceration of the trachea
Mediastinal emphysema
Vocal cord paralysis
GUIDELINE FOR PRACTICAL SKILL
Initial Date:
10/30/02
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 5/30/08
Guideline Number: 2017
The following content will be considered the Guideline/Standard for:
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Approved for use
by:
EMT
Advanced EMT
XX
XX
EMTIntermediate
XX
EMT-Paramedic
XX
PURPOSE:
To decrease work of breathing, sense of dyspnea and need for endotracheal intubation in patients
greater then 12 years of age with exacerbations of asthma, COPD, CHF and pneumonia.
To recruit additional alveoli to improve oxygenation and gas exchange
Note: Not to replace any current treatments for respiratory distress
EQUIPMENT
Commercial CPAP device
Multiple sizes of CPAP masks
Multiple CPAP circuits
Oxygen source (CPAP should be used with portable oxygen cylinders for brief periods only due to the large amount of
oxygen required to operate the device)
Personal protective equipment to prevent exposure to blood/body fluids
PROCEDURE:
APPLICATION
1. Assure scene safety and observe universal precautions (see guideline #107).
2. Assess the patient to assure that a pneumothorax is NOT present.
3. Explain the procedure to the patient.
4. Ensure an adequate supply of oxygen to operate the CPAP device.
5. Place the patient on continuous pulse oximetry.
6. Place delivery device (mask) over the patient’s mouth and nose.
7. Secure the mask with provided straps or other provided device.
8. Use 5 cm of water Positive End Expiratory Pressure (PEEP). (see guideline #111)
9. Check for air leaks.
10. Use supplemental O2 very early in course to assure adequate Oxygen delivery (not
applicable if using 100% fixed flow device)
11. Monitor and document the patient’s respiratory response to treatment.
12. Increase PEEP to achieve maximal benefit if needed (Max 7.5 cm for EMT-B and
Intermediate Tech; 10 cm for Intermediate and Paramedic) {note: 5 cm is intended to
acclimate the patient to the device}
13. Check and document complete vital signs every 5 minutes.
14. Continue to coach the patient to keep the mask in place and adjust as needed.
15. If respiratory status, level of consciousness or SvO 2 deteriorates, remove the device and
consider Bag-Valve-Mask ventilations assistance or endotracheal intubation. (see guideline
#2004, 2009)
16. Document procedure and results, including any unusual circumstances and/or difficulties
encountered.
17. As PEEP increases and patient condition improves, supplemental O 2 may be reduced to
maintain appropriate oxygen saturation
REMOVAL
1. CPAP therapy needs to be continuous and should not be removed unless the patient cannot
tolerate the mask or experiences continued or worsening respiratory failure.
2. Bag-Valve-Mask-assisted ventilation or intubation should be considered if the patient is
removed from CPAP therapy.
3. Since PEEP can cause a reduction in BP, PEEP should be reduced if BPs falls below 100
mmHg
RECOGNIZE/VERBALIZE INDICATIONS FOR THE USE OF CPAP
Any patient who is complaining of shortness of breath for reasons other than pneumothorax and:
Is awake and oriented and
Is able to fit the CPAP mask and
Has the ability to maintain an open airway and
Has signs and symptoms consistent with asthma, COPD, CHF or pneumonia and
Is greater then 12 years of age
And exhibits at least two of the three of the following:
Has a respiratory rate greater than 25 breaths per minute
Uses accessory muscles during respirations
Has an SpO2 of less than 94% on room air
RECOGNIZE/VERBALIZE CONTRAINDICATIONS FOR THE USE OF CPAP
Patient is in respiratory arrest
Patient is unable to follow commands
Patient has active GI bleeding or is vomiting
Patient has major trauma or significant facial trauma
Patient is suspected of having a pneumothorax
Patient has a tracheostomy (technical problem with proper mask fit.)
Patient has hypotension (BPs less than 100mmHg)
RECOGNIZE/VERBALIZE PRECAUTIONS FOR THE USE OF CPAP
Use caution if the patient:
Is not able to cooperate with the procedure.
Has failed past attempts at noninvasive ventilation.
Has history of recent gastric surgery.
Complains of nausea.
Has decreasing respiratory effort.
Has excessive secretions.
Has facial deformity that prevents the use of the CPAP mask.
If patient has a history of pneumothorax but no current clinical evidence of pneumothorax,
CPAP should be avoided unless absolutely necessary pending chest X-ray.
Intubation should be considered (by trained personnel) if:
The patient develops respiratory or cardiac arrest.
The patient is or becomes unresponsive with a Glasgow Coma Scale less than9).
SPECIAL NOTES:
Advise medical control that CPAP is in use so receiving hospital can be prepared for the patient.
Do not remove therapy until specifically asked to do so by hospital personnel.
Most patients will improve in 5-10 minutes.
Watch patient for gastric distention.
Remember CPAP is a secondary adjunct to other methods of treatment for respiratory distress. Do
not forget bronchodilator therapy or nitroglycerin therapy when appropriate.
May be the treatment of choice for a DNR patient.
CPAP is not intended to replace intubation, it is simply another tool to treat the patient with the hope
that the clinical presentation will not deteriorate to where intubation is required.
GUIDELINE FOR PRACTICAL SKILL
Initial Date: 1/5/05
Service Director’s
Signature
Medical Director’s
Signature
Last/Review, Revision: 1-1-09
Guideline Number: 2018
The following content will be considered the Guideline/Standard for:
RAPID SEQUENCE INTUBATION
Approved for use
by:
EMT
Advanced EMT
EMTIntermediate
EMTParamedic
XX
PURPOSE:
 Provide optimal intubation conditions while minimizing risk of aspiration in the
conscious patient, the combative patient, or the unconscious patient with a clenched jaw,
where the need for immediate intubation has been established
EQUIPMENT










Endotracheal intubation equipment (see guideline 2009)
Peripheral IV equipment (see guideline 3002)
Atropine, sedative and neuromuscular blocking agent (Succinylcholine for intubation,
Vecuronium for maintenance if needed)
Cardiac monitor (see guideline 3009)
Pulse oximeter
End tidal carbon dioxide detection device
Alternative airway e.g. Combitube, cricothyroidotomy (see guideline 2008, 2016)
Suction equipment (confirmed operation)
Towel to pad head for airway alignment if needed and appropriate
Personal protective equipment to prevent exposure to blood or body fluids.
PROCEDURE
Preparation & Preoxygenation
 Obtain medical control orders/advice as needed.
 Place patient on cardiac monitor and pulse oximetry.
 Assure patient is placed on 100% oxygen for 5 minutes prior to the procedure.
 Establish your ability to adequately ventilate the patient with a bag-valve-mask on 100%
oxygen
 Predict if patient will have a “difficult airway”. If yes, consider alternate airway options
(e.g. BVM or Nasal Tracheal intubation).
 Start IV in a peripheral vein (see guideline 3002)
 Prepare equipment listed above.
 Reconstitute succinylcholine or other neuromuscular blocking agent. (see drug profile 043,044)
 Prepare the sedative selected (e.g. midazolam, etomidate). (see drug profile 007, 023, 034)

Consider Atropine (0.01-0.02 mg/kg with minimum dose of 0.1 mg) for reflex
bradycardia, especially in children. (see drug profile 005)
End page 1
Rapid sequence intubation
Page 2
Paralysis with induction
 Administer sedative followed by neuromuscular blocker at appropriate interval to allow
for effective sedation.
 Perform Sellick’s Maneuver as patient loses consciousness to prevent regurgitation.
 Monitor pulse oximetry. If SPO2 falls below 90%, stop procedure and ventilate the
patient. If SPO2 was less than93% prior to administration of sedation/paralytic, do not
allow it to drop more than 6% before aborting the procedure and ventilating the patient.
Placement of ET tube with confirmation
 Once patient is fully relaxed (approximately 45 seconds if using Succinylcholine),
perform endotracheal intubation (see guideline 3002).
 Ventilate patient with bag-valve and 100% oxygen.
 Confirm tube placement with auscultation and presence of end tidal CO2.
 Release Sellick’s Maneuver.
Post Intubation Management
 Secure ET tube.
 Consider restraining the patient (chemically or physically). The patient (when
sedation/paralytic wears off) may try to pull tube out.
 Never allow a patient to be paralyzed and not sedated. All paralyzed patient must be
continuously and effectively sedated.
 Reevaluate ET tube position after each patient move and as condition dictates.
 Document procedure and results, including any unusual circumstances and/or difficulties
encountered.
Failed Airway
 Definition: Inability to successfully place ET tube after 3 attempts.
 Evaluate if airway can be maintained with BVM or Combitube, selecting the most
effective device to maintain the airway and ventilate.
 Consider cricothyroidotomy
Recognize/verbalize advantage(s) of rapid sequence intubation:
 Facilitate intubation in a hypoxic patient who is conscious or restless/combative,
including but not limited to head injuries, status epilepticus, respiratory insufficiency
with altered level of consciousness, inhalation injuries.
Recognize/verbalize disadvantages of rapid sequence intubation:
 Inability to further evaluate patient’s neurologic status
Recognize/verbalize complications of rapid sequence intubation:
 Inability to establish the airway after the patient has been paralyzed.
Recognize/verbalize contraindication to rapid sequence intubation:
 Indications that the endotracheal tube will be very difficult or you will be unable to
successfully ventilate the patient once he/she has been paralyzed
 Significant facial trauma
 Laryngeal edema
 Succinylcholine contraindications (see drug guideline043)
Special Notes:
 An alternative airway must be immediately available in case the endotracheal tube cannot
be placed successfully.
GUIDELINE FOR PRACTICAL SKILL
Initial Date:
9/28/06
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 1/1/09
Guideline Number: 2019
The following content will be considered the Guideline/Standard for:
IMPEDANCE THRESHOLD DEVICE (RESQPOD)
Approved for use
by:
EMT
Advanced EMT
EMTIntermediate
XX
XX
XX
Note: Services using the impedance threshold device must show evidence of training in the use of the device.
EMTParamedic
XX
PURPOSE:
To increase blood flow back to the heart, which increases the preload of the heart
To prevent hyperventilation
INDICATIONS:
Cardiac arrest (patient currently without pulse and spontaneous ventilations)
EQUIPMENT:
ResQPOD
Bag-valve device with oxygen reservoir
Oxygen source
Airway adjunct (Mask, Combitube, or ET tube)
Suction machine and catheters
Personal protective equipment to prevent exposure to blood/body fluids
PROCEDURE:
1. Assure scene safety and observe universal precautions (see guideline #107).
2. Apply the ResQPOD to face mask with oral airway, Combitube, or Endotracheal Tube.
Do not delay chest compressions.
3. Maintain a tight face-mask seal at all times during chest compressions.
4. Use a bag-valve-mask (BVM) ventilator, or bag-valve to provide ventilation.
5. Follow standard AHA CPR guidelines.
6. Establish advanced airway device (Endotracheal Intubation or Combitube) and assess
placement per protocol.
7. Place ResQPOD between adjunct and BVM.
8. Turn on Ventilation LED timer. If programmed for one light every five seconds,
ventilate patient once every other light or once every ten seconds. (note: this is a slight
modification from the AHA guideline ventilation rate if using a ResQPod designed for
the 2000 AHA guidelines).
9. Remember importance of full chest recoil during chest compressions.
10. Document the ResQPOD placement.
11. Remove ResQPod if return of spontaneous circulation and respirations.
End page 1
ResQPOD (continued)
List advantages of the ResQPOD:
 Prevents hyperventilation
 Greater preload of heart
List disadvantages of the ResQPOD:
 Additional device during set up
List complications of the ResQPOD:
 Extra weight from ResQPOD could cause ET or Combitube to become dislodged
List contraindications to the ResQPOD:
 Cardiogenic shock
 Suspected pneumothorax
 Chest trauma
 Flail chest
 less than 12 y/o
 less than 100 lbs.
Note: When BLS responds to cardiac arrest and airway being managed appropriately with
face mask (good chest rise with ventilations), continue with ResQPOD on face mask until
ALS arrives. If patient is vomiting, is greater then or equal to 5ft and/or ALS will be delayed
more than 10 minutes, consider inserting Combitube, though endotracheal intubation is the
preferred airway.
END
GUIDELINE FOR PRACTICAL SKILL
Initial Date:
11/01/08
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 1/07/09
Guideline Number: 2020
The following content will be considered the Guideline/Standard for:
LARYNGEAL MASK AIRWAY (LMA) INSERTION
Approved for use
by:
EMT
Advanced EMT
EMTIntermediate
Paramedic
XX
PURPOSE
To provide positive an alternative way to control a patients airway
To give you an alternative airway just prior to where a surgical airway is the only option
To prevent aspiration in a patient with decreased reflexes
CONTRAINDICATIONS
1. Patients that may have a high risk of aspiration
2. Patients who are not profoundly unconscious and that may resist an LMA / oral
airway insertion.
3. Severe maxillofacial or oropharyngeal
4. Greater than 14 weeks pregnant
EQUIPMENT
Body Substance Isolation
Laryngeal Mask Airways (LMA) of appropriate sizes
Syringe with the appropriate volume for LMA cuff inflation
10 to 12 FR suction catheter
Water-soluble lubricant
Tape or other device(s) to secure the LMA
Stethoscope
Ventilation equipment
Oxygen source
Suction device
PROCEDURE
1. Verify the size of the LMA is the proper size for the patient per manufacturer
recommendation
a. Recommended size guideline:
i. Size 1
less than 5kg
ii. Size 1.5
5-10kg
2.
iii. Size 2
10-20kg
iv. Size 2.5
20-30kg
v. Size 3
30kg to small adult
vi. Size 4
adult
vii. Size 5
large adult/poor seal with size 4
Examine the LMA
a. Visually inspect the LMA for tears in the cuff or abnormalities
b. Make sure the tube is free of blockages or loose particles
c. Inflate the cuff to ensure that it does not leak
d. Deflate the cuff to ensure that it will maintain a vacuum
3.
4.
5.
Deflation and Inflation
a. Slowly deflate the LMA cuff to form a smooth flat wedge shape that will pass
easily behind the epiglottis and the back of the tongue.
b. When inflating, the maximum air in the cuff should not exceed:
i. Size 1
4 ml
ii. Size 1.5
7 ml
iii. Size 2
10 ml
iv. Size 2.5
14 ml
v. Size 3
20 ml
vi. Size 4
30 ml
vii. Size 5
40 ml
Lubrication
a. Lubricate with a water soluble lubricant the LMA device
b. Only lubricate the device just prior to insertion
c. Lubricate the back of the LMA thoroughly (avoid too much to reduce the risk of
an obstruction)
Position the patients airway
a. Extend the head and flex the neck
b. Avoid LMA fold over
c. If possible, have a second person pull the lower jaw downward
d. Visualize the posterior oral airway.
e. Ensure the LMA is not folding over in the oral cavity while inserting
LMA INSERTION TECHNIQUE
1.
2.
3.
4.
Grasp LMA by the tube, holding it like a pen as near to the mask end as possible.
Place the tip of the LMA against the inner surface of the patient’s upper teeth.
With direct vision, press the mask tip upward against the hard palate to flatten it out
With direct vision using the index finger, keep pressing upward as you advance the
mask into the pharynx to ensure the tip remains flattened while avoiding the tongue.
5. If no concern for c-spine injury, keep the neck flexed and head extended. Press the
mask into the posterior pharyngeal wall using the index finger.
6. Continue to push mask with your index finger and guide mask downward into position.
7. Grasp tube firmly with the other hand then withdraw your index finger from the
pharynx and simultaneously press gently downward with your other hand to ensure the
mask is fully inserted.
8. Inflate the mask with the recommended volume of air as shown above and do not
overinflate the mask. It is normal for the mask to rise slightly as it is inflated to its
proper position.
9. Connect the LMA to a BVM or other ventilator device
10. Confirm equal breath sounds over both lungs in all fields assuring no epigastrium
sounds.
11. Secure the LMA with the same technique as an ET tube.
Attach end-tidal CO2 monitor and/or pulse ox to confirm proper oxygenation
Blank
GUIDELINE FOR PRACTICAL SKILL
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 3001
The following content will be considered the Guideline/Standard for:
OBTAINING A BLOOD SAMPLE FOR ANALYSIS
Approved for use
by:
EMT
EMT- Intermediate
Technician
XX
EMTIntermediate
XX
EMTParamedic
XX
PURPOSE
To obtain a sample of blood for laboratory analysis
EQUIPMENT
Vacutainer tube
Vacutainer holder
Vacutainer needle
Tourniquet
Alcohol wipe
Gauze sponge
Consent to draw blood sample form
Personal protective equipment to prevent exposure to blood/body fluids
PROCEDURE
Vacutainer Method
1. Assure scene safety and observe universal precautions (see guideline #107).
2. Explain the procedure to the patient and get his/her signature on the consent if
appropriate.
3. Remove the plastic protective cap from the end of the double needle protected by a
rubber sleeve.
4. Screw the double needle into the Vacutainer holder.
5. Place a venous tourniquet on the patient’s arm.
6. Select an appropriate vein in the antecubital fossa.
7. Scrub the selected site with an alcohol wipe.
8. Select a vacuum tube with the desired color-coded rubber stopper.
9. Insert vacuum tube into the sleeve of the Vacutainer holder, do not push needle
completely through rubber stopper.
10. Remove the protective plastic cap from the exposed end of the double needle.
11. Using sterile technique, insert the needle into the vein.
12. Maintaining the position of the needle and holder, push the vacuum tube onto the needle
inside the Vacutainer holder.
13. When the vacuum tube is full, pull it off the needle.
14. Remove the venous tourniquet.
15. Withdraw the needle from the patient’s arm at the same angle that it was inserted.
16. Apply pressure to the puncture site with a gauze sponge.
17. Disassemble and dispose of the needle in the appropriate receptacle.
18. Label the blood specimen with the date, time, patient’s name and drawer’s initials.
19. Document procedure and results, including any unusual circumstances and/or difficulties
encountered.
Note: Some Vacutainer needles have an adapter in place of the needle which is inserted into the
vein. The adapter attaches to an IV catheter already in place in the vein.
End page 1
Blood Sample (cont.)
Syringe Method:
Equipment
Vacutainer tubes
20 cc syringe and appropriate-sized needle
Tourniquet
Alcohol wipes and/or Betadine wipes
Gauze square
Tape or Band-aid
Procedure:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Assure scene safety and observe universal precautions (see guideline #107).
Explain the procedure to the patient and gain his/her consent.
Assemble syringe and needle.
Select venipuncture site, typically antecubital.
Place a venous tourniquet proximal to the venipuncture site.
Cleanse the venipuncture site with alcohol/Betadine.
Remove the protective cover from the syringe needle.
Using sterile technique, insert the needle into the vein.
Keeping the needle and syringe stable, gently withdraw the plunger of the syringe
and fill the syringe with blood.
10. Release the tourniquet
11. Withdraw the needle from the vein and apply direct pressure with the gauze pad until
bleeding has stopped.
12. Insert the needle into the Vacutainer tube(s) to be filled. The vacuum in the tube will
pull blood from the syringe.
13. Dispose of needle and syringe in appropriate receptacle.
14. Label Vacutainer tubes with date, time, patient identification and drawer’s initials.
15. Cover venipuncture site with band-aid.
Recognize/verbalize advantages of obtaining a blood sample in the field:
 Secure a blood sample while the patient is available
Recognize/verbalize disadvantages of obtaining a blood sample in the field:
 Exposure to blood during the procedure
 Pain at the needle insertion point
Recognize/verbalize complications of obtaining a blood sample in the field:
 Hematoma formation
 Possible infection at the puncture site (poor sterile technique)
Recognize/verbalize contraindication to obtaining a blood sample in the field:
 Competent patient refuses procedure
END
GUIDELINE FOR PRACTICAL SKILL
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 3002
The following content will be considered the Guideline/Standard for:
INTRAVENOUS LINE PLACEMENT IN A PERIPHERAL VEIN
Approved for use
by:
EMT
Advanced EMT
XX
EMTIntermediate
XX
EMTParamedic
XX
PURPOSE
To provide a route for administration of fluids and medications into the vascular system via
a peripheral vein.
EQUIPMENT
Normal Saline intravenous solution
Administration set of appropriate size for the volume of fluid to be administered
Extension set
Extracatheter of appropriate size for patient and volume of fluid to be administered
Sizes available include 14, 16, 18, 20, 22 and 24 gauge
Tape
Alcohol preps
Tourniquet
Armboard
Personal protective equipment to prevent exposure to blood/body fluids
PROCEDURE
1. Assure scene safety and observe universal precautions (see guideline #107).
2. Assemble IV bag and tubing using sterile technique and fill the drip chamber and line.
3. Explain the procedure to the patient and get his/her consent if appropriate.
4. Apply a venous constricting tourniquet to the patient’s extremity.
5. Select an appropriate vein and cleanse the site with alcohol.
6. Stabilize the vein with skin traction.
7. Insert the needle with extracatheter, bevel side up, either next to or over the vein.
8. Advance the needle and catheter into the vein until a blood return is noted in the
extracather
9. Holding the needle securely in place, advance the catheter further into the vein.
10. Holding the catheter securely in place, withdraw the needle, tamponading the vein to
avoid unnecessary exposure to blood leaking from the catheter.
11. Release the venous tourniquet.
12. Connect the end of the extension set to the hub of the extracatheter.
13. Open the flow regulation clamp and observe the site for signs of infiltration.
14. If infiltration (pain and swelling at the site) occurs, discontinue the IV line, select an
alternate vein and repeat the above steps.
15. Tape extracatheter and extension set securely in place.
16. Adjust the flow rate to deliver the ordered volume of fluid.
17. Support the extremity and administration site with an armboard.
18. Continue to monitor flow rate and administration site.
19. Dispose of contaminated equipment in an appropriate receptacle.
20. Document procedure and results, including any unusual circumstances and/or difficulties
encountered.
End page 1
Peripheral IV lines, (cont.)
Recognize/verbalize the anatomy of the venous system in the upper extremities
Recognize/verbalize advantages of intravenous line placement:
 Provides route for administration of fluid for volume replacement.
 Provides route for administration of medication
Recognize/verbalize disadvantages of intravenous line placement:
 Causes pain during the insertion process
Recognize/verbalize complications of the intravenous line placement:
 Infiltration of the fluid into the subcutaneous tissue
 Extravasation of some medications can cause tissue sloughing
 Introduction of bacteria during insertion can cause infection
Recognize/verbalize contraindication to intravenous line placement:
 Unacceptable delay in starting transport of critical patients (trauma, OB)
 Infection in the area of the insertion point
Note: In the newborn, peripheral IV lines can be difficult to establish. The vein in the umbilical
cord can be used. There are two small-lumen arteries and one large-lumen vein in the umbilical
cord. The insertion point of the extracatheter should be proximal to the cord clamp (between the
cord clamp and the infant’s abdominal wall.
Note: Consider the size of the patient and volume of fluid to be administered when selecting the
administration set and volume of fluid in the bag being hung.
Note: In situations where it is desirable to have venous access but no fluid administration
is indicated, a capped IV may be placed
CAPPED IV LINE
PURPOSE:
To provide for a precautionary intravenous access line in patients who do not currently need
fluid replacement or intravenous medication administration
EQUIPMENT:
Normal saline in syringe of sufficient volume to fill the extension set
Extension set
Extracatheter of appropriate size for patient
Sizes available include 14, 16, 18, 20, 22 and 24 gauge
Tape
Alcohol preps
Tourniquet
Armboard
Personal protective equipment to prevent exposure to blood/body fluids
PROCEDURE:
1. Assure scene safety and observe universal precautions (see guideline #107).
2. Using sterile technique, fill extension set with normal saline.
3. Follow procedure to establish peripheral IV line (above).
4. Connect end of extension set to hub of extracatheter.
5. Flush line with normal saline, observing for signs of infiltration.
End page 2
Peripheral IV lines, (cont.)
6. Dispose of contaminated equipment in an appropriate receptacle.
7. Document procedure and results, including any unusual circumstances and/or difficulties
encountered.
8
Should the need for IV fluids or medication administration arise during transport, the
administration set of the IV line can be attached to the extension set or medication injected
directly into the extension set and then flushed with normal saline.
Note: External jugular and umbilical veins may not be used as sites for a capped IV line.
DISCONTINUING A PERIPHERAL IV LINE
PURPOSE:
To remove an IV catheter and administration set from a patient
EQUIPMENT
Gauze square
Tape or band-aid
Sharps container
PROCEDURE
1.
2.
3.
4.
5.
6.
7.
8.
END
Assure scene safety and observe universal precautions (see guideline #107).
Close the flow clamp on the IV administration line.
Gently remove tape securing the IV catheter to expose the venipuncture site.
Cover the site with a gauze square and apply gentle pressure as the catheter is removed.
Inspect the catheter to insure it is complete, document any abnormalities.
Maintain direct pressure on the venipuncture site until any bleeding has stopped.
Apply dressing or band-aid to venipuncture site.
Document procedure and results, including any unusual circumstances and/or difficulties encountered.
GUIDELINE FOR PRACTICAL SKILL
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 3003
The following content will be considered the Guideline/Standard for:
INSERTION OF AN INTRAVENOUS LINE INTO THE EXTERNAL JUGULAR VEIN
Approved for use
by:
EMT
Advanced EMT
EMTIntermediate
XX
EMTParamedic
XX
PURPOSE
To place an extracatheter into the external jugular vein for administration of fluids or medications
when a peripheral site is not available.
EQUIPMENT
Normal Saline intravenous solution
Administration tubing of a size appropriate for the volume of fluid to be administered
IV extracatheter of an appropriate size for the patient
Sizes available include 14, 16, 18, 20, 22 and 24 gauge
Extension set
Tape
Alcohol preps
Personal protective equipment to prevent exposure to blood/body fluids
PROCEDURE
1. Assure scene safety and observe universal precautions (see guideline #107).
2. Prepare equipment using sterile technique, attaching the administration set and extension
set to the IV bag, fill the drip chamber and line.
3. Explain the procedure to the patient and get his/her consent if appropriate.
4. Position the patient supine with the head turned away from the vessel to be cannulated.
5. Cleanse the injection site with an alcohol prep.
6. Align the needle of the extracather with the bevel side up in the direction of the blood
flow with the tip pointing toward the torso.
7. Place one finger over the external jugular vein just above the clavicle and press down
lightly until the vein is distended.
8. Stabilize the vein above the puncture site.
9. Perform the venipuncture midway between the angle of the mandible and the clavicle.
10. Advance the needle and catheter into the vein until a blood return in noted in the
extracather.
11. Holding the needle securely in place, advance the catheter further into the vein.
12. Holding the catheter securely in place, withdraw the needle, tamponading the vein to
avoid leakage of blood from the catheter.
13. Connect the end of the extension set to the hub of the extracatheter.
14. Open the flow regulator clamp, observing the site for signs of infiltration.
15. If infiltration occurs (pain and swelling at the site), discontinue the intravenous line and
repeat the attempt in another site.
End page 1
External jugular IV, (cont.)
16. Tape the extracatheter and extension set securely in place.
17. Adjust the flow to the ordered rate.
18. Maintain the patient’s head turned away from the IV site.
19. Monitor the flow rate.
20. Continue to monitor the site for signs of infiltration. If infiltration occurs, discontinue the
intravenous line and repeat the attempt on the other side if the presence of a functioning
IV is critical to patient care.
21. Dispose of contaminated needle in appropriate receptacle.
22. Document procedure and results, including any unusual circumstances and/or difficulties
encountered.
Recognize/verbalize the anatomy of the external jugular vein.
Recognize/verbalize advantages of intravenous line placement:


Provides route for administration of fluid for volume replacement.
Provides route for administration of medication
Recognize/verbalize disadvantages of intravenous line placement:

Causes pain during the insertion process
Recognize/verbalize complications of the intravenous line placement:



Infiltration of the fluid into the subcutaneous tissue
Extravasation of some medications can cause tissue sloughing
Introduction of bacteria during insertion can cause infection
Recognize/verbalize contraindication to the placement of an intravenous line in the
external jugular vein:




Obscured landmarks (trauma, subcutaneous emphysema, etc.)
Presence of cervical collar
Unacceptable delay in starting transport of critical patients (trauma, OB)
Infection in the area of insertion point
Note: Consider the size of the patient and volume of fluid to be administered when selecting the
administration set and volume of fluid in the bag being hung.
END
GUIDELINE FOR PRACTICAL SKILL
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 3004
The following content will be considered the Guideline/Standard for:
INTRAOSSEOUS INFUSION (IO)
Approved for use
by:
EMT
Advanced EMT
EMTIntermediate
XX
EMTParamedic
XX
PURPOSE
To provide access to the bone marrow canal as an alternative to an intravenous line for
administration of fluids and medications
EQUIPMENT
Alcohol preps, Betadine swabs, Chloraprep
Intraosseous needle
Adult - 15 gauge adjustable 3/8  1 7/8 inch
Pediatric 18 gauge adjustable 1/16  1 7/16 inch
Normal Saline IV solution
2% Lidocaine (Preservative free)
Administration set of appropriate size for the volume of fluid to be administered
Extension set
20 cc syringe
Tape
Armboard/splint for the lower extremity
Personal protective equipment to prevent exposure to blood/body fluids
PROCEDURE
1. Assure scene safety and observe universal precautions (see guideline #107).
2. Obtain physician order as necessary and for all patients who have a pulse.
3. Assemble the IV bag, administration set and extension set using sterile technique and fill
the drip chamber and line.
4. Determine indications and rule out contraindications.
5. Identify the intraosseous site -- anteromedial aspect of the proximal tibia 1-2 cm below
the tibial tuberosity -- and cleanse with alcohol/Betadine/Chloraprep.
6. Consider administering 1 ml of 2% Lidocaine subcutaneously at the insertion site if the
patient is conscious.
7. Prepare the IO needle by removing the protective caps and adjusting the depth to a
length which will transverse skin, subcutaneous tissue and penetrate the bone cortex.
Assure that the needle stylette is in place.
8. Insert the needle slightly angled (10º from vertical) toward the foot.
9. Enter the skin and twist the needle to cut through the bone while applying firm
downward pressure.
10. When the tip of the needle enters the marrow cavity, remove the stylette.
End page 1
Intraosseous lines, (cont.)
11. Attach a 10 cc syringe and attempt to aspirate marrow. Liquid resembling blood may
appear in the syringe.
12. Infuse Lidocaine 2% if the patient is conscious
Adult 20-40 mg (1-2 ml) of 2% Lidocaine IO bolus over one minute.
Pediatric: 0.5 mg/kg of 2% Lidocaine IO bolus.
Try to give it enough time to soak into the marrow
13. Inject 5-10 cc of sterile Normal Saline. If no local infiltration is seen and the fluid
infuses easily, stabilize the intraosseous needle in place by taping the intraosseous needle
flange securely to the skin.
14. Connect the end of the extension set to the hub of the intraosseous needle.
15. Open the flow-regulation clamp and observe the site for signs of infiltration.
16. If infiltration (pain and swelling at the site) occurs, discontinue the IO line; repeat the
procedure on the opposite leg if an intravenous line is critical for the care of the patient.
17. Adjust the flow rate to deliver the ordered volume of fluid.
18. Support the extremity and administration site with a splint.
19. Continue to monitor flow rate and administration site.
20. Dispose of contaminated equipment in an appropriate receptacle.
21. Document procedure and results, including any unusual circumstances and/or difficulties
encountered.
Recognize/verbalize advantages of intraosseous line placement:
 Provides route for administration of fluid for volume replacement
 Provides route for administration of medication
Recognize/verbalize disadvantages of intraosseous line placement:
 Requires special equipment and insertion technique
Recognize/verbalize complications of the intraosseous line placement:
 Infiltration of the fluid into the subcutaneous tissue
 Extravasation of some medications can cause tissue sloughing
 Introduction of bacteria during insertion can cause infection
 Fracture of the tibia
Recognize/verbalize contraindications to placing an intraosseous needle
 Fracture in the leg
 Infection/abscess over the administration site
 Unacceptable delay in transport of a critically ill or injured individual
Note: If using commercial IO device (e.g. sternal), follow manufacturer’s directions.
END
GUIDELINE FOR PRACTICAL SKILL
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 3005
The following content will be considered the Guideline/Standard for:
PERICARDIOCENTESIS
Approved for use
by:
EMT
Advanced EMT
EMTIntermediate
EMTParamedic
XX
PURPOSE
To remove blood or fluid from the pericardial sac
EQUIPMENT
Intracardiac needle
60 ml syringe
Alcohol preps
Personal protective equipment to prevent exposure to blood/body fluids
PROCEDURE
1. Assure scene safety and observe universal precautions (see guideline #107).
2. Confirm the order with medical control.
3. Locate the landmark for the subdiaphragmatic approach -- the angle between the xiphoid
and the cartilage of the 7th rib to the left of the xiphoid.
4. Cleanse the area with alcohol.
5. Insert the needle at the landmark at a 45º angle to the thorax in the direction of the
patient’s left shoulder.
6. Maintain traction on the plunger of the syringe as the needle is advanced to create a
vacuum in the barrel of the syringe.
7. Stop advancement of the needle when blood/fluid appears in the syringe.
8. Withdraw approximately 50 ml blood/fluid.
9. Withdraw the needle at the same angle at which it was inserted.
10. Save any aspirated material and transport with patient.
11. Dispose of contaminated equipment in the appropriate receptacle.
12. Report completion and results of the procedure to medical control.
13. Reassess the patient’s condition.
14. Document procedure and results, including any unusual circumstances and/or difficulties
encountered.
Recognize/verbalize signs/symptoms of pericardial tamponade
Hypotension
 Tachycardia
 Distended neck veins
 Narrow pulse pressure
 Lack of pulses with CPR
End page 1

Pericardiocentesis, (cont.)
Recognize/verbalize indications that the diagnosis was correct and the procedure was
successful:





Improved patient color
Loss of jugular vein distention
Increased blood pressure
Obtain pulses with CPR
Blood in syringe does not clot
Recognize/verbalize complications of a pericardiocentesis:



Damage to the left anterior descending coronary artery
Pneumothorax
Laceration of the myocardium
Recognize/verbalize contraindication to infield pericardiocentesis:






END
Any patient with pulses
Severe respiratory distress
Decreased or absent breath sounds on the affected side
Hypotension
Cyanosis
Tracheal deviation away from the affected side
GUIDELINE FOR PRACTICAL SKILL
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 3006
The following content will be considered the Guideline/Standard for:
DEFIBRILLATION
Approved for
use by:
EMT
XX (semiautomatic)
Advanced EMT
XX
(semi-automatic)
EMT-Intermediate
EMT-Paramedic
XX (semi-automatic or
manual)
XX (semi-automatic or
manual)
PURPOSE
To simultaneously depolarize the myocardial cells to terminate ventricular fibrillation or
ventricular tachycardia
EQUIPMENT
Monitor-Defibrillator
Electrode jelly or pre-gelled defibrillator pads
Personal protective equipment to prevent exposure to blood/body fluids
Razor for skin preparation
PROCEDURE (Manual)
1.
2.
3.
4.
5.
6.
Assure scene safety and observe universal precautions (see guideline #107).
Monitor the patient’s electrical rhythm.
Confirm absence of peripheral and central pulses on the patient.
Confirm interpretation of ventricular fibrillation or pulseless ventricular tachycardia.
Ascertain that adequate CPR is in progress.
Standard or pediatric paddles may be used only if the entire surface of the paddle fits
tightly against the chest wall.
7. Apply electrode jelly to the paddles or place the pre-gelled defibrillator pads on the
patient’s chest in the location specified by the device manufacturer (e.g. upper right
anterior chest under the clavicle and on the left chest at the 5th intercostal space between
the midclavicular and the anterior axillary line vs anterior-posterior placement). For
devices with hands-free defibrillation capabilities, apply the patient pads according to the
device manufacturer’s recommendations. Chest hair may need to be shaved to assure
good skin contact.
8. Charge the defibrillator to settings recommended by AHA (monophasic defibrillators).
Biphasic defibrillators will measure resistance and deliver the correct energy levels
without external setting.
9. Start paper recording to document rhythm if available. Information may also be stored
electronically in the defibrillator memory.
10. If using defibrillator paddles, place paddles on patient’s chest in the standard
defibrillation position (step 7). If using hands-free equipment, attach patient pads to
defibrillator.
11. Reconfirm the patient’s rhythm.
12. Assure that all personnel are clear of direct or indirect patient contact.
13. Simultaneously depress both defibrillation buttons, holding paddles in place with
approximately 25 pounds of pressure on each until the machine discharges. If using
hands-free equipment, press the “shock” button(s).
14. Begin CPR and continue for 2 minutes.
15. Monitor patient’s rhythm and vital signs.
16. Document procedure and results, including any unusual circumstances and/or difficulties
encountered.
End page 1
Defibrillation (cont.)
Recognize/verbalize indications/advantages of defibrillation:
 Termination of ventricular fibrillation or ventricular tachycardia in the pulseless, apneic
patient.
Recognize/verbalize disadvantages of defibrillation:
 The electrical current causes some injury to the myocardium.
Recognize/verbalize complications of the defibrillation:
 Poor interface between the paddles and the chest wall can cause burns to the skin
Recognize/verbalize contraindication to defibrillation:
 Any patient with pulses
EMS INTERFACE WITH PUBLIC ACCESS AUTOMATED EXTERNAL
DEFIBRILLATON
Note: During the transition phase from the 2000 to the 2005 ACLS standards, EMTs
should follow the voice directions of the AED that is being used in the field.
PROCEDURE: (2000 AHA guidelines)
1.
2.
3.
4.
5.
6.
7.
8.
9.
Assure scene safety and observe universal precautions (see guideline #107).
Obtain information as to the sequence of treatment thus far.
Assess patient to confirm that the patient is pulseless.
Assess the Public Access AED that is already on the patient. If it is not working, remove
it and apply the EMS unit. If the Public Access AED pads will adapt to your unit, do not
remove the original pads.
If the Public Access AED is working and is in the process of delivering a group of shocks,
continue to operate the unit to complete the series.
If EMS personnel are familiar with the Public Access AED and it seems to be functioning
properly, they may continue to use it. If EMS personnel are not familiar with the Public
Access AED, it should be removed and the EMS unit applied.
EMS personnel should start the AED protocol from the beginning, regardless of the
number of shocks delivered by public access.
The data card from the Public Access AED should be left in place in that unit. The
information on the card will be needed for QA purposes by the AED owner. If the Public
Access AED is transported to the hospital with the patient, it is possible that the
information on the unit could be downloaded at that time.
Return the Public Access AED to the proper owner. They should be reminded to check
supplies and battery function prior to placing the unit back in service.
State of Wisconsin Standards and Procedures of Practical Skills Manual (July 2008 Rev)
is appended and contains step-by-step instructions for AED use. See index for page
numbers.
END
This page intentionally left blank after 9/28/06 revision to maintain paging number of
previous versions.
GUIDELINE FOR PRACTICAL SKILL
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 3007
The following content will be considered the Guideline/Standard for:
SYNCHRONIZED CARDIOVERSION
Approved for use
by:
EMT
Advanced EMT
EMTIntermediate
XX (unstable
patients only)
EMTParamedic
XX
PURPOSE
To deliver an electrical charge to the myocardium synchronized to the depolarization of the
ventricle
EQUIPMENT
Monitor-Defibrillator with synchronized cardioversion capabilities
Electrode jelly or pre-gelled defibrillator pads
Patient electrodes
Patient cables
Personal protective equipment to prevent exposure to blood/body fluids
PROCEDURE
1.
2.
3.
4.
5.
6.
Assure scene safety and observe universal precautions (see guideline #107).
Place electrodes in the standard 3- or 4-lead configuration and attach patient cable.
Monitor and record the patient’s rhythm.
Confirm cardioversion order from medical control.
Explain the procedure to the patient if necessary.
Obtain medical control order for sedation (Paramedics only) /pain medication if necessary.
(See drug
profiles 013, 007, 023)
7. Apply electrode gel to the paddles or place the defibrillation pads in the standard position
recommended by the defibrillator manufacturer. If using hands-free equipment, place the
patient pads as recommended by the manufacturer.
8. Turn energy selection dial to the setting ordered by medical control.
9. Push the synchronizer button on, check for flashing of synchronizer light.
10. Check oscilloscope for sensing mark for each QRS, adjust gain as needed.
11. Place defibrillator paddles in the standard configuration as recommended by the device
manufacturer. If using hands-free equipment, connect the patient pads to the defibrillator.
12. Charge the defibrillator.
13. Assure that all personnel are clear of direct or indirect patient contact.
14. Simultaneously depress both defibrillation buttons, holding paddles in place with
approximately 25 pounds of pressure on each until the machine discharges. If using handsfree equipment, push the “shock” button(s).
15. Monitor patient’s rhythm and vital signs.
16. Document procedure and results, including any unusual circumstances and/or difficulties
encountered.
End page 1
Synchronized cardioversion (cont.)
Recognize/verbalize indications for synchronized cardioversion:
 Unstable atrial or junctional tachycardia with pulses
 Narrow complex tachycardia with pulses which has not responded to adenosine
 Unstable ventricular tachycardia with pulses
 Wide complex tachycardia with pulses which has not responded to lidocaine,
procainamide, adenosine, amiodarone
Recognize/verbalize complications of the synchronized cardioversion:

Electrical depolarization may result in ventricular fibrillation
Recognize/verbalize contraindication to in-field synchronized cardioversion:

END
Patients taking digitalis preparations
GUIDELINE FOR PRACTICAL SKILL
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 3008
The following content will be considered the Guideline/Standard for:
ACQUISITION OF A 12-LEAD ELECTROCARDIOGRAM
Approved for use
by:
EMT
Advanced EMT
EMTIntermediate
XX *
XX
XX
*Requires Operational plan and documentation of training
EMTParamedic
XX
PURPOSE
To obtain and transmit a diagnostic quality 12-lead electrocardiogram
EQUIPMENT
12-lead ECG machine
Patient cables
ECG electrodes
Razor to prep skin surface
Personal protective equipment to prevent exposure to blood/body fluids
PROCEDURE
1.
2.
3.
4.
Assure scene safety and observe universal precautions (see guideline #107).
Explain the procedure to the patient and gain his/her cooperation/consent.
Shave chest hair from electrode sites if it will interfere with good skin contact.
Attach electrodes to the cables from the machine and place the ten electrodes on the
patient as follows:
V1 = 4th intercostal space, right sternal border
V2 = 4th intercostal space, left sternal border
V3 = Midway between V2 and V4
V4 = Mid clavicular line, fifth intercostal space
V5 = Lateral to V4 at the anterior axillary line
V6 = Lateral to V5 at the midaxillary line
RA = Right arm (anywhere on the right arm or right shoulder)
LA = Left arm (anywhere on the left arm or left shoulder)
RL = Right leg (anywhere on the right leg or right lower abdomen)
LL = Left leg (anywhere on the left leg or leg lower abdomen).
5. Obtain the 12 lead ECG per manufacturer’s directions.
6. Detach the leads from the patient. Consider leaving the electrodes in place
7. Document procedure and results, including any unusual circumstances and/or difficulties
encountered
Note: Obtain the 12 lead at the earliest opportunity without compromising patient care.
Do not delay administration of nitroglycerin to obtain a 12 lead ECG.
End page 1
12-Lead ECG (cont.)
Recognize/verbalize indications for 12 lead ECG acquisition:



Chest pain of suspected cardiac origin
Patients exhibiting symptoms/signs suggesting cardiac ischemia
Need for an electrical view of all areas of the myocardium
Recognize/verbalize disadvantages of 12 lead ECG acquisition:

May delay transport
Recognize/verbalize complications of 12 lead ECG acquisition:

None
Recognize/verbalize contraindication to 12 lead ECG acquisition:

END
Unacceptable delay in care and transport of a critical/unstable cardiac patient
GUIDELINE FOR PRACTICAL SKILL
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 3009
The following content will be considered the Guideline/Standard for:
ELECTROCARDIOGRAPHIC MONITORING
Approved for use
by:
EMT
May obtain but not
interpret
Advanced EMT
May obtain but not
interpret
EMTIntermediate
xx
EMTParamedic
xx
PURPOSE
To establish and continue to monitor the electrical rhythm of the heart
EQUIPMENT
Monitor-defibrillator with patient monitoring cable/pads
Disposable monitoring electrodes
Razor
Alcohol wipes
PROCEDURE
1.
2.
3.
4.
Assure scene safety and observe universal precautions (see guideline #107).
Explain the procedure to the patient.
Body hair at the electrode site may need to be removed to assure good skin contact.
Prepare the skin area where the electrodes will be attached.
a.
Rub the area with alcohol wipe.
b.
Shave excess hair.
5. Attach electrodes to the end of the patient cables and adhere to patient skin surface:
a.
RA electrode is placed on the right arm or upper right chest wall.
b.
LA electrode is placed on the left arm or upper left chest wall.
c.
RL electrode is placed on the right leg or on the lower right abdominal wall.
d.
LL electrode is placed on the left leg or on the lower left abdominal wall.
6. If monitoring is to done with defibrillator pads:
a.
Prepare the skin as above.
b.
Place electrodes as specified by the manufacturer (usually right upper and
lower left chest wall).
7. Turn on the ECG machine and establish the patient’s rhythm.
8. If the ECG machine is so equipped, print out the patient’s initial rhythm.
9. Continue to monitor as appropriate for the patient’s condition, including recording
of any ECG changes.
10. Document the procedure and results, including any unusual circumstances and/or
difficulties encountered.
Recognize/verbalize indications/advantages of ECG monitoring
Provides real time monitoring of the patient’s cardiac rhythm
End page 1

ECG Monitoring (cont.)
Recognize/verbalize disadvantages of ECG monitoring

May delay transport
Recognize/verbalize complications of ECG monitoring

None
Recognize/verbalize contraindications to ECG monitoring

Unacceptable delay in care and transport of a critical/unstable patient
END
GUIDELINE FOR PRACTICAL SKILL
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 3010
The following content will be considered the Guideline/Standard for:
TRANSCUTANEOUS PACING
Approved for use
by:
EMT
Advanced EMT
EMTIntermediate
XX (Unstable
patients only)
EMTParamedic
XX
PURPOSE
To deliver repetitive electrical currents through the skin using cutaneous electrodes to
the heart, substituting for a natural pacemaker that is blocked or dysfunctional.
EQUIPMENT
Monitor/defibrillator with pacing capabilities
Pacing electrodes
PROCEDURE
1. Assure scene safety and observe universal precautions (see guideline #107).
2. Complete initial and focused physical assessment. (see guideline # 103)
3. Provide routine medical care. (see guideline # 106)
4. Obtain IV access. (see guideline #3002).
5. Identify patient as candidate for transcutaneous pacing: Symptomatic
bradycardia/heart block (chest pain, dyspnea, altered level of consciousness, hypotension, diaphoresis, congestive
heart failure) that is unresponsive to atropine (See drug profile # 005)
6. Obtain baseline ECG and vital signs.
7. Explain procedure to patient and/or family.
8. Consider sedation (paramedics only).
9. Clean and dry skin, shave if necessary to obtain good skin contact with electrodes.
10. Apply pacing electrodes per manufacturer’s recommendations (usually anteriorposterior).
11. Select pacing mode (fixed-rate or demand).
12. Set rate, usually between 60 and 80 beats per minute.
13. Set milliAmps. Start at minimum for patients with pulses and turn up until capture
is achieved.
14. Turn pacer on. Monitor patient’s vital signs and adjust settings as necessary.
15. Document procedure and results, including any unusual circumstances and/or difficulties encountered.
Recognize/verbalize indications/advantages of transcutaneous pacing


Indications as noted above
Noninvasive, quick and easy to apply
End page 1
Pacing (cont.)
Recognize/verbalize disadvantages of transcutaneous pacing


Cardiac muscle must be capable of responding to electrical current
Can cause muscle twitching, pain and hiccoughs when skeletal muscle/diaphragm
also contract
Recognize/verbalize complications of transcutaneous pacing



Tissue damage from prolonged transcutaneous pacing
Tissue burns in pediatric patients
Change in pacing threshold may necessitate an increase in milliAmps
Recognize/verbalize contraindications to transcutaneous pacing


END
Open wounds or burns of the chest
Wet environment
GUIDELINE FOR PRACTICAL SKILL
Initial Date:
8/24/06
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 3011
The following content will be considered the Guideline/Standard for:
ACCESSING AN EXISTING CENTRAL LINE CATHETER
Approved for use
by:
EMT
Advanced EMT
EMTIntermediate
EMTParamedic
XX
Note: Service Medical Director must indicate which Central Line access devices are approved for use by the paramedic and have documentation
of training/competency.
PURPOSE
To provide a route for administration of fluids and medications into the vascular system via
an indwelling central catheter
INDICATIONS
Some central venous catheters may be used for routine fluid and medication needs and others
should not: (permission to acces different types of devices may vary between services)
 Dialysis catheters should only be used in “code” and “pre-code” situations when no other
peripheral IV access is available.
 PICC lines or other single, double, or triple lumen catheters may be used in place of
starting another peripheral IV for routine medications and fluids
 Implantable central venous catheters (Hickman, Infuse-a-port, etc.) can be used for
routine medications and fluids but require special equipment and technique (see below).
EQUIPMENT
Normal Saline intravenous solution
Administration set of appropriate size for the volume of fluid to be administered
Extension set
Tape
Alcohol preps
Chloraprep (optional)
Clear occlusive dressing e.g.Tegaderm (optional)
0.75 inch Huber needle (optional)
Armboard
Personal protective equipment to prevent exposure to blood/body fluids
PROCEDURE – Lines with external tubing/access
1. Assure scene safety and observe universal precautions (see guideline #107).
2. Assemble IV bag and tubing using sterile technique and fill the drip chamber and line.
3. Explain the procedure to the patient and get his/her consent if appropriate.
4. Assure that the central line is clamped shut
5. Cleanse area around clamp and cap at end of indwelling device (the utmost care should
be taken to maintain sterility of the central line)
6. Remove cap and attach 10 ml sterile syringe
7. Open clamp and withdraw 10 ml of fluid from the indwelling catheter (this may only be
possible through large bore dialysis catheters)
8. Clamp indwelling catheter
End page
Central lines (cont)
9. Attach 10 ml syringe with or without extension set filled with sterile saline
10. Open clamp and flush indwelling line with saline. If resistance is met, abort procedure,
document situation and notify receiving RN of failed access attempt.
11. Close clamp
12. Attach IV administration set
13. Open clamp on indwelling catheter and set fluid administration rate as ordered
14.
Dispose of contaminated equipment in an appropriate receptacle.
15.
Document procedure and results, including any unusual circumstances and/or
difficulties encountered.
16. Continue to monitor flow rate and administration site.
SPECIAL NOTES

Many central lines are not high volume infusing lines. If significant fluid resuscitation is
needed, consider a new peripheral IV site.
ACCESSING IMPLANTABLE PORTS (as above with following modifications)
1. Wear simple mask and maintain clean technique
2. Preload 10cc normal saline syringe to Huber needle and flush air from assemble
3. Locate Port on chest wall and determine if it is single or double lumen
4. Stabilize port on chest wall
5. Thoroughly clean area with Chloraprep in circular expanding motion
6. Place Huber needle into center of port at 90 angle to skin until needle stops
7. Attempt to aspirate blood tinged fluid to confirm port is operational
8. Attempt to gently flush port with prepared 10cc saline syringe. If resistance is met,
abort procedure, document situation, and verbally notify receiving RN of failed access
attempt.
9. If flush successful, pad needle if needed and secure into place with Tegaderm and tape
10. Connect properly prepared IV line as above
Recognize/verbalize advantages of accessing an indwelling central line:

Provides route for administration of fluid for volume replacement.

Provides route for administration of medication

Does not require inserting a new intracatheter into a vein
Recognize/verbalize disadvantages of central intravenous line manipulation:

Can potentially allow an air embolus if proper procedure is not followed
Recognize/verbalize complications of the central intravenous line manipulation:

Air Embolism

Introduction of bacteria with potential for sepsis

Damage to the central line
END
GUIDELINE FOR PRACTICAL SKILL
Initial Date:
08/16/06
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 3012
The following content will be considered the Guideline/Standard for:
“EZ-IO” INTRAOSSEOUS INFUSION (IO)
Approved for use
by:
EMT
Advanced EMT
EMTIntermediate
XX
EMTParamedic
XX
PURPOSE
To provide access to the bone marrow canal as an alternative to an intravenous line for
administration of fluids and medications in a critically ill patient
INDICATIONS
IV cannot be established in 2 attempts or 90 seconds and the patient exhibits one or
more of the following:
a.
An altered mental status (GCS of 8 or less)
b.
Respiratory compromise (SaO2 less than80% after appropriate O2 therapy
or respiratory rate less than10 or greater than 40 per min)
c.
Hemodynamic instability (BPsless than90)
CONTRAINDICATIONS
Fracture of the bone selected for IO infusion
Absence of anatomic landmarks
Previous surgery at site (e.g. knee replacement)
Any knee surgery or IO within previous 24 hours
EQUIPMENT
Alcohol preps
Betadine swabs or Cloraprep
EZ-IO driver
Intraosseous needle set
Adult – EZ-IO AD (40 kg and over)
Pediatric – EZ-IO PD (3-39 kg)
Normal Saline IV solution
Administration set of appropriate size for the volume of fluid to be administered
Extension set
10 ml syringe
Personal protective equipment to prevent exposure to blood/body fluids
Pressure bag or infusion pump
2% Lidocaine (Preservative free)
PROCEDURE
1. Assure scene safety and observe universal precautions (see guideline #107).
2. Obtain physician order in all patients who have a pulse.
3. Assemble the IV bag, administration set and extension set using sterile technique and fill
the
drip chamber and line.
end page 1
EZ-IO (continued)
4. Determine indications.
5. Rule out contraindications.
6. Identify the intraosseous site – anteromedial aspects of the proximal tibia 1-2 cm below
the tibial
tuberosity. Cleanse the site with alcohol and Betadine or Chloraprep.
7. Consider administering 1 ml of 2% Lidocaine subcutaneously at the insertion site if the
patient is
conscious.
8. Prepare the EZ-IO driver and appropriate needle set.
9. Stabilize the site and insert appropriate needle set through the bone into the marrow
canal.
10. Remove the drive from the needle set while stabilizing catheter hub.
11. Remove the stylet from the catheter, place stylet in sharps container.
12. Connect primed extension set.
13. Attach a 10 ml syringe and attempt to aspirate marrow. Liquid resembling blood may
appear in
the syringe.
14. Infuse Lidocaine 2% if the patient is conscious:
Adult: 20-40 mg (1-2 ml) of 2% Lidocaine IO bolus over one minute
Pediatric: 0.5 mg/kg of 2% Lidocaine IO bolus. Try to give it enough time to
soak into the
marrow.
15. Inject 5 ml (pediatric) to 10 ml (adult) Normal Saline rapidly to confirm placement, no
local infiltration is seen and the fluid infuses easily. Repeat if needed.
16. Connect the extension set to the primed line.
17. Open the flow-regulation clamp and observe the site for signs of infiltration.
18. If infiltration (pain and swelling at the site) occurs, discontinue the IO line, repeat the
procedure
on the opposite leg.
19. Adjust the flow rate to deliver the ordered volume of fluid.
20. Consider pressure bag or infusion pump.
21. Dress the site.
22. Continue to monitor flow rate and administration site.
23. Dispose of contaminated equipment in an appropriate receptacle.
24. Document procedure and results, including any unusual circumstances and/or difficulties
encountered.
COMMENTS:



Never attempt a second IO near the site of a recent attempt
Never reuse an IO needle/catheter
To remove EZ-IO, use a syringe and clockwise rotation with traction. Do not rock
or pry on the catheter.
Recognize/verbalize indications/advantages of an intraosseous line placement


Provides route for administration of fluid for volume replacement
Provides route for administration of medication
Recognize/verbalize disadvantages of intraosseous line placement

Requires special equipment and insertion technique
Recognize/verbalize complications of intraosseous line placement




End
Infiltration of fluid into the subcutaneous tissue
Extravasation of some medications can cause tissue sloughing
Introduction of bacteria during insertion can cause infection
Fracture of the tibia
GUIDELINE FOR PRACTICAL SKILL
Last Review/Revision: 12/18/08 Guideline Number: 3013
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
The following content will be considered the Guideline/Standard for:
SEMI-AUTOMATIC EXTERNAL DEFIBRILLATOR (AED)
Approved for use
by:
EMT
Advanced EMT
XX
XX
EMTIntermediate
XX
EMTParamedic
XX
PURPOSE
To simultaneously depolarize the myocardial cells to terminate ventricular fibrillation or
ventricular tachycardia
EQUIPMENT
Semi-automatic Monitor-defibrillator
Pre-gelled defibrillator pads
Personal protective equipment to prevent exposure to blood/body fluids
Razor for skin preparation
AED Considerations:
1.
Consider ALS (Intermediate or paramedic) backup at dispatch to provide
Advanced Cardiac Life
Support (ACLS).
2.
Preparation for transport of patient should begin immediately as staffing allows.
3.
Assuming no ACLS on scene, the patient should be transported when one of the
following occurs:
a.
The patient regains a pulse.
b.
Two (2) shocks are delivered (in addition to shocks delivered by Public
Access
Defibrillator (PAD)
c.
The patient should be transported as soon as possible if no shock is
advised and ALS is not on scene.
4.
For adult patients:
a. If no bystander CPR has been started and EMS arrival is greater than 4 minutes from
patient
collapse, EMS personnel should provide two (2) minutes of CPR before analyzing
rhythm and possible defibrillation attempt.
b. If bystander CPR is being performed upon arrival of EMS, rhythm analysis and possible
defibrillation attempt may be attempted immediately, followed by two (2) minutes of
CPR before reanalyzing.
5.
For pediatric patients:
a. For unwitnessed cardiac arrest in children one to puberty, perform two (2) minutes of
CPR
before using the AED.
b. For witnessed cardiac arrest in children one to puberty, use an AED as soon as it is
available.
6.
All contact with the patient must be avoided during analysis of rhythm and/or
delivery of shock(s).
7.
Automated external defibrillation can be used in cardiac arrest in children over the age
one to “age of
puberty.” The preferred method is to utilize an AED with pediatric capabilities. If
ONLY a standard
AED is available, it may be applied with pads placed anterior and
posterior
8. For victims eight (8) years of age and older, do not use child pads or pediatric only
capability
machines.
9. Older AEDs can not analyze a rhythm properly when an emergency vehicle is in motion.
Per AHA 2005 guidelines, modern AEDs can safely analyze and defibrillate in a moving
vehicle.
PROCEDURE
1. Assure scene safety and observe universal precautions (see guideline #107).
2. Consider ALS (intermediate or paramedic) intercept. Consider early transport if ALS is not available.
3. Stop CPR if in progress,
4. Perform initial assessment (Level of consciousness, airway, breathing, circulation).
5. Confirm absence of peripheral and central pulses and absence of breathing on patient.
6. CPR should be in progress while equipment is being prepared.
7. Adult patient: If Public Access Defibrillator (PAD) is utilized prior to your arrival,
switch from
PAD to your defibrillator.
8. Pediatric patient: IF EMS AED is not pediatric-capable, then continue to use the PAD
with
pediatric capabilities. If neither the PAD nor the EMS AED is pediatric capable,
use the EMS
AED with anterior-posterior pad placement.
9. Attach device to patient
a.
Attach pads per manufactures’’ directions or
b.
Attach the negative electrode to the patient’s right anterior chest wall, slightly
inferior to the
clavicle at the mid-clavicular line and
c.
Attach the positive electrode to the patient’s left lateral chest wall at the midaxillary line
and slightly inferior to the nipple line.
d.
Ensure each pad is securely and firmly adhering to the patient.
e.
Anterior/posterior pad placement may be used in pediatric patients when the chest
wall is
too small to place pads in the standard position.
10.
Stop CPR
11.
Direct everyone to clear the patient.
12.
Initiate the rhythm analysis.
13.
If AED advised defibrillation.
a.
Deliver the shock (be sure everyone is clear of the patient.)
b.
Resume CPR for two (2) minutes (30:2 ratio)
i.
Consider insertion of an advanced airway. INSERT AIRWAY WHILE
DOING
COMPRESSIONS, artificially ventilate with high concentrations of
oxygen.
c.
Stop CPR.
d.
Reanalyze the rhythm and deliver second shock as the machine advises.
e.
Resume CPR for two (2) minutes.
f.
Contact medical control if two (2) total shocks have been given.
g.
Transport promptly.
14.
If, after any rhythm analysis, the machine advised no shock:
a.
Resume CPR for two (2) minutes.
i.
Consider insertion of an advanced airway. INSERT AIRWAY WHILE
DOING
COMPRESSIONS, artificially ventilate with high concentrations of
oxygen.
b.
Stop CPR
c.
Continue sequence until machine givens three (3) consecutive messages separated
by two
(2) minutes of CPR that no shock is advised.
15.
Persistent shockable rhythms and no available ALS backup
a.
If after a maximum of two (2) shocks on scene, transport patient promptly. If
transport is
impossible (i.e. ambulance not at scene) continue the sequence of
one shock followed by
two minutes of CPR for as long as a shockable rhythm
persists or until transport becomes
possible
b.
enroute
After initial two (2) shocks, additional shocks may be delivered at the scene or
ONLY BY APPROVAL OF ON-LINE MEDICAL CONTROL.
SPECIAL NOTES:
 Time if valuable, Rapid defibrillation with airway placement when necessary must be
accomplished as rapidly as possible. Initiate transport early.
 If you are transporting a patient who is in or develops cardiac arrest, you must pull over
and stop the vehicle to analyze. Use common sense. Do not stop so often that it takes a
lengthy period of time to get to the hospital.
End page 2
AED (continued)





If you successfully resuscitated a patient from a shockable rhythm and the patient
subsequently reverts back to a shockable rhythm, you may reinstitute the entire protocol
without an on-line medical control order. This may be done a third time if necessary.
Medical control must be contacted after a third sequence.
Pulse checks should be done carefully for 5-10 seconds. No CPR can be done while the
machine is analyzing.
The EMT shall shock one time as necessary, then place the advanced airway according
to the airway protocol. After a two-minute period of CPR, one more shock may be
given, if indicated. If no conversion, move to the ambulance and begin transport.
The compression rate should be at least 100 per minute. Ventilator rate should be one
breath every 6-8 seconds.
Although contact with Medical Control is highly advised to provide more than two
initial shocks, if communication with a physician cannot be obtained for some reason,
additional shocks as indicated may be given.
Note: EMS INTERFACE WITH PUBLIC ACCESS AUTOMATED EXTERNAL
DEFIBRILLATOR
During the transition phase from the 2000 to the 2005 ACLS standards, EMTs should follow the
voice direction of the AED that is being used in the field.
END
GUIDELINE FOR PRACTICAL SKILL
Initial Date:
9/28/06
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 3014
The following content will be considered the Guideline/Standard for:
AUTO-PULSE
Approved for use
by:
EMT
Advanced EMT
XX
XX
Note: Requires documentation of training and competency of members of the service/
EMTIntermediate
XX
EMTParamedic
XX
PURPOSE:
Continuous mechanical CPR
Increased blood flow
INDICATIONS:
Cardiac arrest
EQUIPMENT:
Auto-Pulse
Single patient use life band
Adjustable cervical collar
Head bed
Carrying tarp
Heavy Zip Strips (To connect to long board)
Personnel protective equipment to prevent exposure to blood/body fluids
PROCEDURE:
1. Assure scene safety and observe universal precautions (see guideline #107).
2. Confirm absence of peripheral and central pulses on the patient.
3. Remove upper body clothing from patient.
4. Begin manual CPR following AHA guidelines, while deploying Auto-Pulse.
5. Consider placing patient in appropriate size C-collar.
6. Sit patient up and slide Auto-Pulse base behind patient so that patient’s head and
shoulders are within designated area. Turn device on.
7. Apply chest band over patient’s chest lining up yellow line on band with yellow line on
board. Be sure there are no twists and the bands are fully extended. Secure patients head
to board with head immobilization device and padding under head
8. Hook-and-loop tape (i.e. Velcro®) the chest bands together being sure they are properly
aligned. Press the green button. The machine will ask if the patient is properly aligned.
If alignment is correct, press the green button again to continue.
9. Begin mechanical CPR following AHA guidelines. Once the advanced airway is secured,
switch to continuous compressions.
10. Confirm pulses with mechanical CPR.
11. Transport the patient.
Note: Deployment of the Auto-Pulse must be practiced frequently to be sure it is done efficiently
with minimal interruption to CPR.
End page 1
Auto-pulse (continued)
List advantages of the Auto-Pulse
 Continuous uninterrupted CPR
 Increased blood flow
 Decreased fatigue of rescuers
List disadvantages of the Auto-Pulse
 Additional weight
List complications of the Auto-Pulse
 Potential Head/Cervical Injury
 May cause friction/rubbing sores on the body
List contraindications to the Auto-Pulse
 Patient less than 18 y/o
 Traumatic cardiac arrest
 Weight greater than 300lbs
END
GUIDELINE FOR PRACTICAL SKILL
Initial Date:
3/01/08
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/4/08
Guideline Number: 3015
The following content will be considered the Guideline/Standard for:
Induced Hypothermia for Return of Spontaneous Circulation (ROSC)
Approved for use
by:
EMT
Advanced EMT
EMTIntermediate
EMTParamedic
xx
PURPOSE


To decrease body temperature between 32 and 34C for patients with ROSC
To improve neurologic outcome in patients with ROSC
EQUIPMENT

Method of maintaining 2 Liters of 0.9% Saline at 4C
INCLUSION CRITERIA

Must include all:
o Cardiac arrest does not need to be witnessed
o Patient was in VT, VF, PEA, or Asystole at some time during this cardiac arrest
o Significant Altered Level of Consciousness for example but not limited to :
 Not following commands
 No purposeful movements
 No purposeful response to pain
 No comprehensible speech
EXCLUSION CRITERIA











Known Surgery within 2 weeks
History of Bleeding disorder (Coumadin, Lovinox, Aspirin, etc.. are not contraindications)
Active bleeding
Currently Pregnant
Age less then 18 y/o
Evidence of Trauma – ie: Trauma as possible cause of arrest
Cardiac instability
o Refractory or recurrent life threatening dysrhythmia
Environmental hypothermia exposure
Obvious pulmonary edema before protocol is started
Other cause of arrest such as; drug overdose, head trauma, hemorrhagic stroke, status
epilepticus, infection, etc.
All appropriate hospitals who have cooling protocols are on diversion
PROCEDURE



Recognize patient with ROSC status post cardiopulmonary arrest
Review and document inclusion and exclusion criteria – Proceed if patient is a candidate
Place endotracheal tube unless a functioning Combi-Tube or King LT is already in place
o
If there is any question as to the status of the alternate advanced airway, intubate
the patient with an ETT.
Induced Hypothermia cont’












Expose the patient
o Undergarments may remain in place
o Consider the location and patient modesty
Apply ice packs to the axilla, neck, and groin – place barrier to prevent freezing of the
skin
Administer Midazolam 0.15mg/kg IVP (max 10mg) if BPs is greater than 90 mmHg
Administer 30ml/kg cold saline fluid bolus (max 2 liters)
o Consider using a pressure bag inflated to 300mmHg
Monitor Blood Pressure and vital signs every 2-5 minutes
Administer Dopamine 5-20 mcg/kg/min IV to maintain the systolic blood pressure (BPs
greater than 90 mmHg)
If shivering develops, administer Vecuronium 0.1mg/kg IVP
o The use of paralytics is not mandatory for this protocol
Do not hyperventilate
o Hypothermia causes metabolic alkalosis
o Goal ETCO2 = 40
Do not delay transport to induce hypothermia
Attempt to obtain second IV access point (KVO or capped line)
Patient must be transported to a hospital prepared to receive patients with induced
hypothermia
Stop administration of cold saline at any time there is a loss of spontaneous circulation
and return to appropriate resuscitation protocol
o If hypothermia protocol is stopped, it should not be restarted in the pre-hospital
setting.
o
Recognize/verbalize advantages of inducing hypothermia:
 Improved neurologic outcome in patients who have survived cardiopulmonary arrest
and at the time of the protocol initiation have significant neurologic impairment.
 Decreased cerebral metabolism
 Decrease in free radical production
 Suppression of Calcium mediated cell death
Recognize/verbalize disadvantages of inducing hypothermia:
 Significant fluid bolus may lead to fluid overload
 If hypothermia is not continued in the hospital, increased likelihood of poor outcome
Recognize/verbalize complications of inducing hypothermia:


Hypothermia induces metabolic alkalosis
Cold saline can induce vasospasm requiring detailed monitoring
Recognize/verbalize contraindication to inducing hypothermia:

END
See list in protocol
Blank
GUIDELINE FOR PRACTICAL SKILL
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 4001
The following content will be considered the Guideline/Standard for:
MEASURING THE BLOOD GLUCOSE LEVEL USING A COMMERCIAL BLOOD
GLUCOSE MONITOR
Approved for use
by:
EMT
Advanced EMT
XX
XX
EMTIntermediate
XX
EMTParamedic
XX
PURPOSE
To obtain a blood sample and use a commercial monitor for analysis of blood sugar level
EQUIPMENT
Single use lancet device
Blood glucose monitor
Blood glucose test strip and calibrator
Alcohol prep
Gauze square
Personal protective equipment to prevent exposure to blood/body fluids
PROCEDURE
1. Assure scene safety and observe universal precautions (see guideline #107).
2. Explain the procedure to the patient if he/she is able to understand
3. Assemble the appropriate equipment
4. Follow manufacturer’s operating instructions for operation of the device.
5. Record and report results displayed.
6. Dispose of contaminated equipment in an appropriate container.
Recognize/verbalize advantages of the blood glucose monitor
 Provides accurate measurement of the blood glucose level
 Quick and easy to use
Recognize/verbalize disadvantages of the blood glucose monitor
 Pain at the site of the finger stick
 Patients on oxygen therapy may have a false low result
 Anemic individuals may have a false high result (hematocrit less than30)
Recognize/verbalize complications of use of the blood glucose monitor
 Infection at the puncture site
Recognize/verbalize contraindication to the blood glucose monitor:




Low or high environmental temperature ranges (less than64F, 18C or greater than 86F,
30C)
Severe dehydration of the patient (gives false low readings)
Patients in shock (gives false low readings)
System has not been evaluated for use with neonatal blood supply
END
GUIDELINE FOR PRACTICAL SKILL
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 4002
The following content will be considered the Guideline/Standard for:
PREPARATION OF MEDICATION FOR ADMINISTRATION
Approved for use
by:
EMT
Advanced EMT
XX
XX
EMTIntermediate
XX
EMTParamedic
XX
PURPOSE
To prepare medication contained in a unit-dose syringe, glass vial or multidose vial for
administration parenterally
EQUIPMENT
Medication as ordered for administration
Alcohol preps
Gauze pad
Sterile syringe of appropriate size to hold volume to be administered
Available syringe sizes on the paramedic unit are 1 ml, 3 ml, 20 ml and 60 ml
Sterile needles of appropriate size to draw up and administer medication
Available needle sizes on the paramedic unit are 20 gauge, 21 gauge and 25 gauge
Premixed medication IV bag
IV solution bag if medication is not premixed
Administration set of appropriate size
20 gauge sterile needle for “piggyback” (if needleless system is not used)
Personal protective equipment to prevent exposure to blood/body fluids
PROCEDURE
PREPARATION OF A MEDICATION CONTAINED IN A GLASS AMPULE
(EPINEPHRINE 1:1000, AMIODARONE)
1. Check medication vial for valid date, clarity and intact sterility safeguards.
2. Shake or rotate the vial to force all liquid into the base of the ampule.
3. Wrap a gauze pad around the neck of the ampule and snap the top off.
4. The use of a filtered needle is recommended when drawing up the medication from the
vial.
5. Assemble the filtered needle and syringe using sterile technique.
6. Remove needle cap, maintaining sterility of the needle and insert into the vial.
7. Withdraw the solution from the vial into the barrel of the syringe.
8. Remove the needle from the vial, point needle upward and expel air and excess
medication from the syringe, taking care not to splash any medication on any person in
the area.
9. Change the filtered needle for the appropriate-sized injection needle prior to
administration to the patient.
PREPARATION OF A MEDICATION CONTAINED IN A MULTIDOSE VIAL
1. Check medication vial for valid date, clarity and intact sterility safeguards.
End page
Prep of medications, (cont.)
2. Wipe off the diaphragm on top of the vial with the alcohol prep.
3. Assemble the needle and syringe (if necessary), using sterile technique.
4. Pull plunger on syringe back to the approximate volume of medication to be withdrawn,
taking care not to contaminate the area of the plunger that will go back into the barrel of
the syringe.
5. Insert the needle through the diaphragm and inject air from the syringe into the vial.
6. Invert the vial, keeping the needle under the fluid level and withdraw slightly more than
the desired volume of medication.
7. Remove the needle from the vial, point the needle upward and expel air and excess
medication from the syringe, taking care not to splash any medication on any person in
the area.
RECONSTITUTION OF MEDICATION
1. Inspect packaging if vial and syringe to insure they contain the correct
solutions/medications, contain the correct volume and/or concentration and have not
expired.
2. Remove the protective cap from the medication vial and wipe the rubber stopper with an
alcohol pad.
3. Remove the needle protector from the syringe and insert the needle through the rubber
stopper of the medication vial.
4. Inject all the diluent from the syringe into the vial.
5. Remove the needle from the vial and gently shake/roll the vial until all medication
dissolves.
6. Using a syringe and appropriate sized needle, pierce the center of the rubber stopper and
withdraw the medication.
7. Remove the needle from the vial.
8. Expel any air and excess medication from the syringe.
PREPARATION OF A MEDICATION CONTAINED IN A PRELOADED SYRINGE
Barrel and plunger type
1. Check medication vial for valid date, clarity and intact sterility safeguards.
2. Assemble the barrel and plunger by twisting the plunger into the threaded stopper of the
barrel.
3. Remove the cap from the needle, point the needle upward and expel air and excess
medication from the syringe, taking care not to splash any medication on any person in
the area.
Prefilled vial type
1. Check medication vial for valid date, clarity and intact sterility safeguards.
2. Select a vial injection sleeve/needle of an appropriate size to hold the medication vial.
3. Pop the protective caps off from both the holder and the medication vial.
4. Screw the vial into the holder.
5. Remove the cap from the needle, point the needle upward and expel air and excess
medication from the syringe, taking care not to splash any medication on any person in
the area.
Tubex, Carpuject type
1. Check medication vial for valid date, clarity and intact sterilization safeguards.
2. Attach the tubex.carpuject administration devise to the medication vial by screwing it to
the stopper.
3. Screw the tubex/carpuject holder onto the vial.
4. Remove the cap from the needle, point the needle upward and expel 1 cc of air, taking
care not to splash any medication on any person in the area.
End page
Prep of medications (cont.)
IV Drip Preparation - Premixed
1. Select premixed medication bag, check expiration date, clarity and sterility safeguards.
2. Using sterile technique, attach the administration set.
3. Fill the drip chamber and the IV line.
4. Label the IV bag with the time started.
5. Attach a 20 gauge sterile needle to the end of the administration line (do not add
extension set).
IV Drip Preparation - standard
1. Select the medication vial(s), check expiration date, clarity and sterility safeguards.
2. Select IV solution bag, wipe the medication port at the bottom of the bag with an alcohol
prep.
3. Maintaining sterile technique, inject the medication ordered into the IV solution bag.
4. Withdraw the syringe and rotate the bag gently to evenly distribute the medication.
5. Maintaining sterile technique, attach the administration set.
6. Fill the drip chamber and the IV line.
7. Attach a 20 gauge sterile needle to the end of the medication administration line. Label
the bag with the name of the medication, amount added to the bag and time started.
8. Dispose of any contaminated equipment in the appropriate receptacle.
Note: Needleless systems may substitute for any of the needle methods.
END
Note: State of Wisconsin Standards and Procedures of Practical Skills Manual (July
2008 Rev) is appended and contains step-by-step instructions for: Auto injectors, metered
dose inhalers. See index for page numbers.
GUIDELINE FOR PRACTICAL SKILL
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 4003
The following content will be considered the Guideline/Standard for:
INTRAVENOUS BOLUS OF MEDICATION
Approved for use
by:
EMT
Advanced EMT
XX
EMTIntermediate
XX
EMTParamedic
XX
PURPOSE
To deliver medication directly into the blood stream for rapid distribution to the rest of the
body
EQUIPMENT
Intravenous line started in a peripheral, external jugular or intraosseous site
Prepared medication
Alcohol Prep
Personal protective equipment to prevent exposure to blood/body fluids
PROCEDURE
1. Assure scene safety and observe universal precautions (see guideline #107).
2. Ascertain the allergy history of the patient.
3. Confirm the dosage, type and route of administration of the medication with medical
control if necessary.
4. Prepare the medication for administration. (see guideline # 4002)
5. Start an intravenous line in a peripheral, external jugular or intraosseous site. (see guideline #
3002-3004)
6. Wipe rubber administration port of IV administration set with alcohol.
7. Insert the needle of the syringe containing medication through the administration port.
Note: Needleless systems may substitute for the piggy-back needle method.
8. Pinch off the IV tubing proximal to the medication port (between the medication port
and the IV bag).
9. Inject the medication into the IV tubing at a rate appropriate for that medication.
10. Open the IV tubing and give 20-30 ml IV fluid, elevate the extremity if possible.
11. Dispose of any contaminated equipment in the appropriate receptacle.
12. Evaluate the patient for response to the medication. Repeat vital signs as needed.
13. Document procedure and results, including any unusual circumstances and/or difficulties
encountered.
Recognize/verbalize the indications, expected actions, usual dose, usual route of
administration, side effects and contraindications of the medication administered.
Recognize/verbalize advantages of intravenous administration of medications:
Delivers medications rapidly to the circulatory system for distribution throughout the
body
End page

IV bolus medication (cont.)
Recognize/verbalize disadvantages of intravenous administration of medications:

Must have a functioning intravenous line in place
Recognize/verbalize complications of the intravenous administration of medications:


Irritation to the vein by the medication injected
Extravasation of the medication into the subcutaneous tissue if the intravenous line
infiltrates
Recognize/verbalize contraindication to intravenous administration of medications:


END
Infiltration of the intravenous line
Injury to the venous system proximal to the injection site
GUIDELINE FOR PRACTICAL SKILL
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 4004
The following content will be considered the Guideline/Standard for:
INTRAVENOUS DRIP ADMINISTRATION OF MEDICATION
Approved for use
by:
EMT
Advanced EMT
EMTIntermediate
EMTParamedic
XX
PURPOSE
To maintain therapeutic blood levels of a medication over a period of time
EQUIPMENT
Peripheral, external jugular or intraosseous line
IV fluid (may be premixed from manufacturer or mixed in field by paramedic)
Administration set
20 gauge sterile needle for “piggyback” Note: Needleless systems may substitute for the
piggy-back needle method.
Alcohol prep
Tape
Personal protective equipment to prevent exposure to blood/body fluids
PROCEDURE
1. Assure scene safety and observe universal precautions (see guideline #107).
2. Ascertain the allergy history of the patient.
3. Confirm the dosage, type and route of administration of the medication with medical
control if necessary.
4. Start IV line Normal Saline in a peripheral, external jugular or intraosseous site. (see
guideline # 3002-3004)
5. Prepare medication for administration (see guideline # 4002).
6. Cleanse the medication port of the end of the original IV line with alcohol.
7. Insert the needle from the medication bag administration set through the medication port
of the original (Normal Saline) IV line and tape in place. Note: Needleless systems may
substitute for the piggy-back needle method.
8. Turn off the original Normal Saline IV line, open the flow regulator on the
administration line containing medication and adjust the flow rate as ordered.
9. Label the IV bag containing the medication with the name of the medication, the amount
added to the IV bag and the time started.
10. Dispose of any contaminated equipment in the appropriate receptacle.
11. Evaluate the patient for response to the medication.
12. Maintain careful observation of the rate of flow of the medication line and for signs of
infiltration.
13. Document procedure and results, including any unusual circumstances and/or difficulties
encountered.
End page
IV drip medication (cont.)
Recognize/verbalize the indications, expected actions, usual dose, usual route of
administration, side effects and contraindications of the medication administered
Recognize/verbalize advantages of intravenous drip administration of medications:

Delivers medications constantly and continuously to the circulatory system for
distribution throughout the body, maintaining a relatively constant blood level of that
medication
Recognize/verbalize disadvantages of intravenous drip administration of medications:


Must have a functioning intravenous line in place
Line must be carefully monitored to assure constant rate of administration
Recognize/verbalize complications of the intravenous drip administration of medications:



Irritation to the vein by the medication injected
Extravasation of the medication into the subcutaneous tissue if the intravenous line
infiltrates
Change in the position of the body or IV bag may suddenly change the drip rate,
decreasing or increasing the rate of administration
Recognize/verbalize contraindication to intravenous drip administration of medications:


END
Infiltration of the intravenous line
Injury to the venous system proximal to the injection site
GUIDELINE FOR PRACTICAL SKILL
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 4005
The following content will be considered the Guideline/Standard for:
ADMINISTRATION OF A NEBULIZED MEDICATION
Approved for use
by:
EMT
Advanced EMT
XX
XX
EMTIntermediate
XX
EMTParamedic
XX
PURPOSE
To aerosolize a medication and deliver it into the pulmonary system for absorption by the
capillaries
EQUIPMENT
Medication as ordered by the physician
Oxygen source and connecting tube
Nebulizer with disposable mouthpiece and corrugated tubing
Nonrebreather or aerosol face mask
Intubation equipment
Adapter, intubating mask
Personal protective equipment to prevent exposure to blood/body fluids
PROCEDURE
Administration via nebulizer
1. Assure scene safety and observe universal precautions (see guideline #107).
2. Ascertain the recent medication use and allergy history of the patient.
3. Confirm the dosage, type and route of administration of the medication with medical
control if necessary.
4. Place medication, diluted with 2.5 ml Normal Saline in the reservoir of the nebulizer.
5. Assemble nebulizer, attach the mouthpiece and corrugated tubing.
6. Attach oxygen source to nebulizer and adjust flow to 6-8 L/min {follow manufacturer
rec}.
7. Check mouthpiece and tubing for presence of nebulized mist.
8. Instruct the patient to inhale the mist and hold it in his/her lungs for as long as possible,
then exhale and repeat the inhalation.
9. Evaluate patient for response to medication.
10. Document procedure and results, including any unusual circumstances and/or difficulties
encountered.
Administration of a nebulized medication via a non-rebreather or aerosol mask
1. Observe universal precautions. (see guideline # 107)
2. Ascertain the recent medication use and allergy history of the patient.
3. Confirm the dosage, type and route of administration of the medication with medical
control if necessary.
4. Place medication, diluted with 2.5 ml Normal Saline, in the reservoir of the nebulizer.
5. Assemble nebulizer.
End page
Nebulized medication, (cont.)
6. Remove reservoir bag if using non-rebreather mask.
7. Attach top of nebulizer (where the mouthpiece normally attaches) to the opening in the
mask.
8. Attach oxygen source to nebulizer and adjust flow to 6-8 L/min {follow manufacturer
rec}.
9. Check mask for presence of nebulized mist.
10. Instruct the patient to inhale the mist and hold it is his/her lungs for as long as possible,
then exhale and repeat the inhalation.
11. Evaluate patient for response to medication.
12. Document procedure and results, including any unusual circumstances and/or difficulties
encountered.
Administration of a nebulized medication via the endotracheal tube (IV tech,
Intermediate and Paramedic)
1. Observe universal precautions. (see guideline # 107)
2. Ascertain the recent medication use and allergy history of the patient.
3. Confirm the dosage, type and route of administration of the medication with medical
control if necessary.
4. Intubate the patient orally or nasally and ventilate with 100% oxygen. (see guideline # 209. 210)
5. Place medication, diluted with 2.5 ml Normal Saline, in the reservoir of the nebulizer.
6. Assemble nebulizer, attach the corrugated tubing.
7. Attach appropriate adapter to the end of the endotracheal tube.
8. Connect the open end of the corrugated tubing to the adapter.
9. Attach second oxygen source to the nebulizer and set flow to 6-8 L/min (per
manufacturer rec.) or detach the oxygen source from the bag-mask device and attach it to
nebulizer and adjust flow to 10 L/min.
10. Connect the bag-valve device to the nebulizer at the opening where the mouthpiece is
usually attached.
11. Hyperventilate the patient, using the bag-valve device.
12. Evaluate patient for response to medication.
13. Document procedure and results, including any unusual circumstances and/or difficulties
encountered.
Recognize/verbalize the indications, expected actions, usual dose, usual route of
administration, side effects and contraindications of the medication administered
Recognize/verbalize advantages of nebulized administration of medications:


Delivers medications rapidly to the circulatory system in the lungs for distribution
throughout the body
Noninvasive, does not require IV line
Recognize/verbalize disadvantages of nebulized administration of medications:


Patients in severe respiratory distress may not be able to follow directions or inhale a
high enough tidal volume to receive sufficient medication to treat their condition
Very few medications can be given this route
Recognize/verbalize complications of the nebulized administration of medications:
Tachyarrhythmias
 Ventricular ectopic beats
End page

Nebulized medication (cont.)
Recognize/verbalize contraindication to nebulized administration of medications:

None
END
Note: State of Wisconsin Standards and Procedures of Practical Skills Manual (July
2008 Rev) is appended and contains step-by-step instructions for: metered dose inhaler.
See index for page numbers.
GUIDELINE FOR PRACTICAL SKILL
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 4006
The following content will be considered the Guideline/Standard for:
ENDOTRACHEAL ADMINISTRATION OF MEDICATION
Approved for use
by:
EMT
Advanced EMT
XX
EMTIntermediate
XX
EMTParamedic
XX
PURPOSE
To deliver medication to the alveoli of the lung for rapid absorption by the capillaries
EQUIPMENT
Intubation equipment
IV bag Normal Saline
20 cc syringe with 20 gauge needle attached
Alcohol preps
Prepared medication
Bag-valve device with oxygen reservoir
Oxygen source and connecting tubing
Right angle swivel connector (optional)
Personal protective equipment to prevent exposure to blood/body fluids
PROCEDURE
1.
2.
3.
4.
Assure scene safety and observe universal precautions (see guideline #107).
Ascertain the allergy history of the patient.
Intubate patient orally or nasally. (see guideline # 2009, 2010)
Attach a right angle swivel connector with medication port to the top of the endotracheal
tube if desired.
5. Attach the bag-valve device with reservoir bag to the swivel connector or directly to the
endotracheal tube and ventilate the patient with 100% oxygen at a rate according to
AHA guidelines.
6. Confirm the dosage, type and route of administration of the medication with medical
control if necessary.
7. Prepare the medication for administration. (see guideline # 4002)
8. Using sterile technique, draw up at least 10 ml Normal Saline into the 20 ml syringe.
9. Stop ventilating (and chest compressions if in progress), open the medication port on the
swivel connector (or disconnect the bag-valve device).
10. Inject the medication into the endotracheal tube.
a. If the volume of medication is less than 5 ml and the patient has an
uncuffed endotracheal tube, follow the medication with a flush of 5 ml of normal
saline.
b. If the volume of medication is less than 5 ml and the patient has a cuffed
endotracheal tube, follow the medication with a flush of 10 ml of normal saline.
c. If the volume of medication is greater than 5 ml, no flush is necessary.
End page
Endotracheal medications, (cont.)
11. Close the medication port (or reconnect the bag-valve device) and slowly compress the
bag-valve device (over a 2 second period) 5 times, then continue to hyperventilate.
12. Dispose of any contaminated equipment in the appropriate receptacle.
13. Evaluate patient for response to medication.
14. Document procedure and results, including any unusual circumstances and/or difficulties
encountered.
Recognize/verbalize medications that can be administered through the endotracheal tube:
Narcan
Atropine
Epinephrine
Lidocaine
(Note: Amiodarone is NOT approved for ET administration!)
Recognize/verbalize the indications, expected actions, usual dose, usual route of
administration, side effects and contraindications of the medication administered
Recognize/verbalize advantages of endotracheal administration of medications:


Delivers medications rapidly to the circulatory system for distribution throughout the
body
Do not need an established intravenous line
Recognize/verbalize disadvantages of endotracheal administration of medications:





Must have an endotracheal tube in place
Medication dosage must be 2-2.5 times the intravenous dose
Some of the medication will adhere to the walls of the endotracheal tube
Not all medications can be given this route
Must stop CPR and ventilation to administer
Recognize/verbalize complications of the endotracheal administration of medications:

Potential damage to lung tissue by the medication
Recognize/verbalize contraindication to endotracheal administration of medications:

END
Medication not approved for endotracheal administration
GUIDELINE FOR PRACTICAL SKILL
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 4007
The following content will be considered the Guideline/Standard for:
INTRAMUSCULAR INJECTION OF MEDICATION
Approved for use
by:
EMT
Advanced EMT
XX
XX
EMTIntermediate
XX
EMTParamedic
XX
PURPOSE
To deliver medication to the muscle tissue for absorption by blood vessels
EQUIPMENT
21-23 gauge, 1.5 inch needle on appropriate sized syringe for the volume to be administered
Prepared medication
Alcohol prep
Personal protective equipment to prevent exposure to blood/body fluids
PROCEDURE
1. Assure scene safety and observe universal precautions (see guideline #107).
2. Ascertain the allergy history of the patient.
3. Confirm the dosage, type and route of administration of the medication with medical
control if necessary.
4. Prepare the medication for administration. (see guideline # 4002)
5. Explain the procedure to the patient and gain his/her consent.
6. Select the appropriate injection site
a. Anterior or lateral aspect of the thigh midway between the hip and knee (preferred
site)
b. Deltoid muscle if less than 2 ml (not in pediatric patients less than16 years)
c. Upper outer quadrant of the buttocks.
7. Cleanse the injection site with alcohol.
8. Tent up the muscle between the thumb and index finger and insert the needle at a 90º
angle into the body of the muscle (approximately 1 inch in the adult).
9. Stabilize the needle and syringe with one hand, pull back on the plunger to be sure the
tip of the needle is not in a blood vessel.
10. If blood appears in the syringe, withdraw and discard the syringe, repeat steps above.
11. Inject the medication slowly.
12. Withdraw the needle at the same angle at which it was inserted.
13. Massage the injection site.
14. Dispose of contaminated equipment in the appropriate receptacle.
15. Evaluate the patient for response to the medication.
16. Document procedure and results, including any unusual circumstances and/or difficulties
encountered.
Recognize/verbalize the indications, expected actions, usual dose, usual route of
administration, side effects and contraindications of the medication administered
End page
Administration of medication, (cont.)
Recognize/verbalize advantages of intramuscular administration of medications:



Delivers medications slowly to the circulatory system for distribution throughout the
body
Effects sustained over a period of time
Does not require an intravenous line in place
Recognize/verbalize disadvantages of intramuscular administration of medications:



Pain at the injection site
Only small volumes (2-5 cc) should be given this route
Cannot give tissue-irritating medication by this route
Recognize/verbalize complications of the intramuscular administration of medications:


Abscess formation at the injection site (poor technique)
Accidental intravenous injection if tip of needle is in a vein
Recognize/verbalize contraindication to intramuscular administration of medications:


Hypotension (lack of peripheral circulation to pick up medication)
Infection in area of injection
END
Note: State of Wisconsin Standards and Procedures of Practical Skills Manual (July
2008 Rev) is appended and contains step-by-step instructions for: alternate method of IM
injection. See index for page numbers.
GUIDELINE FOR PRACTICAL SKILL
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 4008
The following content will be considered the Guideline/Standard for:
SUBCUTANEOUS ADMINISTRATION OF MEDICATION
Approved for use
by:
EMT
Advanced EMT
XX
XX
EMTIntermediate
XX
EMTParamedic
XX
PURPOSE:
To deliver medication to the subcutaneous tissue for absorption by blood vessels
EQUIPMENT
23-25 gauge, 5/8 inch needle on a 1 cc syringe
Prepared medication
Alcohol prep
Personal protective equipment to prevent exposure to blood/body fluids
PROCEDURE
1. Assure scene safety and observe universal precautions (see guideline #107).
2. Ascertain the allergy history of the patient.
3. Confirm the dosage, type and route of administration of the medication with medical
control if necessary.
4. Prepare the medication for administration. (see guideline # 4002)
5. Explain the procedure to the patient and gain his/her consent as needed.
6. Select the appropriate injection site on the deltoid muscle.
7. Cleanse the injection site with alcohol.
8. Tent up the skin and subcutaneous tissue between the thumb and index finger and insert
the needle at a 45º angle into the subcutaneous tissue (approximately 0.5 inch in the
adult).
9. Stabilize the needle and syringe with one hand, pull back on the plunger to be sure the
tip of the needle is not in a blood vessel.
10. If blood appears in the syringe, withdraw and discard the syringe, repeat steps above.
11. Inject the medication slowly.
12. Withdraw the needle at the same angle at which it was inserted.
13. Massage the injection site.
14. Dispose of needle and syringe in appropriate receptacle.
15. Evaluate the patient for response to the medication.
16. Document procedure and results, including any unusual circumstances and/or difficulties
encountered.
Recognize/verbalize the indications, expected actions, usual dose, usual route of
administration, side effects and contraindications of the medication administered
Recognize/verbalize advantages of subcutaneous administration of medications:
 Delivers medications slowly to the circulatory system for distribution throughout the
body
 Effects sustained over a period of time
 Does not require that an IV line be in place
End page
Subcutaneous medication, (cont.)
Recognize/verbalize disadvantages of subcutaneous administration of medications:
 Pain at the injection site
 Only small volumes (0.5 cc or less) should be given this route
 Cannot give tissue-irritating medication by this route
Recognize/verbalize complications of the subcutaneous administration of medications:
 Abscess formation at the injection site (poor technique)
 Accidental intravenous injection if tip of needle is in a vein
Recognize/verbalize contraindication to subcutaneous administration of medications:
 Hypotension (lack of peripheral circulation to pick up medication)
 Infection in area of injection
END
Note: State of Wisconsin Standards and Procedures of Practical Skills Manual (July
2008 Rev) is appended and contains step-by-step instructions for: alternate method of
subcutaneous injection. See index for page numbers.
GUIDELINE FOR PRACTICAL SKILL
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 4009
The following content will be considered the Guideline/Standard for:
RECTAL ADMINISTRATION OF MEDICATION
Approved for use
by:
EMT
Advanced EMT
EMTIntermediate
XX
EMTParamedic
XX
PURPOSE
To provide a route of administration for selected medications in patients on whom an
intravenous line cannot be established
EQUIPMENT
2.5 mm endotracheal tube
1, 3 or 20 ml syringe with removable needle
Prepared medication
Tape
Personal protective equipment to prevent exposure to blood/body fluids
PROCEDURE
1. Assure scene safety and observe universal precautions (see guideline #107).
2. Ascertain the allergy history of the patient.
3. Confirm the dosage, type and route of administration of the medication with medical
control if necessary.
4. Transfer ordered dose of medication into the syringe with the removable needle.
5. Draw up an additional 1 cc of air into the syringe.
6. Remove the white bag-valve adapter from a 2.5 mm endotracheal tube.
7. Connect the syringe to the endotracheal tube.
8. Insert the endotracheal tube into the rectum approximately 2 inches.
9. Invert the syringe, making sure the air bubble is above the liquid and slowly inject the
drug into the rectum.
10. Clear the syringe and tube of medication by continuing to depress the plunger of the
syringe, forcing the air through the endotracheal tube.
11. Withdraw the endotracheal tube and hold or tape the buttocks together for several
minutes to prevent expulsion of the drug.
12. Dispose of equipment in appropriate receptacle.
13. Evaluate the patient for response to the medication.
14. Document procedure and results, including any unusual circumstances and/or difficulties
encountered.
Recognize/verbalize the indications, expected actions, usual dose, usual route of
administration, side effects and contraindications of the medication administered
End page
Rectal administration of medications (cont.)
Recognize/verbalize advantages of rectal administration of medications:
 Delivers medications slowly to the circulatory system for distribution throughout the
body
 Effects sustained over a period of time
Recognize/verbalize disadvantages of rectal administration of medications:
 Uncertain absorption rate because of rectal contents, local drug irritation
 Uncertainty of medication retention
Recognize/verbalize complications of the rectal administration of medications:
 Trauma to the rectal mucosa with the tube
Recognize/verbalize contraindication to rectal administration of medications:
 Rectal bleeding
 Diarrhea
 Any known rectal abnormality (e.g. fistula, atresia)
END
GUIDELINE FOR PRACTICAL SKILL
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 4010
The following content will be considered the Guideline/Standard for:
ORAL/SUBLINGUAL ADMINISTRATION OF MEDICATION
Approved for use
by:
EMT
Advanced EMT
XX
XX
EMTIntermediate
XX
EMTParamedic
XX
PURPOSE
To deliver medication directly into the gastrointestinal tract
EQUIPMENT
Prepared medication
PROCEDURE
1. Assure the patient is alert, cooperative, able to follow directions, and has an intact gag
reflex.
2. Ascertain allergy history of the patient.
3. Confirm the dosage, type and route of administration of the medication.
a.
Chewable tablets:
 Instruct the patient that the medication must be chewed.
 Allow patient to self-administer medication or place medication in patient’s
mouth.
b.
Oral Glucose (Gel)
 Instruct patient that the gel must be swallowed
 Allow patient to self-administer gel incrementally or assist with squeezing gel
into patient’s mouth incrementally.
 Repeat as necessary until tube content has been consumed.
c.
Sublingual tablets
 Instruct patient to place tablet under his/her tongue and allow it to dissolve
there.
 Allow patient to self-administer medication or ask patient to open mouth and
lift tongue, place medication in patient’s mouth.
d.
Sublingual spray
 Tell patient you are going to spray medication under his/her tongue.
 Instruct patient to open mouth and lift tongue
4. Report administration of medication to medical control.
5. Evaluate the patient for response to the medication.
6. Document procedure and results, including any unusual circumstances and/or difficulties
encountered.
Recognize/verbalize the indications, expected actions, usual dose, usual route of administration,
side effects and contraindications of the medication administered.
Recognize/verbalize advantages of oral administration of medications:
 Convenient, does not require invasive technique.
End page
Oral/sublingual medication (cont.)
Recognize/verbalize disadvantages of oral administration of medications:
 Slower absorption into the body
 Some forms of medications are not tolerated by the gastrointestinal tract
Recognize/verbalize complications of the oral administration of medications:


Aspiration
Gastrointestinal irritation
Recognize/verbalize contraindication to oral administration of medications:


END
Altered level of consciousness
Absent gag reflex
Note: State of Wisconsin Standards and Procedures of Practical Skills Manual (July 2008 Rev) is
appended and contains step-by-step instructions for: buccal administration of medications. See index for
page numbers.
GUIDELINE FOR PRACTICAL SKILL
Initial Date: 1/1/05
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 4011
The following content will be considered the Guideline/Standard for:
MARK 1 AUTO-INJECTOR
Approved for use
by:
EMT
Advanced EMT
XX
XX
EMTIntermediate
XX
EMTParamedic
XX
PURPOSE
To administer antidotal therapy to EMS personnel who meet criteria for exposure to chemical nerve agent or organophosphate pesticides in
Weapons of Mass Destruction situations
EQUIPMENT
Mark 1 auto-injector antidote kit containing:
1 – Atropine auto-injector (2 mg in 0.07 ml)
1 – Pralidoxime chloride auto-injector - 2-PAM-CL (600 mg in 2 ml)
INDICATIONS
1. Mark 1 auto-injectors may be used:
a.
If signs and/or symptoms (see below) of nerve agent or organophosphate
poisoning are
present, or
b.
2.
3.
4.
+
If know exposure to nerve agent or organophosphate has occurred prior to signs or
symptoms
Mark 1 kits may either be self-administered or administered by another EMT
The Mark 1 kit should be rapidly administered
Signs and symptoms of nerve gas or organophosphate poisoning include: SLUDGEBAM
RESPIRATION + AGITATION
S – salivation (excessive drooling)
L – lacrimation (tearing)
U – urination
D – diarrhea
G – GI upset (cramps)
E – emesis (vomiting)
B – bradycardia
A – Apnea, asystole
M – muscle twitching
RESPIRATION – difficulty breathing, respiration distress, wheezing
AGITATION + CNS SIGNS – confusion, agitation, seizure, coma
PROCEDURE
1. Assure scene safety and observe universal precautions (see guideline #107)
2. Immediately evacuate the contaminated area
3. If dermal (skin) exposure has occurred, decontamination is critical and should be done with
procedures
standard decontamination
end page 1
Mark 1 auto injections page 2
4. Consider request for ALS transport or intercept. Intermediate (99) and Paramedic level
providers carry Atropine as one of their standard medication. Continued pre-hospital
treatment with Atropine is essential to survival (see guideline #005)
5. Remove Mark 1 kit from package
6. Normal injection site is outer thigh muscle. It is important that the injection is into a
large
muscle.
7. Injection may go through clothing.
8. Grasp the atropine auto-injector (the smaller of the two) with the thumb and first two
fingers. DO NOT cover or hold the needle end with your thumb, hand or fingers to avoid
accidental
injection into the hand.
9. Pull the auto-injector out of the clip, which arms the device.
10.
Position of green (needle) end of the auto-injector against the injection site –
midway between the hip and the knee on the anterior or lateral thigh. Do not inject close to
the hip or knee.
11.
Apply firm pressure (not a jabbing motion) to hold the needle end of the injector
against the
injection site. The needle will automatically extend into the thigh muscle.
12.
Hold the auto-injector firmly in place for at least 10 seconds to be sure all
medication is injected.
13.
Remove the atropine injection from the administration site and place into sharps
container.
14.
Remove the 2-PAM-CL from the clip to arm the mechanism.
15.
Inject the 2-PAM-CL into the thigh muscle in the same manner as the atropine
was injected.
16.
Massage the injection site if time permits.
17.
Transport to the appropriate hospital for further evaluation and treatment.
Recognize/verbalize advantages of use of the Mark 1 auto-injector antidote kit:

Provides life-saving antidotal therapy to the EMS provider with known exposure or
symptoms/signs from exposure to a nerve gas or organophosphate agent
Recognize/verbalize disadvantages of use of the Mark 1 auto-injector antidote kit:

May impair the EMS provider, particularly if used unnecessarily
Recognize/verbalize complications of use of the Mark 1 auto-injector antidote kit:


Atropine: Impaired vision, increased blood pressure, fever, palpitations, tachycardia
Pralidoxime: tachycardia, nausea, vomiting, visual disturbances, hypertension
Recognize/verbalize contraindication to use of the mark 1 auto-injector antidote kit:


END
Allergy to atropine or pralidoxime
No significant exposure to toxic nerve gas or organophosphate agent
GUIDELINE FOR PRACTICAL SKILL
Initial Date:
12/5/08
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision:
Guideline Number: 4012
The following content will be considered the Guideline/Standard for:
INTRANASAL ADMINISTRATION OF MEDICATION
Approved for use
by:
EMT
Advanced EMT
XX?
EMTIntermediate
XX
EMTParamedic
XX
PURPOSE
To deliver medication directly into the nasal mucosa
EQUIPMENT
Prepared medication
Specialized syringe designed to deliver nasal medications (ie. MAD nasal) Mucosal
Atomization Device
PROCEDURE
1. Ascertain allergy history of the patient.
2. Confirm the dosage
3. Add 0.1ml to each dose calculation to account for “dead space” at the tip of the
delivery device
4. Place atomizer within the nostril
5. Briskly compress syringe to administer no more than 1cc per nostril
6. Evaluate the patient for response to the medication.
7. Document procedure and results, including any unusual circumstances and/or
difficulties encountered.
Medications approved for nasal administration (may use standard IV or IM doses):




Versed
Fentanyl
Naloxone
Glucagon
Recognize/verbalize disadvantages of nasal administration of medications:
 Dose limited by drug concentration and maximum volume
Recognize/verbalize advantages of nasal administration of medications:

Convenient, does not require invasive technique.
End page
Recognize/verbalize complications of the nasal administration of medications:


Aspiration
Loss of medication due to poor absorption (swallow, sneeze, or cough out medication)
Recognize/verbalize contraindication to nasal administration of medications:


END
Medications that are too dilute
Lack of proper atomizing equipment
Blank
GUIDELINE FOR PRACTICAL SKILL
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 1/07/09
Guideline Number: 5001
The following content will be considered the Guideline/Standard for:
HEMORRHAGE CONTROL, BANDAGING
Approved for use
by:
EMT
Advanced EMT
XX
XX
EMTIntermediate
XX
EMTParamedic
XX
PURPOSE
To control bleeding from an open wound
To prevent further contamination of an open wound
EQUIPMENT
Sterile gauze pads of a size appropriate to the area to be covered (i.e. ABD pad or 4x4)
Elastic Trauma Dressing (Israeli bandage, Emergency Trauma Dressing®)
Tape
Commercial Tourniquet (C.A.T.® SOF-T®)
Personal protective equipment to prevent exposure to blood/body fluids
PROCEDURE
General principles
1. Assure scene safety and observe universal precautions (see guideline #107).
2. Complete primary and secondary physical assessment. (see guideline # 103, 1001)
3. Expose the wound and assess potential damage.
4. Control severe hemorrhage with Direct Pressure, if unable to stop bleeding apply
tourniquet (see guidline #5013) For an anatomical areas that a tourniquet cannot be used
apply a “Hemostatic Agent” (see guideline #5014).
5. Assess distal circulation, sensation and movement if the wound is on an extremity or
potentially involves the spinal cord.
6. Maintaining the sterility, apply the gauze dressing pad or elastic bandage, covering the
entire wound.
7. Secure the dressing pad with tape or roller bandage, applying gentle even pressure.
8. Monitor distal circulation, sensation and movement after bandaging wounds on an
extremity. Loosen bandage if necessary to maintain distal circulation, but control
bleeding.
9. Splint area as necessary to prevent motion.
10. Continue to evaluate the patient’s condition.
11. Document procedure and results, including any unusual circumstances and/or difficulties
encountered.
Recognize/verbalize advantages of hemorrhage control and bandaging:
 Prevents further loss of blood
 Decrease opportunities for wound contamination
Recognize/verbalize disadvantages of hemorrhage control and bandaging:
 Obscures view of the wound
 Continued hemorrhage into a bulky dressing may go unrecognized
Hemorrhage control, bandaging (cont.)
Recognize/verbalize complications of hemorrhage control and bandaging:


Injury to surrounding soft tissue
Circumferential bandage may become a venous tourniquet if soft tissue swelling occurs
Recognize/verbalize contraindication to hemorrhage control and bandaging:

None
Note: Sites where the EMT must demonstrate appropriate dressing and bandaging
techniques include the head, eye, neck, open chest wound, penetrating wounds,
abdominal evisceration, external genitalia injuries, shoulder, axilla, hand, traumatic
amputation and burns.
END
Note: State of Wisconsin Standards and Procedures of Practical Skills Manual (July
2008 Rev) is appended and contains step-by-step instructions for: Abdominal
evisceration, amputations, axillary wounds, burns, chest injuries open, chest injuries
penetration, eye injuries, genitalia wounds, hand injuries, head wounds, neck wounds
shoulder wounds, torso injuries. See index for page numbers.
GUIDELINE FOR PRACTICAL SKILL
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 5002
The following content will be considered the Guideline/Standard for:
EYE INJURIES
Approved for use
by:
EMT
Advanced EMT
XX
XX
EMTIntermediate
XX
EMTParamedic
XX
PURPOSE
To evaluate, remove foreign material from and appropriate dress and bandage injuries to the
eye(s).
EQUIPMENT
Cotton tipped applicators
Normal Saline intravenous bag
Minidrip administration set
Personal protective equipment to prevent exposure to blood/body fluids
PROCEDURE
REMOVAL OF SUPERFICIAL FOREIGN BODY
1. Assure scene safety and observe universal precautions (see guideline #107).
2. Pull down the lower lid; inspect the fornix for presence of foreign body.
3. If present in the lower fornix, remove particulate matter with moistened cotton-tipped
applicator or irrigate out with Normal Saline solution.
a. Attach the minidrip administration set to the bag of Normal Saline.
b. Fill the drip chamber and line.
c. Position the bag just slightly above the level of the patient’s head to avoid having the
solution leave the end of the administration set at a high pressure.
d. Hold the end of the administration set over the area to be irrigated.
e. Adjust the flow rate of the IV solution.
f. Holding the lids open, direct the flow of Normal Saline over the area to be irrigated.
4. Evert the upper lid to check for foreign body.
a. Ask the patient to look downward (keep face perpendicular to the floor,
roll eyeball downward).
b. Grasp the lashes; gently pull down and out to loosen the lid from the eye
surface.
c. Place cotton-tipped applicator against the top of the lid and fold the lid back by gently
pulling out and up on the lashes.
5. If superficial foreign body present on the upper lid, remove particulate matter with
moistened cotton-tipped applicator or irrigate out with Normal Saline solution.
6. If unable to easily remove foreign body, patch both eyes and arrange transport for
appropriate treatment.
7. Document procedure and results, including any unusual circumstances and/or difficulties
encountered.
End page
Eye injuries, cont.
IRRIGATION FOR SUSPECTED CHEMICAL SUBSTANCE IN THE EYE
1.
2.
3.
4.
5.
Assure scene safety and observe universal precautions (see guideline #107).
Assemble Normal Saline intravenous bag and administration set as outlined above.
Position patient spine with head turned toward affected side.
Hold eyelid(s) open without exerting pressure on the eyeball.
Direct the IV fluid across the surface of the eye from medial to lateral with IV bag only
slightly above the level of the patient’s head to avoid undue pressure from the fluid
stream.
6. Transport to appropriate facility, continue irrigation during transport.
7. Document procedure and results, including any unusual circumstances and/or difficulties
encountered.
Recognize/verbalize complications of eye irrigation:
 Ocular injury from the tip of the irrigating line or from pressure from the fluid stream
 Vagal stimulation due to ocular pressure
Recognize/verbalize contraindication to eye irrigation:

Ruptured globe
NON-PENETRATING EYE INJURIES
1. If area around eye is lacerated but eyeball is not involved, use direct pressure to control
bleeding.
2. If eyeball injury is suspected, close eye lid and apply a loose dressing.
3. If thermal burns are involved, apply dressing moistened with sterile saline.
4. If light burns are involved, cover eyes with moist, light-proof pads.
5. Cover both eyes when eye injury occurs because sympathetic eye movement may cause
further injury.
6. Maintain verbal and physical contact with the patient whose eyes are bandaged.
PENETRATING INJURIES/EXTRUDED EYEBALL
1.
2.
3.
4.
5.
6.
7.
8.
END
Do not touch the eyeball or the penetrating object with your hands.
Maintain verbal and physical contact with the patient
Surround the injured eye with sterile padding.
If a penetrating object is present, cut hole in the end of a cup just large enough for the
object to pass through
Place cup/cone over the eye, resting on the pads, but not touching the eye.
Secure cup/cone to the head with bandage
Cover uninjured eye
Restrain the patient’s hands as necessary to prevent him/her from touching the area.
GUIDELINE FOR PRACTICAL SKILL
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 5003
The following content will be considered the Guideline/Standard for:
SEATED PATIENT EXTRICATION DEVICE
Approved for use
by:
EMT
Advanced EMT
XX
XX
EMTIntermediate
XX
EMTParamedic
XX
PURPOSE
To provide rigid stabilization of the cervical and thoracic spine during movement of a
patient with a suspected spinal injury from a sitting to supine position
EQUIPMENT
Seated-Patient Extrication Device (e.g. KED, XP-1)
Rigid cervical collar
Sizes available include tall, regular, short, no-neck, no-neck baby, pediatric
Cravats
Long board with straps
Personal protective equipment to prevent exposure to blood/body fluids
PROCEDURE
1. Assure scene safety and observe universal precautions (see guideline #107).
2. Maintain stabilization of the head, supporting it in neutral position until the head is
secured in the device (or in the position found if resistance is encountered when
attempting to return head to neutral position).
3. Assess neurologic status with particular emphasis on peripheral sensation and
movement.
4. Apply a rigid cervical collar of appropriate size.
5. Slip the device behind the patient without disturbing the patient’s position.
6. Wrap the side panels of the device around the torso and slide the device up until the tops
of the side panels are firmly engaged in the patient’s axillae.
7. Fasten the middle and bottom torso straps just tight enough to hold the device in place.
8. Wrap the head portion of the device around the patient’s head, padding behind the neck
as needed to maintain neutral position.
9. Secure the head section with forehead straps or Kling wrapped around forehead. Chin
cup should not be used.
10. Slide the pelvic straps under the patient’s thighs (right strap under the right thigh over
the left thigh to the left side buckle; left strap under the left thigh over the right thigh to
the right side buckle.
11. Fasten the top strap.
12. Tighten all straps.
13. Tie upper extremities together with cravats to prevent injury during movement.
14. Use the support loops on the device to lift the patient and slide onto a long board.
15. Loosen the pelvic straps when the patient is supine.
16. Secure the patient to the long board with straps.
17. Loosen the chest strap to make chest movement during respiration easier.
End page
Seated-Patient Extrication Device (cont.)
18. Document the patient’s neurologic condition before and after movement in addition to
standard physical assessment documentation.
19. Document procedure and results, including any unusual circumstances and/or difficulties
encountered.
Recognize/verbalize advantages of the device:


Easy to apply
Provides rigid stabilization of head and spine when properly applied
Recognize/verbalize disadvantages of the device:


Chest and abdominal straps may restrict respirations
Obscures visualization of back and sides
Recognize/verbalize complications of the device:

Use of the chin strap prevents the patient from being able to open his/her mouth if has to
vomit
Recognize/verbalize contraindication to of the device:

None
END
Note: State of Wisconsin Standards and Procedures of Practical Skills Manual (July 2008
Rev) is appended and contains step-by-step instructions for XP-1 extrication device. The
above procedure is for the Kendrick Extrication Device. See index for page numbers.
GUIDELINE FOR PRACTICAL SKILL
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 5004
The following content will be considered the Guideline/Standard for:
APPLICATION, INFLATION AND DEFLATION OF THE PNEUMATIC ANTI-SHOCK
GARMENT (PASG) (MAST)
Approved for use
by:
EMT
Advanced EMT
XX
XX
EMTIntermediate
XX
EMTParamedic
XX
PURPOSE
To provide rigid stabilization for suspected fractures of the pelvis and lower extremities
EQUIPMENT
Pneumatic Anti-Shock Garment (PASG)(MAST)
Sphygmomanometer
Stethoscope
Long Board with straps
Personal protective equipment to prevent exposure to blood/body fluids
PROCEDURE
INFLATION
1.
2.
3.
4.
5.
6.
Assure scene safety and observe universal precautions (see guideline #107).
Complete initial and focused physical assessment. (see guideline # 103, 1001)
Unfold the PASG on the long board.
Remove the patient’s clothing.
Dress any wounds. (see guideline # 5001)
Note and subsequently document the physical assessment findings of any pathology that
will be covered by the PASG.
7. Move the patient onto the PASG, using patient movement device/technique.
8. Position the patient on the PASG with the superior edge of the suit just below the rib
cage.
9. Beginning at the ankles, secure the Velcro straps to mold the suit around the patient.
10. Attach the inflation pump and open all three valves.
11. Medical control should be contacted if using the device to increase peripheral vascular
resistance/blood pressure before inflating.
12. If using the device as a splint, inflate the suit until: (Note: Medical control contact is not required before
inflation.)
a. The Velcro straps crackle
b. Air escapes from the relief valves.
13. Close valves to all compartments.
14. Assess and monitor changes in the patient’s condition.
15. Document procedure and results, including any unusual circumstances and/or difficulties
encountered.
End page
PASG, (cont.)
DEFLATION
1. Assure scene safety and observe universal precautions (see guideline #107).
2. Assure that IV line(s) are in place and all blood/fluid loss has been controlled.
(see guideline #
3002-3004, 5002)
3. Close all valves and remove tubing.
4. Slowly deflate the abdominal portion, approximately 1/3 of the air at a time, monitoring
vital signs and level of consciousness. .
(Note: Deflation should be stopped anytime the patient’s systolic pressure falls more
than 5 mmHg or pulse increases by more than 5 beats/min or there is any change
in the level of consciousness.)
5. Slowly deflate first one leg and then the other, monitoring vital signs and level of
consciousness.
(Note: Deflation should be stopped anytime the patient’s systolic pressure falls more
than 5 mmHg or pulse increases by more than 5 beats/min or there is any change
in the level of consciousness.)
6. If there is a decrease in blood pressure or increase in pulse rate, re-inflate the PASG and
reassess volume status.
7. Assess and monitor changes in the patient’s condition.
8. Document procedure and results, including any unusual circumstances and/or difficulties
encountered.
Recognize/verbalize indications for the use of the PASG in the EMS system:
 Pelvic fracture
 Abdominal aortic aneurysm
 Extensive soft tissue injury of the groin or lower extremities
Recognize/verbalize disadvantages of the PASG:
 Covers the abdomen, pelvis and lower extremities, obscuring visualization
Recognize/verbalize complications of the PASG:
 Increase in hemorrhage from sites not under the suit
 May prolong infield time in hypotensive patients for application and inflation
Recognize/verbalize contraindication to the use of the PASG:
 Pulmonary edema
 Penetrating thoracic injury
Recognize verbalize contraindication to the inflation of the abdominal portion of the
PASG:
 Abdominal evisceration
 Acute abdominal distention
 Impaled objects in the abdomen
 Third trimester pregnancy
Recognize/verbalize indications to stop PASG deflation process:
 Pulse increase of 5 or more beats per minute
 Systolic blood pressure drop of 5 or more mmHg
 Change in the level of consciousness
END
GUIDELINE FOR PRACTICAL SKILL
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last/Review, Revision: 1/23/03
Guideline Number: 5005
The following content will be considered the Guideline/Standard for:
SPINAL STABILIZATION
Approved for use
by:
EMT
Advanced EMT
XX
XX
EMTIntermediate
XX
EMTParamedic
XX
PURPOSE
To provide rigid stabilization of the spinal column in a patient with a suspected spinal
fracture/dislocation and/or potential for spinal cord injury
EQUIPMENT
Rigid cervical collar
Sizes available include tall, regular, short, no-neck, no-neck baby, pediatric
Cervical stabilization device
Long board with straps
Scoop stretcher
Cravats or other material to secure extremities
Personal protective equipment to prevent exposure to blood/body fluids
PROCEDURE
Initial Assessment of Spinal Injuries
1. A complete patient assessment will be completed on all trauma patients including those
who are potential candidates for cervical spinal stabilization exclusion under this section.
2. This section does not exclude any patient from cervical spinal immobilization if the EMS
crew feels cervical spinal stabilization precautions are warranted.
3. Documentation on the patient care report should reflect positive and negative physical
findings as outlined below.
Note: Cervical spine stabilization exclusion may be instituted only after approval by
the service medical director and appropriate training of all personnel.
4. Cervical spinal stabilization may be excluded only if the patient meets all of the
following criteria:
a.
The traumatic incident is minor with no significant mechanism of injury, vehicle
or
environmental damage.
b.
The patient does not have significant head or facial trauma.
c.
The patient denies neck or spine pain or tenderness, numbness or paresthesia and
does not exhibit weakness associated with the trauma. Note: The term “neck pain” includes any
stiffness or tenderness upon palpation at the posterior midline or paraspinal area of the cervical spine or back. The patient
must be calm, cooperative, sober, oriented and alert. There can be no communication barriers including but not limited to:
age, language, closed head injury, deafness, intoxication or other injury that interferes with the patient’s ability to concentrate
on or cooperate with the examination.
d.
e.
there
There is no history of loss of consciousness associated with the trauma.
The patient has no history of altered mental state associated with the trauma nor is
suspicion of drug use or clinical intoxication.
End page
Spine stabilization, (cont.)
f.
There are no significant distracting injuries that may distract the patient from
perceiving
pain/tenderness. Note: Distracting injuries include, but are not limited to fractures, lacerations, burns and crush
injuries.
Spinal Stabilization - supine or prone patient
1. Assure scene safety and observe universal precautions (see guideline #107).
2. Stabilize the head/cervical spine in neutral position with manual stabilization at the base
of the skull with fingers under the jaw.
3. Maintain stabilization until the patient is secured to the long board.
4. Use appropriate technique/adjunct to maintain the airway.
5. Select the correct size cervical collar appropriate for the patient.
6. Slip cervical collar under patient’s neck without flexing the head.
7. Apply the collar without releasing previously applied stabilization and close Velcro
straps.
8. Restrain patient’s extremities in an appropriate manner.
9. Particular attention is made to documenting the patient’s neurologic condition
(circulation, sensation, movement) before and after splinting.
10. Document procedure and results, including any unusual circumstances and/or difficulties
encountered.
11. Move patient to long board using one of the following techniques.
Log roll to long board - supine patient
Assure scene safety and observe universal precautions (see guideline #107).
Maintain cervical stabilization.
A minimum of 3 people knowledgeable in the technique are needed.
First rescuer maintains cervical stabilization and directs the team in patient movement.
Position the long board along one side of the patient.
Second rescuer kneels at the shoulder of the patient (on the opposite side of the patient
from the long board) raising the patient’s arm nearest to self up along side the patient’s
head and grasping the patient’s furthest shoulder and small of back.
7. Third rescuer kneels on the same side of the patient at the hip level, grasping the furthest
hip and thigh.
8. First rescuer gives signal to turn the patient toward the kneeling rescuers, maintaining
spinal alignment, examine patient’s back for injury.
9. Second and third rescuers hold patient stable with one hand and pull the long board flush
against the patient’s back.
10. First rescuer gives signal to roll patient back onto long board, maintaining spinal
alignment.
11. First rescuer gives signal to center the patient on the long board if necessary, using
gentle even motion and maintaining spinal alignment.
12. Place patient’s arms at his/her side.
13. Position and secure the Cervical Immobilizer.
14. Secure the patient to the long board with straps.
15. Particular attention is made to documenting the patient’s neurologic condition before and
after splinting.
16. Document procedure and results, including any unusual circumstances and/or difficulties
encountered.
1.
2.
3.
4.
5.
6.
Movement of a supine patient to a long board using the scoop stretcher
1. Assure scene safety and observe universal precautions (see guideline #107).
2. Maintain cervical stabilization.
3. Adjust stretcher length to the height of the patient.
End page
Spine stabilization, (cont.)
4. Release stretcher locks and separate into two sections, one on each side of the patient.
5. Slide stretcher halves under the patient without disturbing spinal alignment.
6. Close and lock the head end of the scoop stretcher.
7. Close and lock the foot end of the scoop stretcher, taking care not to pinch the patient.
8. Maintain head stabilization while patient is lifted onto the long board.
9. Open the foot end of the scoop stretcher.
10. Open the head end of the scoop stretcher.
11. Remove scoop stretcher without disturbing spinal alignment.
12. Position and secure the Cervical Immobilizer.
13. Secure the patient to the long board with straps.
14. Particular attention is made to documenting the patient’s neurologic condition before and
after splinting.
15. Document procedure and results, including any unusual circumstances and/or difficulties
encountered.
Long roll to long board - prone patient
Assure scene safety and observe universal precautions (see guideline #107).
Maintain cervical stabilization.
A minimum of 3 people knowledgeable in the technique are needed.
First rescuer maintains cervical stabilization and directs the team in patient movement.
Patient should be rolled so that the occiput of the patient’s head is down during the turn.
The long board is placed between the rescuers and the patient with the board next to the
back of the patient’s head and rescuer’s kneeling on the board.
7. Second rescuer kneels at the shoulder of the patient, raising the patient’s arm nearest to
self up along side the patient’s head and grasping the patient’s furthest shoulder and
waist.
8. Third rescuer kneels on the same side of the patient at the hip level, grasping the furthest
hip and thigh.
9. First rescuer gives signal to turn the patient toward the kneeling rescuers, maintaining
spinal alignment.
10. First rescuer gives signal to center the patient on the long board if necessary, using
gentle even motion and maintaining spinal alignment.
11. Place patient’s arms at his/her side.
12. Apply rigid cervical collar without disturbing cervical stabilization.
13. Position and secure the Cervical Immobilizer.
14. Secure the patient to the long board with straps.
15. Particular attention is made to documenting the patient’s neurologic condition before and
after splinting.
16. Document procedure and results, including any unusual circumstances and/or difficulties
encountered.
1.
2.
3.
4.
5.
6.
Application of the Cervical Immobilizer
1. Assure scene safety and observe universal precautions (see guideline #107).
2. Place patient on long board as outlined above.
3. Place cervical immobilizer under the patient’s head with the occipital cushion under the
back of the head and the patient’s head positioned as recommended by the manufacturer
of the device.
4. Pad as necessary behind the neck to maintain neutral position.
5. Wrap the side panels of the device up against the head, rescuer holding cervical
stabilization holds them in place.
6. Secure the patient’s head to the device using hoop-loop fasteners or tape as supplied by
the manufacturer.
End page
Spine stabilization, (cont.)
7. Secure the device to the long board, using the system supplied by the manufacturer.
8. Document the patient’s neurologic condition before and after splinting.
9. Document procedure and results, including any unusual circumstances and/or difficulties
encountered.
Recognize/verbalize advantages of spinal stabilization:
 Prevent further injury
Recognize/verbalize disadvantages of spinal stabilization:
 Immobilizes patient supine. Airway is easily compromised if patient vomits for
secretions/blood are present in the upper airway
 Straps may restrict respiratory effort
Recognize/verbalize complications of spinal stabilization:

None
Recognize/verbalize contraindication to spinal stabilization:

None
END
Note: State of Wisconsin Standards and Procedures of Practical Skills Manual (July
2008 Rev) is appended and contains step-by-step instructions for Long Spineboard,
Standing Patient; Sling Long Spineboard; Straddle Slide Rapid Extrication and Horse
Collar Extrication. See index for page numbers.
GUIDELINE FOR PRACTICAL SKILL
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 5006
The following content will be considered the Guideline/Standard for:
BOARD SPLINT
Approved for use
by:
EMT
Advanced EMT
XX
XX
EMTIntermediate
XX
EMTParamedic
XX
PURPOSE
To provide rigid splinting for a suspected fracture in an extremity
EQUIPMENT
Padded or rigid board
Dressing/bandage material
Kling or Kerlix
Personal protective equipment to prevent exposure to blood/body fluids
PROCEDURE
1. Assure scene safety and observe universal precautions (see guideline #107).
2. Cover any open wound with a sterile dressing, control bleeding; support fracture site
during process. (see guideline # 5001)
3. Check distal pulse, sensation and movement.
4. Straighten any severe angulation with gentle longitudinal traction above and below break
and maintain traction while splint is applied and fixed in place by second rescuer.
5. If resistance is felt when attempting to straighten, stop attempt and splint in position
found.
6. Apply rigid splint to the extremity, extending from the joint above through the joint
below the fracture site.
7. Maintain hand in position of function.
8. Secure splint to extremity with bandage.
9. Check distal circulation, sensation and movement after splinting and frequently
thereafter.
10. Loosen bandages on splint if necessary to maintain circulation.
11. May use sling and swathe to further support upper extremity. (see guideline # 5009)
12. Document procedure and results, including any unusual circumstances and/or difficulties
encountered.
Recognize/verbalize the fractures/injuries appropriately treated with a board splint:

Radius
Wrist
 Ulna
 Midshaft humerus
 Tibia/fibula
End page

Board splint (cont.)
Recognize/verbalize advantages of the board splint:


Easy to apply
Readily available (armboards)
Recognize/verbalize disadvantages of the board splint:

Soft tissue swelling can cause bandages holding the board in place to become too tight
and restrict peripheral circulation
Recognize/verbalize complications of the board splint:

None
Recognize/verbalize contraindication to the board splint:

None
END
Note: State of Wisconsin Standards and Procedures of Practical Skills Manual (July
2008 Rev) is appended and contains step-by-step instructions for: ankle and foot, arm,
clavicle, elbow, femur, forearm, hand, hip, humerus knee, leg, pelvis, radius/ulna,
scapula, tibia/fibula and wrist injuries. See index for page numbers.
GUIDELINE FOR PRACTICAL SKILL
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 5007
The following content will be considered the Guideline/Standard for:
RIGID BOARD SPLINT FOR JOINT INJURY
Approved for use
by:
EMT
Advanced EMT
XX
XX
EMTIntermediate
XX
EMTParamedic
XX
PURPOSE
To provide rigid stabilization of a suspected joint fracture
EQUIPMENT
Padded or rigid splint
Dressing/bandage material
Kling, Kerlix or cravats
Personal protective equipment to prevent exposure to blood/body fluids
PROCEDURE
1. Assure scene safety and observe universal precautions (see guideline #107).
2. Cover any open wound with a sterile dressing and control bleeding/ support fracture
during process. (see guideline # 5001)
3. Check distal pulse, sensation and movement.
4. Apply padded/rigid splint across joint from bone above to bone below joint to form a
triangle.
5. Secure both ends of the splint to the extremity on each side of the joint.
6. Check distal circulation, sensation and movement after splinting and frequently
thereafter.
7. Loosen bandaging, cravats if necessary to maintain circulation.
8. May use sling and swathe to further stabilize upper extremity. (see guideline # 5009)
9. Document procedure and results, including any unusual circumstances and/or difficulties
encountered.
Recognize/verbalize the fractures/injuries appropriately treated with a rigid board splint
for a joint injury:
 Elbow
 Knee
Recognize/verbalize advantages of the board splint:
 Easy to apply
 Readily available (armboards)
Recognize/verbalize disadvantages of the board splint:
 Soft tissue swelling can cause bandages holding the board in place to become too tight
and restrict peripheral circulation
End page
Board splints (cont.)
Recognize/verbalize complications of the board splint:
 None
Recognize/verbalize contraindication to the board splint:
 None
END
GUIDELINE FOR PRACTICAL SKILL
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 5008
The following content will be considered the Guideline/Standard for:
PRO SPLINTS
Approved for use
by:
EMT
Advanced EMT
XX
XX
EMTIntermediate
XX
EMTParamedic
XX
PURPOSE
To provide rigid stabilization of a suspected fracture site
EQUIPMENT
Pro Splint
Dressing/bandage material
Personal protective equipment to prevent exposure to blood/body fluids
PROCEDURE
1. Assure scene safety and observe universal precautions (see guideline #107).
2. Cover any open wound with a sterile dressing, control bleeding; support fracture site
during process. (see guideline # 5001)
3. Check distal pulse, sensation and movement.
4. Straighten any severe angulation with gentle longitudinal traction above and below break
and maintain traction while splint is applied and fixed in place by second rescuer.
5. If resistance is felt when attempting to straighten, stop attempt and splint in position
found.
6. Apply splint to the extremity, extending from the joint above through the joint below the
fracture site.
7. Secure splint to extremity with Velcro straps.
8. Check distal circulation, sensation and movement after splinting and frequently
thereafter.
9. Loosen straps on splint if necessary to maintain circulation.
10. May use sling and swathe to further stabilize upper extremity. (see guideline # 5009)
11. Document procedure and results, including any unusual circumstances and/or difficulties
encountered.
Recognize/verbalize the fractures/injuries appropriately treated with a Pro splint:
 Any upper or lower extremity injury as long as the splint extends from the joint below
through the joint above the fracture site.
Recognize/verbalize advantages of the Pro splint:
 Easy to apply
Recognize/verbalize disadvantages of the Pro splint:
 Soft tissue swelling can cause Velcro straps holding the splint in place to become too
tight and restrict peripheral circulation
End page
Pro splints (cont.)
Recognize/verbalize complications of the Pro splint:
 None
Recognize/verbalize contraindication to the Pro splint:
 None
END
GUIDELINE FOR PRACTICAL SKILL
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 5009
The following content will be considered the Guideline/Standard for:
SLING AND SWATHE
Approved for use
by:
EMT
Advanced EMT
XX
XX
EMTIntermediate
XX
EMTParamedic
XX
PURPOSE
To immobilize the shoulder girdle and upper extremity
EQUIPMENT
Cravats
Personal protective equipment to prevent exposure to blood/body fluids
PROCEDURE
1. Assure scene safety and observe universal precautions (see guideline #107).
2. Check distal circulation, sensation and movement.
3. Fold forearm of injured side across chest, hand slightly elevated toward the opposite
shoulder.
4. Place triangular bandage under and over the arm with the point at the elbow and two
ends tied around neck, knot should not be directly over the spine.
5. Pin or tie the pointed end to form a cup to support the elbow.
6. Leave fingers exposed to check circulation.
7. Wrap wide bandage/cravat around the injured arm and body as swathe to secure the
injured arm to the body.
8. Transport in a sitting or semi-sitting position if patient’s condition permits.
9. Check distal circulation, sensation and movement after splinting and frequently
thereafter. Loosen splint if necessary to maintain circulation.
10. Document procedure and results, including any unusual circumstances and/or difficulties
encountered.
Recognize/verbalize the fractures/injuries appropriately treated with a sling and swathe.
Clavicle
Humerus
Scapula
As a support for board splints on the elbow
Shoulder dislocation
Forearm or wrist
Rib Injuries
Recognize/verbalize advantages of the sling and swathe splint:
 Easy to apply
 Supports the shoulder girdle and upper extremity well
Recognize/verbalize disadvantages of the sling and swathe splint:
 Patient must be in a sitting position
 Does not provide rigid protection by itself
End page
Sling and swathe (cont.)
Recognize/verbalize complications of the sling and swathe splint:
 None
Recognize/verbalize contraindication to the sling and swathe splint:
 None
END
GUIDELINE FOR PRACTICAL SKILL
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 5010
The following content will be considered the Guideline/Standard for:
TRACTION SPLINTING
Approved for use
by:
EMT
Advanced EMT
XX
XX
EMTIntermediate
XX
EMTParamedic
XX
PURPOSE
To provide stabilization and anatomic position of a femur fracture
EQUIPMENT
Traction splint
Bandage/dressing material
Personal protective equipment to prevent exposure to blood/body fluids
PROCEDURE
1. Assure scene safety and observe universal precautions (see guideline #107).
First rescuer
2. Take position at the injured extremity out of the way of the person applying the splint
3. Assess circulation and sensation distal to the fracture.
4. Grasp and support the calf just distal to the knee with one hand and the lower leg just
proximal to the ankle with the other hand. Allow sufficient space for application of the
ankle hitch.
5. Apply longitudinal traction with sufficient force to restore alignment of the injured thigh.
6. Maintain manual traction until traction is assumed by the splint.
Second rescuer
7. Apply countertraction if needed to assist in restoring alignment of the injured thigh.
8. Cover any open wound with a sterile dressing and control bleeding.
9. Adjust the length of the splint to the patient, measuring against the uninjured leg, lock
splint.
10. Position the leg support straps on the splint along its length with 2 straps proximal to the
knee and 2 distal.
11. Release the traction mechanism of the splint and extend the traction strap.
12. Remove the patient’s shoe and assess circulation.
13. Position the splint under the injured extremity, sliding it in from the foot.
14. Extend heel stand to support splint.
15. Verify that the ischial pad is against the ischial tuberosity.
16. Secure the groin strap, taking care not to pinch the external genitalia.
17. Position the padded ankle hitch on the patient’s ankle so as to maintain the foot at right
angle to the leg when traction is applied.
18. Attach traction mechanism to the ankle hitch.
End page
Traction splinting, (cont.)
19. Tighten the traction mechanism until:
a. First rescuer reports that the mechanical traction equals manual traction or
b. Patient acknowledges pain relief or
c. Loss of distal pulses (loosen traction mechanism until pulses return).
20. Adjust the limb support straps with two proximal to the knee, one distal to the knee and
one just proximal to the ankle hitch.
21. Secure the limb support straps.
22. Assess circulation, sensation and movement after splint application and frequently
thereafter.
23. Document procedure and results, including any unusual circumstances and/or difficulties
encountered.
Recognize/verbalize the fractures/injuries appropriately treated with a traction splint:

Isolated midshaft femur fractures
Recognize/verbalize advantages of the traction splint:


Decrease pain, muscle spasm
Prevent further damage
Recognize/verbalize disadvantages of the traction splint:

Time to apply may extend field time on the multiple trauma patient
Recognize/verbalize complications of the traction splint:

Straps holding the splint in place may become tight enough to restrict peripheral
circulation if soft tissue swelling occurs
Recognize/verbalize contraindication to the traction splint:




Fracture/Dislocation of the knee or ankle
Hip fracture/dislocation
Pelvic injuries
Tibia-fibula fractures
END
Note: State of Wisconsin Standards and Procedures of Practical Skills Manual (July 2008 Rev) is appended and
contains step-by-step instructions for Sager and Kendrick traction splints. See index for page numbers.
GUIDELINE FOR PRACTICAL SKILL
Initial Date:
12/05/2002
Service Director’s
Signature
Medical Director’s
Signature
Last/Review, Revision: 1/1/09
Guideline Number: 5011
The following content will be considered the Guideline/Standard for:
THORACIC INJURIES
Approved for use
by:
EMT
Advanced EMT
XX
XX
EMTIntermediate
XX
EMTParamedic
XX
PURPOSE:

To provide appropriate splint/bandaging/dressing for thoracic injuries
EQUIPMENT





Occlusive dressing
Tape
Liter IV bag or object of similar size, weight and compliance
Equipment for endotracheal intubation (see guideline 2009)
Personal protective equipment to prevent exposure to blood or body fluids
PROCEDURE
Flail Chest
1. Complete initial patient assessment and mitigate any immediate life-threatening
problems.
2. Use a gloved hand to manually stabilize the flail segment, preventing paradoxical
movement of the chest.
3. If any soft tissue injury over the flail segment, cover with sterile dressing.
4. Place a liter bag or appropriate pressure dressing (on an adult) over the flail segment and
tape in place. Avoid circumferential binding of the chest wall.
5. Provide oxygen and assist ventilations as necessary.
6. For patients who are unresponsive without a gag reflex, endotracheal intubation and
positive pressure ventilation may be substituted for the weighted bag.
Penetrating injuries
1. Complete initial patient assessment and mitigate any immediate life-threatening
problems.
2. If a foreign object is impaled in the wound, it should be stabilized in place.
3. If an open thoracic wound is present, cover it with an occlusive dressing, secured on 3
sides. (note: if using a commercial device, follow manufacturer’s directions)
4. Carefully observe for signs/symptoms of a tension pneumothorax. If signs/symptoms
appear, consider removing the dressing and/or performing thoracic decompression (see
guideline 2015.)
End page
Thoracic injuries (cont.)
Recognize/verbalize advantages of stabilization of flail segment:

Prevents paradoxical movement of the chest wall during breathing which interferes with
normal pressure changes inside the chest. Without normal pressure changes, movement
of air and blood flow in the chest is compromised.
Recognize/verbalize advantages of closing open thoracic wounds:

May prevent sucking chest wound and development of tension pneumothorax
Recognize/verbalize disadvantages of stabilization of flail segment:

None if the flail segment is present
Recognize/verbalize disadvantages of closing open thoracic wounds:

May develop tension pneumothorax
Recognize/verbalize complications of stabilization of flail segment:


Those of endotracheal intubation and positive pressure ventilation
If done improperly or with too much pressure, can restrict breathing or cause further
internal damage
Recognize/verbalize complications of closing open thoracic wounds:

Tension pneumothorax may develop
Recognize/verbalize contraindication to stabilization of flail segment

None if the condition is present
Recognize/verbalize contraindications to closing open thoracic wounds:

None if the condition is present
Recognize/verbalize signs/symptoms of tension pneumothorax:





END
Restless, agitated
Increased resistance to ventilation
Jugular vein distention
Decreased or absent breath sounds on the affected side
Hypotension
GUIDELINE FOR PRACTICAL SKILL
Initial Date:
12/06/2002
Service Director’s
Signature
Medical Director’s
Signature
Last/Review, Revision: 1/1/09
Guideline Number: 5012
The following content will be considered the Guideline/Standard for:
HELMET REMOVAL
Approved for use
by:
EMT
Advanced EMT
XX
XX
EMTIntermediate
XX
EMTParamedic
XX
PURPOSE:

Removal of head-protecting helmet in an injured patient while maintaining in-line spinal
stabilization
EQUIPMENT


Spinal immobilization (see guideline 5005)
Personal protective equipment to prevent exposure to blood or body fluid
PROCEDURE
1. Rescuer 1 immobilizes the helmet and head in an in-line position by pressing his/her
palms on each side of the helmet with the fingertips curled over its lower margin.
2. Rescuer 2 removes the face shield and chin strap, assessing the patient airway and
ventilatory status.
3. Rescuer 2 grasps the patient’s mandible by placing the thumb at the angle of the
mandible on one side and two fingers at the angle on the other side. Rescuer 2’s other
hand is placed under the neck at the base of the skill, taking over in-line stabilization of
the patient’s head.
4. Rescuer 1 carefully spreads the sides of the helmet away from the patient’s head and ears.
The helmet is then rotated toward the rescuer to clear the patient’s nose and removed
from the patient’s head in a straight line. Just before removing the helmet from under the
patient’s head, rescuer 1 assumes in-line immobilization by squeezing the sides of the
helmet against the patient’s head.
5. Rescuer 2 repositions his or her hands to support the head and to prevent it from dropping
as the helmet is completely removed by placing a hand further up on the occipital area of
the head and by grasping the maxilla with the thumb and first fingers of the other hand on
each side of the nose. After this position is secured, rescuer 2 takes over in-line
stabilization.
6. Rescuer 1 rotates the helmet about 30 degrees, following the curvature of the patient’s
head. The helmet is completely removed by carefully pulling it in a straight line.
7. After removal of the helmet, rescuer 1 applies in-line stabilization and a rigid cervical
collar is applied.
8. Padding may be required under the occiput to fill the void after the helmet has been
removed.
Note: If other protective equipment is being worn (e.g. shoulder pads), care must be taken to
insure spinal alignment is maintained during the log roll and once the helmet is removed.
End page
Helmet removal (cont.)
Recognize/verbalize advantages of helmet removal:


Gain access and control of the patient’s airway
Accomplish spinal stabilization on standard long spineboard
Recognize/verbalize disadvantages of helmet removal:


Some cervical movement may be unavoidable.
The procedure requires 2 trained individuals to accomplish safely.
Recognize/verbalize complications of helmet removal:

Cervical spinal damage if excessive movement occurs.
Recognize/verbalize contraindication to helmet removal:
 Obvious death
 Impaled object involving the helmet
END
Note: State of Wisconsin Standards and Procedures of Practical Skills Manual (July
2008 Rev) is appended and contains step-by-step instructions for alternate method to
remove a full-face helmet. See index for page numbers.
GUIDELINE FOR PRACTICAL SKILL
Initial Date:
12/18/08
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision:
Guideline Number: 5013
The following content will be considered the Guideline/Standard for:
Tourniquet Application in Trauma
Approved for use
by:
EMT
Advanced EMT
xx
xx
EMTIntermediate
xx
EMTParamedic
xx
PURPOSE
Stop massive hemorrhage associated with penetrating extremity trauma or amputation not
controlled by constant direct pressure.
First line use in the tactical and disaster environment
***** All information in this procedure has been taken from the July 2008 Tactical Combat
Casualty Care (TCCC) Guideline as established by the US Military Committee on TCCC*****
EQUIPMENT
Commercially available and approve tourniquet device example: C.A.T® or SOF-T®
PROCEDURE
1. Assess scene safety (keep in mind in the tactical environment the scene may NOT be
safe, the intent is to rapidly evacuate to an area that provides substantial ballistic
protection. The risk/benefit of treat-in-place must be evaluated on a scene by scene basis.
2. Verify the patient has sustained an injury that may benefit from tourniquet application
(massive external blood loss or visualized extremity distension i.e. bilateral femur
fractures with the presence of shock or Traumatic Amputation.)
3. Ideally the tourniquet should be applied approximately 2-3 inches above the point of
injury on bare skin. In a dynamic tactical environment, the tourniquet can be applied as
high on the extremity as possible over the clothing if necessary. Remember: Direct
Pressure may be appropriate, but if it cannot be firmly and consistently applied, default to
tourniquet application.
4. The windlass of the chosen device must be tightened enough to visibly see the cessation
of bleeding (Ideally the distal pulse of the effected extremity should be absent). Do not
forget to secure the windlass to prevent unwanted loosening of the device.
5. The application of the tourniquet can be very painful; consider ALS pain control (see
guideline 112).
6.
7.
8.
9.
Very early notification of medical control is REQUIRED.
Constant assessment of the bleeding site must be done and documented.
Never remove the tourniquet once applied.
If Bleeding is not successfully controlled with one tourniquet, consider the application of
a second right next to the first, making sure to offset the windlass as to not tangle the
devices.
Recognize/verbalize advantages of Tourniquet Application
 Rapid control of massive extremity hemorrhage
 Increased success of hemorrhage control over direct pressure, related to better
consistent overall circumferential pressure on the bleeding vessel
 Greater time saving over conventional hemorrhage control especially in a tactical and
disaster environment
End page 1
Recognize/verbalize disadvantages of Tourniquet Application
 Additional education must be obtained prior to implementation and use of device,
Improper application may increase negative outcome of patient
Recognize/verbalize complications of Tourniquet Application
 Prolonged application greater than 6 hours has been associated with increase
incidence of limb damage
 Prolonged application greater than 6 hours has been associated with increase
incidence of systemic rhabdomyolysis, especially in “Crush Syndrome”
Recognize/verbalize contraindication to Tourniquet Application
 Application to patient who is not in need of massive hemorrhage control
 Application to wound in an anatomical location that is not compressible by a
tourniquet
 Application to wounds that could be controlled by direct pressure
END
GUIDELINE FOR PRACTICAL SKILL
Initial Date:
12/18/08
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision:
Guideline Number: 5014
The following content will be considered the Guideline/Standard for:
Use of Hemostatic Dressing in Trauma
Approved for use
by:
EMT
Advanced EMT
xx
xx
EMTIntermediate
xx
EMTParamedic
xx
PURPOSE
Stop massive hemorrhage associated with trauma
Second line agent for the control of Massive Hemorrhage not controlled by or anatomically
amenable to application of a tourniquet
Especially important consideration in the Tactical and Disaster Environment
Hemostatic Dressings have been designed to control massive bleeding at the site of the vessel
either through +/- charges or by literally using their chemical make-up to create a clot.
EQUIPMENT
Commercially available Hemostatic Dressings: Combat Gauze®, Celox gauze® or Quick Clot
ACS® are currently recommended.
PROCEDURE
1. Assess Scene Safety (keep in mind the tactical scene may NOT be safe, the intent is to
rapidly evacuate to an area that provides substantial ballistic protection. The risk/benefit
of treat-in-place must be evaluated on a scene by scene basis.
2. Verify patient has sustained a traumatic injury that may benefit from the use of a
Hemostatic Dressing (i.e. penetrating trauma, severe lacerations, scalp lacerations and
hemorrhage that cannot be controlled by conventional means, direct pressure and or
pressure dressings).
3. Hemostatic dressings should also be considered for wounds that are not amenable to
tourniquet application (i.e. High Groin or Armpit wounds).
4. Gauze-type Hemostatic agents work well for superficial injuries and deep penetrating
injuries.
5. Once wound is identified, apply immediate firm direct pressure while preparing your
Hemostatic Agent
6. Remove direct pressure, and wrap or pack the wound. If a cavity is identified, the agent
must ‘Packed to the Bone” meaning the Hemostatic agent must be deeply packed to reach
the site of bleeding.
7. Very firm direct pressure must be applied for 3 minutes, at which time the wound should
be assessed for cessation of bleeding. If bleeding continues, remove Hemostatic agent
and reapply. (Repeat steps 5-7).
8. Once bleeding is controlled, the wound should be dressed with a pressure-type dressing.
9. Assess and treat the patient for signs of shock (see guideline #505).
10. The process for addressing a wound with a Hemostatic Agent should NOT affect
transport time.
Recognize/verbalize advantages of Hemostatic Dressings
 Rapid treatment of moderate to severe hemorrhage
 Ease of application, minimal education
 Nearly 100% efficacy
 No systemic effects
End page 1
Recognize/verbalize disadvantages of Hemostatic Dressing
 None
Recognize/verbalize complications of Hemostatic Dressings
 None
Recognize/verbalize contraindication to Hemostatic Dressings
 Application to a patient who is not in need of a Hemostatic Dressings
END
GUIDELINE FOR PRACTICAL SKILL
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 6001
The following content will be considered the Guideline/Standard for:
OBSTETRICAL DELIVERY AND COMPLICATIONS
Approved for use
by:
EMT
Advanced EMT
XX
XX
EMTIntermediate
XX
EMTParamedic
XX
PURPOSE
To monitor and assist in the vaginal delivery of infants presenting cephalic (head first)
EQUIPMENT
Obstetrical kit
Containing bulb syringe, cord clamps, sterile scissors, receiving blanket, perineal pads
Sterile gloves
Standard airway and medication equipment
Intravenous fluids and administration sets
Personal protective equipment to prevent exposure to blood/body fluids
PROCEDURE (Cephalic presentation)
1. Assure scene safety and observe universal precautions (see guideline #107).
2. Evaluate the progress of labor to determine if delivery in the field in imminent. If not,
begin transport.
3. Begin transport regardless of the progress of labor for women whose history and/or
physical assessment indicate potential complications (vaginal bleeding, abnormal vital
signs, history of diabetes, etc.).
4. Position the mother supine with legs flexed on a bed, floor, or ambulance cot.
5. Protect the mother’s privacy.
6. Place absorbent material under the mother’s buttocks.
7. Evaluate vital signs and progress frequently. Begin transport if mother shows signs of:
a.
Hypertension
b.
Hypotension
c.
Tachycardia greater than 120/min
d.
Decrease in the frequency or intensity of contractions
e.
Contractions lasting longer than 70 seconds
f.
Vaginal bleeding.
8. Open obstetrical kit, maintaining sterility and aseptic technique.
9. Start IV of Normal Saline in the mother. Run at keep-open rate unless volume
replacement is indicated. (see guideline # 3002-3004)
Note: When expeditious transport is appropriate, intravenous lines should only be started when their need is critical.
10. Observe color/content of the amniotic fluid. Anticipate airway problems in the newborn
if meconium staining is present. (Suction airway prior to stimulating respiration).
11. Maintain a slight well-distributed pressure on the fetal head as it emerges to prevent
explosive delivery.
12. Wipe the infant’s face with sterile gauze pads and suction mouth, then nose when head is
delivered. (see guideline # 2002)
13. Clear any fetal membranes away from the infant’s nose and mouth.
Obstetrics, (cont.)
14. Check for a cord loop around the infant’s neck. If noted:
a.
Loosen cord and slip over newborn’s head
b.
If cord cannot be loosened, place two clamps on the cord and cut
between the clamps.
15. Gently guide the baby’s head downward to deliver the top shoulder.
16. Gently guide the baby’s head upward to deliver the bottom shoulder.
17. Maintain secure grip on infant as body is delivered.
18. Complete newborn assessment and care.
19. Record time of birth and sex of infant.
20. Evaluate the newborn using the Apgar score at one minute and again at five minutes
after birth, document findings. (see guideline # 6002)
21. Place 2 clamps the first 10 inches from the baby and the second 7 inches from the baby.
22. Cut the umbilical cord between the clamps.
23. Dry infant’s skin, wrap in warm, dry blankets. Cover the head, leaving the face exposed.
24. Do not pull on the umbilical cord to deliver the placenta. When cord lengthens and gush
of blood indicates placental separation, instruct mother to “push” to expel the placenta.
Note: Do not delay transport awaiting delivery of the placenta.
25. Place placenta in a plastic bag or basin and bring with mother and infant to the hospital.
26. Massage the “grapefruit size” uterus through the abdominal wall with a circular motion
to keep it firm, following delivery of the placenta. Place perineal pad over the vaginal
opening. Do not place anything in the vagina. Straighten the legs.
27. Continuously monitor mother and infant.
28. Document procedure and results, including any unusual circumstances and/or difficulties
encountered. Both mother and infant need completed patient care reports.
Obstetrical Complications
BREECH PRESENTATION
1. Assure scene safety and observe universal precautions (see guideline #107).
2. Provide high flow oxygen to the mother.
3. Begin transport as soon as possible, notify receiving hospital placing mother in a headdown position with the pelvis elevated.
4. Open obstetrical kit, maintaining sterility.
5. Do not pull on the presenting part.
6. Support the infant’s trunk as shoulders deliver.
7. Encourage the mother to continue to “push”.
8. When arms have delivered, if head does not deliver within 3 minutes, lift the fetal body
and attempt to bring the infant’s face into the perineal opening to create an airway.
9. If the infant is delivered, provide appropriate newborn care. (see guideline # 6002)
10. Continue to monitor and evaluate condition of mother and infant.
11. Document procedure and results, including any unusual circumstances and/or difficulties
encountered.
Limb PRESENTATION
1. Assure scene safety and observe universal precautions (see guideline #107).
2. Provide high flow oxygen to the mother.
3. Begin transport as soon as possible, notify receiving hospital placing mother in a headdown position with the pelvis elevated.
4. Continue to monitor and evaluate condition of mother and infant; be alert for prolapsed
cord.
5. Document procedure and results, including any unusual circumstances and/or difficulties
encountered.
End page
Obstetrics (cont.)
PROLAPSED CORD
1. Assure scene safety and observe universal precautions (see guideline #107).
2. Provide high flow oxygen to the mother.
3. Begin transport as soon as possible, notify receiving hospital.
4. Place mother in a head-down position with the pelvis elevated.
5. Check for a pulse in the cord. If the pulse is present and greater than 100/min, continue
transport and monitor cord pulse.
6. If pulse in cord is less than100/min or absent, insert sterile-gloved hand into the vagina
and hold the presenting part to avoid compression of the cord. Direction and force of
pressure on infant may have to be changed to achieve or maintain pulse.
7. Transport to a facility capable of emergency cesarean section.
8. Wrap the exposed cord using a sterile towel from the OB kit to keep the cord moist and
warm.
9. Continue to monitor and evaluate condition of mother and infant.
10. Document procedure and results, including any unusual circumstances and/or difficulties
encountered.
1.
2.
3.
4.
5.
6.
1.
2.
3.
4.
5.
6.
END
MULTIPLE BIRTHS
Assure scene safety and observe universal precautions (see guideline #107).
Provide high flow oxygen to the mother.
Begin transport as soon as possible, notify receiving hospital.
If deliver is imminent, perform procedures as for cephalic or breech presentation while
en route to the hospital. Clamp and cut the cord of the first baby before the second baby
is born. The second baby may be born either before or after the placenta is delivered.
Provide care for the babies, umbilical cords, placenta(s), and the mother as you would in
a single-baby delivery. The babies may have lower birth weights; special care should be
taken to prevent hypothermia.
Continue to monitor and evaluate condition of mother and infant.
Document procedure and results, including any unusual circumstances and/or difficulties
encountered.
PROLAPSED/BULGING AMNIOTIC SAC
Assure scene safety and observe universal precautions (see guideline #107).
Provide high flow oxygen to the mother.
Do NOT rupture the membranes. If the fetal head is not engaged, the cord may prolapse.
Place mother in Trendelenburg position, transport.
Continue to monitor and evaluate condition of mother and infant.
Document procedure and results, including any unusual circumstances and/or difficulties
encountered.
GUIDELINE FOR PRACTICAL SKILL
Initial Date:
11/01/01
Service Director’s
Signature
Medical Director’s
Signature
Last Review/Revision: 12/18/08
Guideline Number: 6002
The following content will be considered the Guideline/Standard for:
ASSESSMENT AND CARE OF A NEWBORN INFANT
Approved for use
by:
EMT
Advanced EMT
XX
XX
EMTIntermediate
XX
EMTParamedic
XX
PURPOSE
To assess and care for a newborn infant
EQUIPMENT
Stethoscope
Standard airway and medication kits; pediatric kit
Dry receiving blanket
Bulb syringe, DeLee mucous trap or meconium aspirator
Personal protective equipment to prevent exposure to blood/body fluids
PROCEDURE
1. Assure scene safety and observe universal precautions (see guideline #107).
2. At birth, lay the baby on his side with his head slightly lower than his body, to facilitate
drainage from the airway. Suction the mouth and nose again. Keep the infant at the same
level as the vagina until the umbilical cord stops pulsating. Cut the cord.
3. Assess breathing. If shallow, slow, or absent after 30 seconds, ventilate according to
AHA standards. Reassess after 30 seconds. If no change, continue with ventilations.
4. Assess heart rate. If <100 beats per minute, ventilate according to AHA standards. If
<60, initiate chest compressions 3:1 at a rate of 120 per minutes.
5. If infant has adequate respirations and a pulse rate >100 per minute, but exhibits
cyanosis of the face and/or torso, provided supplemental oxygen.
6. At one and five minutes after birth, calculate the Apgar score.
7. If Apgar score is 7-10, maintain warmth and monitor vital signs.
8. If Apgar score is 4-6, suction and stimulate the infant by tapping the soles of the feet and
rubbing the back.
9. If Apgar score is less than 4 or remains less than 6 after stimulation and suctioning,
begin CPR.
10. Monitor patency of nostrils (babies are obligate nose breathers).
11. If newborn must be positioned on back, place pad under shoulders. The large head size
in newborns will cause the head to flex and partially obstruct the airway if not
maintained in slight extension.
12. Meconium staining of amniotic fluid indicates potential small airway obstruction may be
present. DeLee suction or intubate and use the endotracheal tube to suction as necessary
before stimulating respirations.
13. Keep infant warm and dry, cover head with stocking cap. During transport:
a.
The stable newborn should be transported in a rear-facing car seat with a cap in
place (for warmth, to minimize heat loss) while taking appropriate warming
considerations.
b. The temperature in the ambulance should be raised (“light perspiration temperature
range for an adult”).
c. The newborn should have been dried and wrapped in dry, warm blankets as soon as
the initial assessments are complete.
d.
Warm packs should be placed outside the blankets but inside the car seat.
14. If the newborn’s pulse is less than 60/minute, begin chest compressions at 100/min.
15. The umbilical vein should be used for intravenous access if needed.
16. Document procedure and results, including any unusual circumstances and/or difficulties
encountered.
Recognize/verbalize criteria to calculate the Apgar score
CRITERIA
Appearance (color)
Pulse
Grimace (response to
suctioning)
Activity (muscle
tone)
Respiratory effort
END
APGAR SCORE
0 POINTS
1 POINT
Cyanotic
Body pink,
extremities cyanotic
Absent
less than100/min
None
Weak
2 POINTS
Pink
greater than 100/min
Vigorous
Limp
Weak
Vigorous
None
Slow, irregular
Strong, crying
Blank
State of Wisconsin
Department of Health Services
Emergency Medical Services Section
State of Wisconsin
Standards & Procedures of
Practical Skills Manual
July 2008
State of Wisconsin
Department of Health Services
Emergency Medical Services Section
This manual is intended to provide examples of tried and proven techniques of caring for patients with the various injuries or illnesses that EMS
personnel will encounter in the field. It does not provide the only method or technique that may be an acceptable approach in caring for an injury or
illness. However, since the various certification examinations used within the state are based on the current edition of this document as well as the
current edition of the US DOT National Standard Curriculum, the State of Wisconsin EMT Basic: A Practice-Based Approach to EMS Education and
the State of Wisconsin Scope of Practice, it is an advantage to use these skill procedures as the basis for practice. This is a consensus document,
endorsed by the EMS Training Centers, the Bureau of Local Public Health Practice and EMS of the Department of Health Services as well as the
EMS Physician Advisory Committee. Bureau of Local Public Health Practice and EMS, Wisconsin’s EMS State Medical Director, the EMS
Physician Advisory Committee, as well as regional and local physician medical direction are charged with developing and promulgating these
minimum standards of care for EMS providers
This manual contains descriptions of those skills included in the scope of practice for all EMS personnel. The scope of practice for each level of
provider, as defined by the EMS Section of the Bureau of Local Public Health Practice and EMS and local protocol, shall define which of these skills
may be used at each provider level.
State of Wisconsin – Standards & Procedures of Practical Skills
TABLE OF CONTENTS
SECTION 1 – ASSESSMENT TOOLS: BLOOD PRESSURE MEASUREMENT; PULSE OXIMETRY; BLOOD GLUCOSE MEASUREMENT
SECTION 2 – LIFTING AND MOVING PATIENTS
1
SECTION 3 – AIRWAY, RESPIRATORY MANAGEMENT AND OBSTRUCTED AIRWAY PROCEDURES
SECTION 4 – PATIENT ASSESSMENT 1
SECTION 5 – CARDIAC MANAGEMENT
1
SECTION 6 - MEDICATION PREPARATION AND ADMINISTRATION 1
SECTION 7 – MANAGEMENT OF SOFT TISSUE INJURIES
SECTION 8 – PNEUMATIC ANTI-SHOCK GARMENT 1
SECTION 9 – MUSCULOSKELETAL INJURIES
SECTION 10 – SPINAL INJURIES
1
GLOSSARY OF ABBREVIATIONS
G-11
1
1
1
1
State of Wisconsin – Standards & Procedures of Practical Skills
– ASSESSMENT TOOLS: BLOOD PRESSURE MEASUREMENT;
PULSE OXIMETRY; BLOOD GLUCOSE MEASUREMENT
TEACHING POINTS
OBJECTIVES:
1. To consistently obtain an accurate blood pressure measurement through the use of auscultory and
palpatory methods
2. To objectively measure the percent of circulating hemoglobin saturated with oxygen.
3. To accurately measure the blood glucose level through the use of a glucometer
I. BLOOD PRESSURE MEASUREMENT
IMPORTANT POINTS:
1. Correctly size and position the blood pressure cuff
2. Locate the brachial artery pulse in the antecubital space
3. Inflate the cuff 30 mm Hg above the point at which the pulse is lost
4. Deflate cuff proportionate to the rate of the pulse and record the results.
SKILL:
A. PALPATION METHOD
1. Position the patient with the arm at heart level
2.
Apply the cuff snugly around the extremity with the lower edge at least one (1) inch above the antecubital space with the cuff’s bladder centered
over the brachial artery
3.
4.
5.
6.
Palpate the brachial or radial pulse.
Inflate the blood pressure cuff to 30 mm Hg above the point at which the pulse disappears
Deflate cuff slowly while noting the reading at which the pulse is felt to return
Record systolic blood pressure as #/P
Revised: July 212008
Too large a cuff will give a false low
reading
Too small a cuff will give a false
high reading.
1
State of Wisconsin – Standards & Procedures of Practical Skills
B. AUSCULTORY METHOD
1. Position the patient with the arm at heart level
2. Apply the cuff snugly around the extremity with the lower edge at least one (1) inch above the
antecubital space and the cuff’s bladder centered over the brachial artery
3. Insert stethoscope earpieces in ears with earpieces pointing slightly forward: test diaphragm for
sound conduction by gently tapping on diaphragm
4. Palpate or auscultate brachial artery while inflating cuff to 30 mm Hg above the loss of pulse
5. Deflate cuff slowly with stethoscope diaphragm over brachial artery, noting the systolic and
diastolic pressures
II. PULSE OXIMETRY
Important Points:
1. Do not depend on oximeter reading alone to assess patient’s oxygenation status
SKILL:
A. Select and place the appropriate transducer on the patient (finger, toe, earlobe, etc.)
1. Clean site with alcohol wipe, if necessary
2. Tape around great toe or foot –pediatric patient
3. Tape across the bridge of the nose-pediatric transducer on adult patient.
B. Turn on monitor.
C. Verify that pulse reading on oximeter is equal to patient’s pulse.
D. Note and record reading
Revised: July 212008
The accuracy of the measurement
may be affected by low blood flow,
CO poisoning, nail polish, gel nails,
dirt, jaundice, pt. movement, bright
light. If pulse does not correlate with
the machine, the accuracy of the
reading should be questioned
A pediatric adhesive style transducer
can be utilized for an adult patient
when the finger does not provide a
reading. Adhere the transducer over
the bridge of the patients’ nose.
2
State of Wisconsin – Standards & Procedures of Practical Skills
III. BLOOD GLUCOSE MEASUREMENT
Important Points:
1. Use appropriate body substance isolation precautions
2. Record reading in mg/dL
3. Consider use on all patients with altered level of consciousness
4. Ensure unit is calibrated
5. Check expiration date on test strips
SKILL:
1. Prepare equipment (glucometer, lancet device, alcohol wipes, band-aid) in advance, according to
manufacturer’s recommendations
2. Clean finger with alcohol prep pad, allowing alcohol to dry for 30 seconds
3. Turn unit on
4. Confirm test strip code with glucometer display reading
5. Prick finger with lancet to obtain blood sample
6. Apply sample to test strip
7. Cover puncture site with band-aid if bleeding continues
8. Properly dispose of lancet
9. Note and record reading
Revised: July 212008
Protocols may suggest wiping away
first drop of blood, using second
drop for sample.
3
State of Wisconsin – Standards & Procedures of Practical Skills
TEACHING POINTS
– LIFTING AND MOVING PATIENTS
Ortho stretcher should be moved to this section as it is used for more than just spinal injury.
OBJECTIVES:
1. To provide mechanisms of patient movement and transport, which eliminate or minimize the potential for
further patient injury while providing a rate of transport of movement appropriate to existing emergency
conditions
2. To provide mechanisms of patient movement and transport, which provide the greatest degree of patient
and rescuer safety
SKILL:
EMERGENCY MOVES: When using emergency moves it is assumed the patient must be moved to
a position of relative safety immediately and no time is available to begin an assessment or
provide spinal immobilization
IMPORTANT POINTS:
1. The greatest danger in moving a patient quickly is the potential of aggravating a spine injury
2. Always pull in the direction of the long axis of the patient’s body
3. Do not pull a patient sideways; avoid bending or twisting the patient’s torso
4. The patient should be supine whenever possible
A. BLANKET DRAG
1. Place patient on blanket
2. Drag blanket in direction of long axis of patient’s body
a. Keep head as close to floor as possible
b. Move patient head first whenever possible
Only three emergency moves are
listed here; there are many more
acceptable emergency moves.
B. CLOTHES DRAG
1. Grasp patient’s clothing pulling from the neck or shoulder area
2. Drag in direction of the long axis of the patient’s body
a. Keep patient’s head as close to the floor as possible
b. Drag in direction of the long axis of the body
C. ONE-RESCUER DRAG
1. Place hands under the patient’s armpits from the back
2. Grasp the patient’s forearms and drag in the direction of the long axis of the body
Revised: July 21, 2008
1
State of Wisconsin – Standards & Procedures of Practical Skills
TEACHING POINTS
URGENT MOVES: Urgent moves are required when the patient must be moved quickly but adequate time
is available to perform an initial assessment and provide spinal immobilization precautions
IMPORTANT POINTS:
1. The greatest danger in moving a patient quickly is the potential of aggravating a spine injury
2. Always pull in the direction of the long axis of the patient’s body
3. Do not pull a patient sideways; avoid bending or twisting the patient’s torso
4. The patient should be supine whenever possible
D. RAPID EXTRICATION (Patient sitting in vehicle)
1. First rescuer brings cervical spine into neutral, in-line position and provides manual stabilization
2. Second rescuer applies cervical immobilization device (rigid cervical collar)
3. Third rescuer positions the foot-end of a long spineboard at the door opening, then moves to
opposite side of patient
4. Second rescuer supports and stabilizes the patient’s torso as the third rescuer frees the patient’s
legs
5. At the direction of the rescuer holding manual C-spine stabilization, the patient is rotated in
several short, coordinated moves until the patient’s back is in the open doorway and his/her legs
are on the seat
6. The end of the long spineboard is placed against the patient’s buttocks. Additional rescuers
support the opposite end of the board as the first and second rescuers lower the patient to the board
7. The second and third rescuers slide the patient into the proper position on the board in short
coordinated moves while the first rescuer maintains manual C-spine stabilization
8. First rescuer maintains manual stabilization as the patient is moved to a place of relative safety
Manual C-spine stabilization may
need to be transferred between
rescuers during body rotation
because of vehicle obstacles
E. HORSE COLLAR EXTRICATION (patient sitting)
OBJECTIVES:
1. To permit emergency extrication of a patient when their condition does not allow the time required to
apply full head and torso immobilization with a short extrication device
2. To permit emergency extrication in a hazardous situation (fire, haz/mat, etc)
3. To provide an alternative extrication technique when a short immobilization device is not available
4. To permit emergency patient movement when only one rescuer is available
SKILL:
1. Hold a full size cloth blanket diagonally at opposite corners: Loosely swing like a jump rope to make a
Revised: July 21, 2008
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State of Wisconsin – Standards & Procedures of Practical Skills
TEACHING POINTS
bulky, long cravat
2. Position the blanket for C-spine control and movement
a. Place the middle of the blanket behind the patient’s neck
b. Bring the ends over the shoulders
c. Cross the blanket in front of the chest
d. Pass the ends under the armpits
e. Cross the ends behind the patient’s back
3. Hold the blanket ends close to the armpits
4. Tilt the patient’s upper body to clear the doorframe as needed
5. Slide the patient off and lower into a sitting position onto the ground or directly on to a long spineboard
6. Lower the patient to a supine position
Manual C-spine stabilization may be
done if time and personnel allow
Hold the blanket snuggly against the
neck to provide support
Twisting the ends may provide better
stabilization and control of the
patient
NON-URGENT MOVES: Non-urgent moves are those moves, which are used when adequate time is
available to perform a thorough assessment and provide all appropriate immobilization precautions
F. DIRECT GROUND LIFT (no suspected spinal injury)
1. Two or three rescuers line up on one side of the patient
2. Rescuers kneel on one knee (preferably the same knee for all rescuers)
3. The rescuer at the head places one arm under the patient’s neck and shoulders while cradling the
patient’s head. S/he places the other hand under the patient’s lower back
4. The second rescuer places one arm under the patient’s knees and the other arm just above the
patient’s buttocks
5. If a third rescuer is available, s/he should place both arms under the patient’s waist and the other
rescuers should slide their arms either up to the mid-back or down to the buttocks as appropriate
6. On signal, the rescuers lift the patient to their knees and roll the patient toward their chests
7. On signal, the rescuers stand and move the patient to the stretcher
8. To lower the patient, the steps are reversed
G. EXTREMITY LIFT (no suspected spinal or extremity injuries – patient supine)
1. Properly position the stretcher beside the patient
2. One rescuer kneels at the patient’s head and one kneels at the patient’s side by the knees
3. The rescuer at the head places one hand under each of the patient’s shoulders while the rescuer at
the foot grasps the patients wrists and pulls the patient to a sitting position
4. The rescuer at the head slips his/her hands under the patient’s arms and grasps the patient’s wrists
5. The rescuer at the patient’s feet places his/her hands under the patient’s knees
6. Both rescuers move to a crouching position
Revised: July 21, 2008
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State of Wisconsin – Standards & Procedures of Practical Skills
TEACHING POINTS
7. Both rescuers stand simultaneously and move with the patient to the stretcher
H. SUPINE TRANSFER - Direct Carry
1. Position the stretcher perpendicular to the bed with the head end of the stretcher at the foot of the
bed or the foot end of the stretcher at the head of the bed
2. Both rescuers stand between bed and stretcher, facing patient
3. First rescuer slides arm under patient’s neck and cradles patient’s head and shoulders
4. Second rescuer slides hands under patient’s hips and lifts slightly
5. First rescuer slides other arm under patient’s back
6. Second rescuer places arms under hips and calves
7. Rescuers slide patient to edge of bed
8. On signal, patient is lifted and curled toward rescuer’s chests
9. Rescuers rotate and place patient gently on stretcher
I. SUPINE TRANSFER – Draw Sheet Method
1. Loosen bottom sheet beneath patient
2. Position stretcher next to and parallel to bed
3. Prepare stretcher and adjust to bed height
4. Rescuers then reach across stretcher and grasp sheet firmly at the patient’s head, chest, hips and
knees
5. On signal, slide the patient gently onto stretcher
If a transfer board is used, it should
be placed over the seam formed
between the stretcher and bed
J. STAND AND PIVOT (seated patient)
OBJECTIVES:
1. To move a seated patient to the cot
IMPORTANT POINTS:
1. The patient must be able to bear some weight
2. One or two rescuers may be used
3. Position the cot close to the patient with its height about the same as a chair seat
4. The cot must be stabilized to avoid movement
SKILL:
1. While facing the patient, grasp the patient by the waistband or under the armpits
2. On the rescuer’s count, assist the patient to a standing position
Revised: July 21, 2008
The patient may want to hold onto
the rescuer’s shoulders. If the patient
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State of Wisconsin – Standards & Procedures of Practical Skills
3. Assist the patient in turning (pivoting) so their posterior is toward the cot
4. Once the patient’s legs are touching the cot, lower the patient to a seated position
5. Position the patient on the cot
TEACHING POINTS
has footwear that will easily slide on
the floor’s surface, the rescuer may
need to stand toe-to-toe with the
patient to prevent slipping
Secure patient to device at chest,
thighs and legs. Secure hands as
appropriate.
K. EQUIPMENT MOVES:
1. Stair Chair- Follow manufacturer’s instructions for proper use
2. Stretchers – Follow manufacturer’s instructions for proper use
Revised: July 21, 2008
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State of Wisconsin – Standards & Procedures of Practical Skills
TEACHING POINTS
– AIRWAY AND RESPIRATORY MANAGEMENT
OBJECTIVES:
1. To create a properly functioning oxygen delivery system, through the assembly of individual
components, capable of providing appropriate oxygen concentrations for the purpose of patient
resuscitation and inhalation therapy
2. To provide the proper positioning of an unconscious patient for the purpose of maintaining patency
of the patient’s airway
3. To facilitate the patency of a patient’s airway through the use of basic and advanced airway adjuncts
4. To create a properly functioning suction system, through the assembly of individual system
components, capable of removing foreign materials, blood, fluids and bodily secretions from the
upper airway
5. To facilitate the removal of foreign body and/or displaced body tissues from the patient’s upper
airway through appropriate use of the Magill forceps and laryngoscope
6. To provide adequate resuscitation and/or ventilatory assistance through the use of adjunct airway
devices to include: the bag-valve-mask, pocket mask, and flow restricted oxygen powered
ventilation device (FROPVD)
GENERAL PRINCIPLES:
1. Use appropriate body substance isolation precautions
2. Always position the patient properly to assure an open airway
3. Open the airway using the head-tilt/chin lift or jaw thrust maneuvers
4. Modifications for maintaining the airway may be necessary due to the patient’s injuries and/or
condition
5. Confirm a patent airway by observing chest rise and fall, and air exchange
6. Artificial ventilation should never be delayed if airway adjuncts are not readily available
I. OXYGEN ADMINISTRATION/DISCONTINUANCE
IMPORTANT POINTS:
1. Oxygen cylinders must be handled carefully since the contents are under high pressure
2. Selection of a delivery device will depend on the patient’s condition
3. Regulators reduce the cylinder’s pressure to a safe level and regulate the flow of gas in liters per
minute
SKILL:
Revised: July 21, 2008
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State of Wisconsin – Standards & Procedures of Practical Skills
TEACHING POINTS
A. OXYGEN ADMINISTRATION
1. Identify oxygen cylinder by color, correct pin code and 100% USP marking
4. Remove protective cap or tape
5. Quickly open and close cylinder valve to “crack” so as to remove any impurities, which may
have accumulated on the mating surfaces between the tank and regulator
6. Attach regulator and flowmeter and insure a leakproof seal
7. Turn on cylinder and check pressure gauge to insure adequate pressure
8. Attach appropriate delivery device to flowmeter
9. Adjust flow control to deliver recommended level
10. Fit delivery device to patient
11. Check adequacy of flow to patient
Cylinders should retain a safe residual
volume of 500 psi or per local protocol
B. OXYGEN DISCONTINUANCE
1. Remove oxygen delivery device from patient
2. Shut off cylinder and bleed regulator
3. Return flowmeter control to “off” position
II. PATIENT POSITIONING (Non-trauma unresponsive patient)
IMPORTANT POINTS:
1. This position may be useful for maintaining a patent airway and preventing aspiration in patients
who are unable to properly protect their own airway
2. Airway, ventilations and vital signs should be monitored continuously
SKILL:
A. RECOVERY/LATERAL RECUMBANT POSITION
1. Roll the patient onto their side while supporting the head and neck
2. Flex uppermost leg and position knee to support weight
3. Position lower arm out behind patient or place lower arm and forearm under head for support
4. Position upper arm along side patient’s face to assist in supporting weight
5. Ease patient’s head back and jut chin to facilitate airway
III. OROPHARYNGEAL AIRWAY INSERTION (Unresponsive patient with no gag reflex)
IMPORTANT POINTS:
1. Use appropriate body substance isolation precautions
Revised: July 21, 2008
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State of Wisconsin – Standards & Procedures of Practical Skills
TEACHING POINTS
2. Always measure airway
3. Use jaw thrust without head-tilt for patients with possible cervical spine injury
4. Tongue depressor or similar device may be used to ease insertion
SKILL:
A. Select airway by measuring from the corner of the patient’s lips to the bottom of the earlobe or
angle of the jaw
B. Open mouth using cross-finger technique
C. Insert airway
1. Adult only – with tip pointing toward roof of mouth, insert airway until point touches soft
palette, rotate 180 degrees into position with flange resting against lips or teeth
2. Adult, child or infant – Using a tongue depressor or similar device. Move the patient’s
tongue forward and down. Insert airway in anatomical position so as to follow the normal
curvature of the oropharynx until the flange rests against the lips or teeth
D. Check for adequate air exchange
IV. NASOPHARYNGEAL AIRWAY INSERTION (Responsive or unresponsive patient)
IMPORTANT POINTS:
1. Use appropriate body substance isolation precautions
2. If resistance is felt, remove and try other nare
SKILL:
A. Visualize the nares and select a nasopharyngeal airway slightly smaller in diameter than the
patient’s largest nare
B. Size the device by measuring from the tip of the patient’s nose to the tip of the earlobe or angle
of the jaw
C. Lubricate the distal surface of the airway with water or a water soluble lubricant
D. Insert the airway into the nare
1. If placed in the right nare, insert so as to follow the normal anatomical curvature of the
nasopharynx with the bevel toward the septum. Direct it along the floor of the nose and into
the oropharynx
2. If placed in the left nare, invert the airway so the bevel of the airway follows the septum of
the nose. Once the tip of the airway reaches the nasopharynx, rotate the airway 180 degrees
to resume alignment with the normal anatomical curvature of the nasopharynx. Continue to
insert the airway into the oropharynx
Revised: July 21, 2008
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State of Wisconsin – Standards & Procedures of Practical Skills
TEACHING POINTS
E. Check for adequate air exchange
V. NON-VISUALIZED ADVANCED AIRWAY INSERTION
IMPORTANT POINTS:
1. Use appropriate body substance isolation precautions
2. Ventilate the patient per AHA guidelines for a minimum of thirty (30) seconds prior to attempting
placement.
3. Patient must have inadequate or absent breathing
4. Patient must not have a gag reflex and no foreign body airway obstruction
5. All contraindications for airway use must be considered prior to insertion
6. A maximum of thirty (30) seconds should be allowed for each airway attempt
7. A maximum of three (3) attempts per patient to place airway may be made
8. The patient should be ventilated per AHA guidelines for a minimum of thirty (30) seconds between
airway placement attempts
9. Definitive assurance of placement through proper auscultation of breath and gastric sounds must be
made.
10. Removal, when necessary, should not be delayed by repeated attempts to contact medical control
11. The ability to suction the airway must be constantly available when inserting or removing the airway
12. Obtaining baseline breath sounds prior to advanced airway placement can assist with evaluation of
tube placement
Gastric distention should be relieved by
using gentle pressure to the abdomen.
Suctioning of the oropharynx should be
done according to suctioning S and P.
SKILL:
A. ESOPHAGEAL-TRACHEAL COMBITUBE (ETC)
1. INSERTION
a. Reconfirm assessment of absent or inadequate breathing without a gag reflex
b. Determine cuff integrity
1) Inflate cuffs
2) Disconnect syringes
3) Carefully inspect pharyngeal and distal cuffs
4) Carefully inspect valves and pilot cuffs
5) Deflate both cuffs
Revised: July 21, 2008
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State of Wisconsin – Standards & Procedures of Practical Skills
TEACHING POINTS
c. Prepare all necessary accessories
1) Preset inflation syringes to 100 mL and 15 mL (For Small Adult [SA] Model – Preset
at 85 mL and 12 mL)
2) Bag-valve-mask with supplemental oxygen
3) Water soluble lubricant
4) Suction device
5) Stethoscope
d. Suction as necessary; inspect patient’s airway for obstructions, broken teeth, dentures,
dental appliances, tongue piercings or other items that could damage cuffs
e. Ventilate for a minimum of thirty (30) seconds
f. Lubricate airway with water soluble lubricant as necessary
g. Position the patient supine with head in the neutral position. Do not hyperextend the
patient’s head
h. Remove oropharyngeal or nasopharyngeal airway if previously inserted
i. Inspect patient’s airway for obstructions, broken teeth, dentures, dental appliances or
other items that could damage cuffs
j. While holding the patient’s tongue and lower jaw to facilitate insertion:
1) Insert Combitube airway following the normal anatomical curvature of the
oropharynx
2) Insert firmly but gently until the insertion markers (two black lines which encircle the
proximal end of the airway) are aligned on opposite sides of the patient’s teeth or
gums
(a) Do not use force – If airway does not insert easily, withdraw and reattempt
(b) Ventilate for a minimum of thirty (30) seconds between attempts
(c) Maximum of thirty (30) seconds for each attempt
(d) Maximum of three (3) attempts
(e) Suction as necessary between attempts
k. When Combitube is positioned
1) Inflate the pharyngeal cuff with 100 mL of air using large syringe (85 mL for Small
Adult [SA] Model) through line #1 (blue)
2) Insure Combitube has remained in proper position. (Combitube will move slightly
with inflation)
3) Remove syringe and insure pharyngeal cuff inflation has occurred by observing pilot
balloon
4) Inflate distal cuff with 15 mL of air using smaller syringe (12 mL for Small Adult
[SA] Model) through line #2 (white)
Revised: July 21, 2008
Use the tongue-jaw lift to open the airway.
Use appropriate C-spine stabilization in
cases of known or suspected trauma
Always be certain that both syringes stay
with the patient as long as s/he is intubated
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State of Wisconsin – Standards & Procedures of Practical Skills
5) Remove syringe and insure distal cuff inflation has occurred by observing pilot
balloon
l. Ventilate the patient
1) Attach bag-valve-mask (BVM) to primary tube #1 (blue) and ventilate patient
2) While ventilating, confirm tube placement by auscultation of breath and epigastric
sounds
(a) Assess breath and epigastric sounds
i. Esophageal placement
(1) Breath sounds present high axillary
(2) Breath sounds present bilaterally
(3) Epigastric sounds are absent
(4) Continue to ventilate through tube #1 (blue)
ii. Tracheal placement
(1) Breath sounds are not present high axillary
(2) Breath sounds are not present bilaterally
(3) Epigastric sounds are present
(4) Discontinue ventilation through primary tube #1 (blue)
(5) Ventilate through secondary tube #2 (clear)
(6) Reassess breath and epigastric sounds to confirm tracheal placement
iii. Unknown placement
(1) Breath sounds are not present high axillary
(2) Breath sounds are not present bilaterally
(3) Epigastric sounds are not present
(4) Deflate cuffs (blue then white)
(5) Reposition airway – withdrawing approximately ½ inch
(6) Reinflate cuffs with appropriate volume of air (blue then white)
(7) Begin ventilations through primary tube #1 (blue) and reassess breath
and epigastric sounds to confirm placement
(8) Ventilate as appropriate
iv. Placement remains unknown
(1) Follow removal procedures
(2) Ventilate patient for minimum of thirty (30) seconds
(3) Reattempt placement (maximum of three (3) attempts) starting at the
beginning of the insertion steps
2. REMOVAL
a. Contact medical control (local protocol)
Revised: July 21, 2008
TEACHING POINTS
with the Combitube
The presence of certain chest injuries (i.e.
pneumothorax, hemothorax, etc) will
result in absent or diminished breath
sounds on the affected side(s) even with
proper placement
Local protocols may alter the sequence in
which breath and epigastric sounds are
checked.
Regardless of the sequence order,
epigastric and bilateral breath sounds must
be assessed
Bilateral breath sounds, and/or epigastric
sounds, may or may not be present due to
reasons other than incorrect tube
placement
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State of Wisconsin – Standards & Procedures of Practical Skills
b. Prepare suction and emesis collection devices
c. Position patient in lateral recumbent position when feasible, observing appropriate Cspine precautions for trauma patients
d. Use large syringe to deflate cuff #1 (blue) until pilot balloon is completely deflated
e. Use small syringe to deflate cuff #2 (white) until pilot balloon is completely deflated
f. Immediately withdraw airway with a smooth and steady motion while maintaining
normal curvature of the pharynx
g. Suction as necessary
h. Monitor the patient’s airway and breathing closely
i. Provide high-flow oxygen via non-rebreather mask
j. Consider nasopharyngeal airway and assist ventilations as necessary
SKILL:
C. KING LTS-D ADVANCED AIRWAY
1. INSERTION
a. Reconfirm assessment of absent or inadequate breathing without a gag reflex
b. Determine correct size airway based on patient’s height
c. Determine cuff integrity
1) Inflate cuffs
2) Disconnect syringes
3) Carefully inspect pharyngeal and distal cuff
4) Carefully inspect valve and pilot cuff
5) Deflate cuffs
d. Prepare all necessary accessories
1) Preset inflation syringe to correct amount for device size
2) Bag-valve-mask with supplemental oxygen
3) Water soluble lubricant
4) Suction device
5) Stethoscope
e. Suction as necessary; inspect patient’s airway for obstructions, broken teeth, dentures,
dental appliances, tongue piercings or other items that could damage cuffs
f. Ventilate for a minimum of thirty (30) seconds
g. Lubricate airway with water soluble lubricant as necessary
h. Position the patient supine with head in the neutral or sniffing position. Do not
hyperextend the patient’s head
2. Normal Insertion
Revised: July 21, 2008
TEACHING POINTS
Expect that the patient will vomit
A chin lift or laryngoscope and tongue
depressor can be used to lift the tongue
anteriorly to allow easy advancement
Obese patient may need padding under
shoulders and upper back
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State of Wisconsin – Standards & Procedures of Practical Skills
a. Hold the King LTS-D at the connector with dominant hand
b. With non-dominant hand, hold mouth open and apply chin lift unless contraindicated by
C-spine precautions or patient position
c. Using a lateral approach, introduce the tip into the corner of the mouth
d. Advance the tip behind the base of the tongue while rotating the tube back to midline so
that the blue orientation line faces the chin of the patient
e. Without exerting excessive force, advance tube until base of connector is aligned with
teeth or gums
f. Deeper placement and subsequent retraction is preferred
g. When the King LTS-D is positioned
1) Inflate cuffs to volume sufficient to seal the airway
2) Attach ventilation device to the connector of the King LTS-D
3) At the same time, gently bag the patient and withdraw the King LTS-D until
ventilation is easy and free flowing
4) Readjust cuff inflation to “just seal” volume
5) Check breath sounds, epigastric sounds and chest rise and fall
3. Secure the airway
a. Disconnect the ventilation device
b. Aggressively tape the King LTS-D in the midline to the maxilla
c. Avoid taping over gastric access lumen
d. Reattach the ventilation device
4. Removal
a. Remove the King LTS-D when protective reflexes have returned
b. Contact medical control (local protocol)
c. Prepare suction and emesis collection devices – suction as indicated
d. Position patient in lateral recumbent position when feasible, observing appropriate Cspine precautions for trauma patients
e. Deflate cuffs
f. Immediately withdraw airway with a smooth and steady motion while maintaining
normal curvature of the pharynx
g. Monitor the patient’s airway and breathing closely
h. Provide high-flow oxygen via non-rebreather mask
i. Consider nasopharyngeal airway and assist ventilations as necessary
Revised: July 21, 2008
TEACHING POINTS
Important that the tip of the device be
maintained at midline to assure that the
distal tip is properly placed in the
hypopharynx/upper esophagus
During insertion, if tip is placed or
deflected laterally, it may enter the
periform fossa and will appear to bounce
back upon full insertion and release.
Insertion can be accomplished via a
midline approach by applying a chin lift
and sliding the distal tip along the palate
and into position in the hypopharynx –
head extension may be helpful
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State of Wisconsin – Standards & Procedures of Practical Skills
TEACHING POINTS
VI.
PHARYNGEAL SUCTION
IMPORTANT POINTS:
1. Use appropriate body substance isolation precautions
2. Always measure flexible catheter
3. Use cross-finger technique or tongue blade devices to prevent rescuer and/or patient injury
4. Apply suction after reaching insertion depth
5. Suction the mouth first, then the nose on infants
SKILL:
A. FLEXIBLE/RIGID TIP
1. Attach suction tip to suction device
2. Measure flexible catheter from tip of earlobe to corner of mouth to determine insertion
length
3. Switch on suction unit (or begin pumping) and insure suction is present
4. Open mouth using cross-finger technique or tongue blade device
5. Insert suction device to oropharynx with no suction at tip
6. Suction across oropharynx (maximum of 15 seconds for adult patient)
7. Remove device while maintaining suction
8. Flush system with water as necessary
9. Check for adequate air exchange
B. BULB SYRINGE (Infants)
1. Squeeze air from bulb prior to insertion
2. Gradually reduce pressure on bulb to provide suction while removing from nose or mouth
3. Check for adequate air exchange
4. Repeat as necessary
VII.
Do not lose sight of the distal tip of rigid
wands
For pediatric patients, shorter suction time
should be used.
LARYNGOSCOPE AND MAGILL FORCEPS
IMPORTANT POINTS:
1. Use appropriate body substance isolation precautions
2. The laryngoscope should never be pried or levered against the teeth
3. The Magill forceps should be held so the handle does not obstruct the view of the pharynx
4. This device is intended for use on unconscious patients
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State of Wisconsin – Standards & Procedures of Practical Skills
TEACHING POINTS
SKILL:
1. Choose appropriate-sized forceps, laryngoscope handle and blade
2. Assemble blade and handle, insure light is bright and tightly secured in the blade
3. Place the patient’s head in the “sniffing” position
4. Hold laryngoscope in left hand
A. Adult patient – Hold handle with entire hand
B. Infant patient – Hold handle with thumb, index and middle fingers
5. With the rescuer in the cephalic position, insert blade in right side of mouth and displace tongue to
left by moving blade to midline
6. In infant: Support chin with ring and little fingers of left hand for leverage
7. Lift tongue in direction of long axis of the handle without prying on teeth or gums
8. Visualize obstruction
9. Holding the Magill forceps in the right hand, remove obstruction
10. Visualize airway for further obstructions before removing laryngoscope blade
11. Check for adequate air exchange
Curved blades are to be used for foreign
body removal
IX. BAG-VALVE-MASK VENTILATION
IMPORTANT POINTS:
1. Use appropriate body substance isolation precautions
2. This technique should be used with supplemental oxygen to deliver high concentrations of oxygen
3. Inflate only enough to make visible chest rise
4. The bag-valve-mask may be used on patients who are not breathing or patients who are breathing
but not exchanging adequate amounts of air
5. This procedure should be performed as a two rescuer technique whenever possible
6. Appropriate C-spine considerations should be taken when managing patients with potential spinal
injuries
SKILL:
1. Select and insert appropriate airway adjunct
2. Select adult, pediatric or infant size bag-valve-mask and assemble components
3. Attach oxygen supply to bag-valve-mask; adjust oxygen supply to recommended level
4. Seal mask on patient’s face while maintaining head-tilt, chin-lift or attach to advanced airway
adjunct fitting
5. Squeeze bag, ventilating patient according to AHA guidelines
6. Observe chest rise and fall with each ventilation. If no chest rise, reassess equipment, technique and
Revised: July 21, 2008
Discuss pediatric pop-off valves
Do not delay ventilations to attach
supplemental oxygen
Use modified jaw thrust with C-spine
stabilization if potential for spinal injury
exists
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State of Wisconsin – Standards & Procedures of Practical Skills
TEACHING POINTS
patient
7. If two rescuers are available, one rescuer uses two hands to maintain the airway and mask seal,
while the second rescuer uses two hands to compress the bag to provide ventilations
X. FLOW-RESTRICTED, OXYGEN-POWERED VENTILATION DEVICE (FROPVD)
IMPORTANT POINTS:
1. Use appropriate body substance isolation precautions
2. Prolonged depression of ventilation button may result in gastric distention
3. Proper airway positioning minimizes the potential of gastric distention
4. The FROPVD is not recommended for use with pediatric or chest trauma patients
5. Must be reduced to deliver no more than 40 LPM of oxygen
6. May be used by spontaneously breathing patients
7. Follow local medical protocols governing the use of this device
8. Appropriate C-spine considerations should be taken when managing patients with potential spinal
injuries
SKILL:
1. Connect device to oxygen source
2. Open cylinder and check for leaks
3. Select and insert appropriate airway adjunct, if indicated
4. Press ventilation button to clear line and check operation
5. Seal mask on patient’s face while maintaining head-tilt, chin-lift or attach to advanced airway
adjunct fitting
6. Depress ventilation button until patient’s chest rises
7. Release ventilation button and observe patient’s exhalation
8. Ventilate per AHA guidelines
Use modified jaw thrust with C-spine
stabilization if potential for spinal injury
exists
XI. POCKET MASK
IMPORTANT POINTS:
1. Use appropriate body substance isolation precautions
2. Oxygen concentrations will be increased by attaching supplemental oxygen
3. Appropriate C-spine considerations should be taken when managing patients with potential spinal
injuries
Revised: July 21, 2008
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State of Wisconsin – Standards & Procedures of Practical Skills
TEACHING POINTS
SKILL:
1. Select and insert properly sized oropharyngeal or nasopharyngeal airway, if available
2. Unfold pocket mask as appropriate and attach one-way valve
3. If available, attach oxygen delivery tube to oxygen source and to mask inlet
4. Turn on oxygen and adjust liter flow to recommended level
5. While maintaining head-tilt, chin-lift, seal mask on patient’s face
6. Ventilate patient through one-way valve attached to mask until chest rises
7. Allow patient to exhale while maintaining mask seal to face
8. Ventilate per AHA guidelines
Revised: July 21, 2008
Do not delay ventilations to attach
supplemental oxygen
Use modified jaw thrust with C-spine
stabilization if potential for spinal injury
exists
Remove one-way valve when attaching
pocket mask to bag-valve device
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State of Wisconsin – Standards & Procedures of Practical Skills
TEACHING POINTS
– PATIENT ASSESSMENT
General Information:
The assessment process recognizes that trauma patients and medical patients have different assessment
priorities. Patients may be divided into four broad categories: Medical patients who are responsive; Medical
patients who are not responsive; Trauma patients with a significant mechanism of injury (MOI); and,
Trauma patients without a significant mechanism of injury. Trauma patients are assigned a category based
on severity, or potential severity, of their injuries. Medical patients, on the other hand, are assigned based
on their ability to participate, or not participate, in the assessment rather than on the severity of their
illnesses.
OBJECTIVES:
1. To determine the presence or absence of actual or potential hazards which pose a threat to the health and
safety of rescuers, patients or bystanders during rescuer operations and/or during transport
2. To determine the presence or absence of injury or illness through a systematic assessment process
incorporating inspection, auscultation, palpation, and the taking of a patient history
Safety is paramount throughout the
call
IMPORTANT POINTS:
1. Use appropriate body substance isolation precautions
2. ALWAYS conduct a scene size-up
3. If a scene is not safe, and cannot be made safe, do not enter
4. Always obtain a general impression of the patient and conduct an initial assessment of the patient’s
mental status, airway, breathing and circulation (including a visual check for life-threatening external
bleeding) no matter how stable a patient appears
5. Patients who are not responsive should include those with an altered mental status and those who are
unable to respond reliably or provide a history
6. Intervene immediately to correct any life-threatening problem
Remember: Any airway, breathing, circulation problem or severe external bleeding, which cannot be
managed during the initial assessment, mandates urgent transport with continued efforts to manage the
problem en route
7. A patient’s condition may deteriorate rapidly. Perform frequent reassessments of the patient’s mental
status, airway, breathing and circulation
8. If the patient becomes unstable at any time, immediately repeat the initial assessment
SKILL:
Revised: July 21, 2008
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State of Wisconsin – Standards & Procedures of Practical Skills
TEACHING POINTS
I. PATIENT ASSESSMENT
A. SCENE SIZE-UP
1. Determine the Nature of Illness (NOI) or Mechanism of Injury (MOI)
a. En route to scene:
1) Dispatch information
2) Other units at scene
b. Upon arrival at scene:
1) Inspect the scene
2) Patient, family, witnesses, bystanders, other rescuers
2. Use appropriate body substance isolation precautions
3. Determine whether the scene is safe
a. Environmental considerations
b. Social considerations
c. Crime scene considerations
d. Unruly or violent persons
e. Unstable surfaces
f. Other hazards
g. If the scene is not safe, make it safe, or do not enter
4. Determine the number of patients
5. Determine the need for, and request, additional resources prior to patient contact
B. INITIAL ASSESSMENT
1. Form a general impression of the patient as you approach, while telling the patient your first name
and explaining that you are an EMT
a. Establish approximate age
b. Establish gender
c. Identify chief complaint
d. Assess environment clues
Revised: July 21, 2008
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State of Wisconsin – Standards & Procedures of Practical Skills
TEACHING POINTS
2.
3.
4.
5.
6.
e. Identify any obvious life-threatening conditions requiring urgent intervention
f. Intervene immediately to correct any life-threatening conditions
Assess the patient’s mental status and provide C-spine stabilization as appropriate
a. Speak to the patient
b. Alert
Responds to Verbal stimuli
Responds to Painful stimuli
Unresponsive
Assess the patient’s airway
a. Is the patient talking or crying?
1) Yes: Assess breathing
2) No: Open airway
Assess the patient’s breathing
a. If the patient is not responsive, but breathing is adequate, open and maintain the airway and
initiate oxygen therapy
b. If the patient is not breathing adequately, open and maintain the airway, initiate oxygen
therapy, utilize appropriate adjuncts and/or assist ventilations
c. If the patient is not breathing, open and maintain the airway, utilize appropriate adjuncts and
ventilate with supplemental oxygen
Assess the patient’s circulation
a. Pulse - present
1) Less than one-year-old: Palpate the brachial artery
2) More than one-year-old and responsive: Palpate the radial artery
3) More than one-year-old and unresponsive; or more than one-year-old with absent radial
pulse: Palpate carotid pulse
b. If pulse - absent
1) Initiate CPR
2) Implement AED protocol as appropriate
c. Assess and control major external bleeding
d. Assess skin color, temperature and condition (Assess capillary refill in patients under six years
or age)
e. Expose the patient, as needed
f. Establish a field impression and differential diagnosis
Determine the patient’s transport priority, consider ALS back-up
Discuss normal rates and adequate
breathing for all age ranges.
C. FOCUSED HISTORY AND PHYSICAL EXAM
Revised: July 21, 2008
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State of Wisconsin – Standards & Procedures of Practical Skills
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1. Assign the patient to one of the four patient assessment categories to determine which of the
following items apply to that patient. The sequence in which these items are performed may
depend on circumstances, the number of available EMTs and the presence of life-threatening
problems requiring urgent intervention. Remember: The patient’s priority is constantly being
evaluated and subject to change
2. Reconsider NOI or MOI as necessary
3. Obtain a SAMPLE history
a. Signs and symptoms
b. Allergies
1) Medicines
2) Foods
3) Environmental
c. Medications
1) Prescriptions
2) Over-the-counter
3) Alternative medication, herbal supplements
d. Pertinent/past medical history
1) Heart disease
2) Diabetes
3) Seizures
4) Recent hospitalizations
5) Recent injuries
6) Medical patients: previous similar episodes
e. Last oral intake
f. Events leading to the injury or illness
Revised: July 21, 2008
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TEACHING POINTS
4. Assess baseline vital signs
a. Breathing - rate, rhythm and quality
b. Pulse - rate, rhythm and quality
c. Blood pressure
d. Pupils
e. Skin color and condition (Capillary refill under 6 years of age) – if not previously done
5. Perform an appropriate physical exam
a. Physical assessment conducted for a responsive medical patient or a trauma patient with no
significant mechanism of injury should be based on the patient’s chief complaint
b. Rapid trauma assessment or rapid assessment for unresponsive medical
1) DCAP/BTLS
2) While maintaining manual stabilization, apply cervical collar only after neck has been
assessed
3) Assess for obvious signs of trauma, plus:
a) Head: Crepitus
b) Neck: Jugular vein distention, crepitus
c) Chest: Paradoxical motion, crepitus, bilateral breath sounds (mid-axillary, midclavicular)
d) Abdomen: Rigidity, guarding, distention
e) Pelvis: Gently compress for pain or crepitus, inspect for incontinence, priapism
f) All extremities: Distal circulation, movement and sensation
4) Roll patient taking appropriate spinal precautions, and assess posterior
6. Assess history of present illness (OPQRST)
a. Onset
b. Provocation
c. Quality
d. Radiation
e. Severity
f. Time
7. Establish a management plan and initiate appropriate interventions
8. Reevaluate transport decision
Revised: July 21, 2008
OPQRST may be used for evaluating
pain associated with trauma injuries
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TEACHING POINTS
D. DETAILED PHYSICAL ASSESSMENT
1. Limited to the patient with a significant MOI or medical not responsive
2. Performed as time permits, in the ambulance, during transport
3. Repeat rapid trauma assessment with emphasis on:
a. Ears: Drainage or blood, cerebral spinal fluid
b. Eyes: Discoloration, equality, foreign bodies, blood in the anterior chamber
c. Nose: Drainage of blood or cerebral spinal fluid
d. Mouth: Loose or missing teeth, obstructions, soft tissue injuries
e. Careful evaluation for potentially subtle signs on trunk and extremities
E. ONGOING ASSESSMENT
1. Repeat initial assessment and reassess vital signs
a. At least every five minutes for urgent, unstable or deteriorating patients
b. At least every fifteen minutes for non-urgent, stable patients
c. Any time the patient’s condition is noted to change
2. Repeat focused assessment regarding patient’s chief complaint or injuries
3. Reevaluate effectiveness of interventions and patient response to treatment
a. Adequacy of oxygen delivery, assisted ventilations or artificial ventilations
b. Management of soft tissue injuries
c. Adequacy of other interventions
Revised: July 21, 2008
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State of Wisconsin – Standards & Procedures of Practical Skills
Revised: July 21, 2008
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State of Wisconsin – Standards & Procedures of Practical Skills
TEACHING POINTS
– CARDIAC MANAGEMENT
I. CARDIOPULMONARY RESUSCITATION
All Cardiopulmonary Resuscitation procedures shall be performed as directed in the current American
Heart Association guidelines
II. AUTOMATED EXTERNAL DEFIBRILLATION
All AED procedures shall be performed as directed in current American Heart Association guidelines in
concurrence with local protocols/ DHS Sample Approved protocol
Revised: July 21, 2008
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State of Wisconsin – Standards & Procedures of Practical Skills
TEACHING POINTS
- MEDICATION PREPARATION AND ADMINISTRATION
OBJECTIVES:
1. To prepare the appropriate delivery device for the purpose of administering medications
2. To prepare the appropriate delivery device for the purpose of administering fluids
3. To prepare the appropriate delivery device for the purpose of administering a medication via a
nebulizer
4. To administer medication enteral and parenteral routes
IMPORTANT POINTS:
1. Use appropriate body substance isolation precautions
2. Medication must be administered in compliance with local protocols and medical direction
3. A comprehensive assessment must be performed on all patients to whom medications will be
administered to determine:
 Indication for medication
 Contraindication(s) for medication
 Appropriate dose for patient
 Response to medication
4. All skills in this section assume the patient is being provided with supplemental oxygen as
appropriate
5. Before administering any medication, always be certain you have:
- The right patient
- The right medication
- The right dose
- The right time
- The right route
- The right documentation
6. Prior to medication preparation and delivery, inspect the medication to insure it:
 Contains the correct medication
 Contains the correct dose
 Has not expired
 Has not been contaminated in any manner. Non-intact packaging may indicate loss of
sterility
Revised: July 21, 2008
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7. Documentation should include (per local protocol):
- Medication
- Dose delivered
- Route
- Site/method
- Time given
- Physician ordering medication
- EMT delivering medication
I. ORAL, SUBLINGUAL AND BUCCAL MEDICATIONS
A. PREPARATION OF ORAL, SUBLINGUAL AND BUCCAL MEDICATIONS
1. Tablets
a.
b.
c.
d.
e.
Inspect the medication
Shake out the proper number of tablets to obtain the proper dose
Recheck the label for proper medication and dosage information
Give directions to patient for medication administration
The medication is now ready to be administered
2. Sublingual spray
a. Inspect the medication
b. Give directions to patient for medication administration
c. The medication is now ready to be administered
The tablets should be placed in the
lid of the medication bottle or an
appropriate container
The medication should be transferred
from the lid to the patient’s hand or
to the rescuer’s gloved hand for
administration
3. Buccal (between cheek and gum):
a. Inspect the medication
b. Give directions to patient for medication administration
c. The medication is now ready to be administered
B. ADMINISTRATION OF ORAL, SUBLINGUAL AND BUCCAL MEDICATIONS
1. Prepare medication as previously described in this section
2. Recheck medication label for the rights
3. Explain procedure to the patient:
a.
b.
c.
d.
Oral: Swallow the medication with a small amount of water
Chewed: Chew the medication and do not swallow for about 10 seconds
Sublingual: Place the medication under the tongue and do not swallow for 10 seconds
Sublingual spray: Spray on or under the tongue; be careful the patient does not inhale
medication
e. Buccal: Apply medication between patient’s cheek and gum
Revised: July 21, 2008
Buccal medication may be applied to
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State of Wisconsin – Standards & Procedures of Practical Skills
4. Give the medication to the patient to take or place medication in the patient’s mouth
5.
TEACHING POINTS
a tongue depressor for administration
Assure the medication is swallowed, chewed or dissolved
6. Document medication administration
7. Provide an ongoing assessment of your patient to identify any effects of the
medication
II. INHALED MEDICATIONS
A. PREPARATION OF INHALED MEDICATIONS
1. Metered dose inhaler
2.
a. Inspect the medication
b. Shake the inhaler canister vigorously
c. Wait 1-2 minutes between inhalations; shake canister before each inhalation
Nebulizer
a. Select a nebulizer delivery method
1) If using the hand held delivery, attach the reservoir hose and mouthpiece to opposite
ends of the “T” fitting
2) If using a mask delivery, use a nebulizer mask or remove the reservoir bag and the oneway valves (flaps) from a non-rebreather mask
b. Assemble the medication cup by screwing the top and bottom sections together
c. Inspect the medication
d. Place the ordered dose of medication(s) into the medication cup and attach it to the bottom
of the “T” fitting or mask
e. Attach the oxygen tubing to the inlet port of the medication cup. Attach the other end to
an oxygen source capable of delivering a 4-6 lpm flow
f. Turn on oxygen and adjust flow for best results
Revised: July 21, 2008
Choosing between the “T” piece and
mask is based on the patient’s ability
to hold the device and coordinate
inhalation and breathing technique
Most cups must be kept upright to
avoid spilling the medication
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State of Wisconsin – Standards & Procedures of Practical Skills
TEACHING POINTS
B. ADMINISTRATION OF INHALED MEDICATIONS
1. Metered dose inhaler
a. Inspect the medication
b. Verify the inhaler belongs to the patient
c. Shake the inhaler canister vigorously
d. Explain procedure to the patient:
1) Forcibly exhale
2) Place lips around the inhaler
3) Activate inhaler with deep inhalation
4) Hold breath as long as comfortably able
e. Remove supplemental oxygen from the patient if needed for the medication administration
f. Assist with medication administration as needed
g. Replace oxygen and encourage patient to take several deep breaths
h. Repeat steps c-g to obtain ordered dosage(s). Wait 1-2 minutes between inhalations
2. Nebulizer
a. Assemble nebulizer delivery device as previously described in this section
b. Recheck medication label for the rights
c. Explain procedure to the patient:
1) Seal lips around the mouthpiece of the hand held nebulizer or place mask on patient
2) Take slow breaths and inhale as deep as possible
3) Hold breath as long as comfortably able, up to 10 seconds
4) Continue until the medication is gone; there is no misting
d. Remove supplemental oxygen from patient
e. Start nebulizer with oxygen at 4-6 lpm – adjust until it makes a fine mist
f.
Encourage patient to take slow, deep breaths until the medicine is gone from the
medication cup
g. Replace supplemental oxygen when the treatment is completed
III.
The mist should "disappear" with
each breath. Much of the mist that
can actually be seen is too large to
actually be absorbed
Follow manufacturer’s
recommendation for liter flow
As the medication is administered
and the level drops in the medication
cup, the cup may need to be tapped
to deliver all the medication
INJECTABLE MEDICATIONS
IMPORTANT POINTS
1. Maintain sterility of needles and medication for injections
Revised: July 21, 2008
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TEACHING POINTS
2. Utilize safety engineered devices to minimize risk of needle sticks (mandatory except for auto-injectors)
3. Always ensure that all sharps are properly disposed of in a timely manner in an approved sharps disposal
container
4. Route of administration and size of the patient are used to determine the appropriate size needle
a. A 23- to 25-gauge, 5/8-inch-long needle is appropriate for subcutaneous injections.
b. The needle gauge for I.M. injections should be larger to accommodate viscous solutions and
suspension. Recommend 21G to 23G needles 1” to 2” in length
As a rule of thumb, a 200-lb (90-kg)
patient requires a longer needle (i.e.
2” ) for an IM injection; a 100-lb
(45-kg) patient will require a 11⁄4” to
11⁄2” needle
5. Pre-filled systems may have an air bubble that will need to be purged prior to medication administration
6. When drawing up medication from a vial or ampule, draw up a little extra that can be wasted when
purging air bubbles
7. Assure the proposed site for injection is free of inflammation, swelling, infection and any skin lesions
8. Never recap used needles
9. If blood is present when aspirating, withdraw the needle and discard the medication. Start over with new
medication and a new site
A. PREPARATION OF INJECTABLE MEDICATIONS
SYRINGE AND VIAL
1. Inspect the medication
2. Select an appropriate size syringe for the medication to be delivered
3. Remove the protective “flip-off” cap from the top of the vial
4. Wipe the rubber stopper with an alcohol prep or other suitable antiseptic swab
5. a. If reconstituting a medication:
1) Pierce the center of the medication vial’s stopper with the needle on the syringe of diluting
solution
2) Inject diluting solution
3) Remove the needle/syringe from the vial
4) Gently shake the vial to assure the medication dissolves
5) Continue with drawing up the medication with a new needle and syringe repeating steps
#1-4
b. If drawing a medication or diluting solution from a vial:
1) Draw up the same volume of air as the volume to be withdrawn
2) Pierce the center of the vial’s stopper with the needle on the syringe
3) Inject air
6. Holding the vial upside down in one hand and being careful to keep the end of the needle within
the fluid level of the vial, pull back gently on the plunger to draw the medication or diluting
Revised: July 21, 2008
Common practice is to use a larger
needle for drawing up the drug,
smaller needle for injecting
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State of Wisconsin – Standards & Procedures of Practical Skills
TEACHING POINTS
solution into the syringe
7. Withdraw the needle and syringe from the vial
8. Replace the needle with an appropriate size safety engineered needle for subcutaneous or IM
injections
9. With the needle pointing upward, gently tap the syringe to move any air bubbles to the top
For comfort, change the needle prior to
injection. Most needles have a fine
silicon coating to facilitate easy entry
into muscle mass. This may be lost
when drawing up the medication.
Also, literature has shown some rubber
stoppers to contain trace amounts of
latex that may cause a sensitivity
reaction
10. Gently depress the plunger of the syringe until air is expelled and only the desired amount of
medication remains in the syringe
11. The medication is now ready to be delivered
SYRINGE AND AMPULE
1. Inspect the medication
2. Select a syringe of appropriate size for the volume of medication to be delivered
3. Select a filter needle of appropriate size and length to withdraw the medication and attach to the
Also called a “filter straw”
syringe
4. Hold the ampule upright and gently “flick” it to move any medication trapped in the head of the
ampule to the base
5. Wipe the area between the head and base of the ampule with an alcohol prep or other suitable
antiseptic swab
6. Once the medication is removed from the head of the ampule, use a commercially available device Hold the ampule at arms length and
or a gauze square to grasp the head of the ampule and break the head from the base
break by snapping the top toward
you. This will cause any glass
shards to be directed away rather
than toward you when the ampule
breaks
If the ampule fails to break cleanly
and glass shards can be observed,
dispose of the ampule and replace
with another
7. Using the filter needle and syringe withdraw medication for administration. Discard any
Revised: July 21, 2008
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State of Wisconsin – Standards & Procedures of Practical Skills
TEACHING POINTS
remaining medication and properly dispose of both portions of the ampule in a sharps container
8. Remove the filter needle used to withdraw the medication from the ampule and properly dispose
of the filter needle in an sharps container
9. Replace the filter needle with an appropriate size safety engineered needle for subcutaneous or IM
injections
10. With the needle pointing upward, gently tap the syringe to move any air bubbles to the top of the
syringe
11. Gently depress the plunger of the syringe until air is expelled and only the desired amount of
medication remains in the syringe
12. The medication is now ready to be delivered
PRE-LOADED SYRINGES
1. Pre-filled Systems
a. Inspect the medication
b. Remove the protective caps from the medication cartridge and the barrel of the syringe
assembly
c. Insert the medication cartridge into the barrel assembly and rotate clockwise until the
medication cartridge is secure in the barrel. The medication cartridge is now the plunger
d. With the unit now fully assembled, remove the protector from the distal tip and gently depress
the plunger until air is expelled and only the desired amount of medication remains in the
syringe
e. Attach an appropriate size safety engineered needle for subcutaneous or IM injections
f. The medication is now ready to be delivered
2. Syringe Cartridge Systems (e.g. Carpuject and Tubex)
a. Inspect the medication cartridge
b. Insert and secure the syringe cartridge into the cartridge holder following the manufacturer’s
directions
c. Attach an appropriate size safety engineered needle for subcutaneous or IM injections
d. With the unit now fully assembled, remove the protector from the distal tip and gently depress
the plunger of the syringe until air is expelled and only the desired amount of medication
remains in the syringe
d.
e. The medication is now ready to be delivered
3. Auto-injector systems
a. Inspect the medication
b. Remove the safety cap only after placing the device against the previously prepared injection
Revised: July 21, 2008
Never place your thumb or finger
over the ends of the auto-injector
7
State of Wisconsin – Standards & Procedures of Practical Skills
TEACHING POINTS
site
c. The medication is now ready to be administered
B. ADMINISTRATION OF INJECTABLE MEDICATIONS
INTRAMUSCULAR INJECTION
1. Prepare medication as previously described in this section
2. Recheck medication label for the rights
3. Ensure the correct size safety needle is attached for administration route (not applicable for autoinjector)
4. Select an injection site
a. Deltoid
b. Vastus lateralis (lateral thigh)
5. Cleanse the injection site with an alcohol prep or other suitable antiseptic swab in an outward
circular motion for about 2 inches
6. Hold the syringe in dominant hand and remove the needle cover
7. Stabilize the injection site with your non-dominant hand using:
a. “Pinch“ technique
b. Stretch technique
8. Holding the syringe like a dart, quickly but not forcefully, insert the needle into the injection site
at a 90 degree angle until the proper depth is reached
9. Release the skin while continuing to hold the syringe in place with the dominant hand
10. Grasp the plunger with one hand and the barrel of the device with the other. Pull back (aspirate)
slightly on the plunger and wait five seconds
11. If no blood aspirates into the syringe, proceed with the injection. Slowly depress the plunger to
administer the injection (10 seconds per mL)
12. Once the medication has been administered, wait ten seconds, then withdraw the needle using
appropriate safety features and/or activating the needle safety engineering device
13. Cover the injection site with an alcohol or gauze pad and apply gentle pressure to the area to help
reduce pain and improve absorption
14. Properly dispose of the syringe and needle assembly in an appropriate sharps container
15. Place a bandage over the injection site
Revised: July 21, 2008
After selecting the injection site,
gently tap it to stimulate the nerve
endings which will minimize pain
when the needle is inserted.
Using the stretch technique may
accomplish this also
Allow alcohol to dry for 30 seconds
for bacteria to be killed and to
minimize discomfort of the injection
Prior to injection, tell the patient that
they will feel a poke.
Aspiration takes longer with smaller
needles
A slow, steady injection rate allows
the muscle to distend gradually and
accept the medication under minimal
pressure.
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State of Wisconsin – Standards & Procedures of Practical Skills
TEACHING POINTS
AUTO-INJECTOR
1. Prepare medication as previously described in this section
2.
3.
4.
5.
Recheck medication label for the rights
Select the vastus lateralis (lateral thigh) injection site
Cleanse the injection site with an alcohol prep or other suitable antiseptic swab in an outward
circular motion for about 2 inches
Grasp the auto-injector by wrapping fist around the unit
6.
7.
8.
Place black end of auto-injector against the prepared site on the lateral thigh at a 90 degree angle
Remove the gray protective cap
Stabilize the patient’s leg to prevent pulling away
Never place your thumb or finger
over the ends of the auto-injector
9.
10.
11.
12.
Apply a gentle pressure against leg with auto-injector until it clicks
Hold in place for 10 seconds before removing auto-injector
Properly dispose of the auto-injector in an appropriate sharps container
Place a bandage over the injection site
Prior to injection, tell the patient that
they will feel a poke
Allow alcohol to dry for 30 seconds
for bacteria to be killed and to
minimize discomfort of the injection
SUBCUTANEOUS INJECTION
1. Prepare medication as previously described in this section
2. Recheck medication label for the rights
3.
Insure the correct size safety needle is attached for administration route (not applicable for autoinjector)
4. Select an injection site
5. Cleanse the injection site with an alcohol prep or other suitable antiseptic swab in an outward
circular motion for about 2 inches
6. Hold the syringe in dominant hand and remove the needle cover
7. Stabilize the injection site with your non-dominant hand using the “pinch” technique
8. Holding the syringe like a dart, quickly but not forcefully, insert the needle into the injection site
at a 45-90 degree angle until the proper depth is reached
9. Release the skin while continuing to hold the syringe in place with the dominant hand
10. Slowly depress the plunger to administer the injection (10 seconds per mL)
11. Once the medication has been administered, wait ten seconds, then withdraw the needle using
appropriate safety features
12. Cover the injection site with an alcohol or gauze pad and put gentle pressure on the area to help
Revised: July 21, 2008
Allow alcohol to dry for 30 seconds
for bacteria to be killed and to
minimize discomfort of the injection
Shorter needles or patient size may
affect the angle of injection
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State of Wisconsin – Standards & Procedures of Practical Skills
TEACHING POINTS
reduce pain and improve absorption
13. Properly dispose of the syringe and needle assembly in an appropriate sharps container
14. Place a bandage over the injection site
INTRAVENOUS BOLUS MEDICATIONS (IVP) - Assumes a patent IV is present
1. Prepare medication as previously described in this section
2. Recheck medication label for the rights
3. Insure the correct size safety needle is attached for administration route (not applicable for autoinjector)
3. Use an alcohol prep or other suitable antiseptic swab to wipe the surface of the IV tubing med-port
closest to the patient
4. Remove the protective cap from the syringe
5. Connect the syringe to the prepared med-port by:
a. Twisting clockwise for luer lock connections
b. Inserting blunt cannula for ports designed for this safety device
c. Inserting needle through self-sealing ports designed for needle puncture
6. Kink off the IV tubing between the selected med-port and the IV solution bag
7. Inject the medication at the proper rate
8. Disconnect syringe from med-port
9. Following injection of the medication, flush the IV tubing
a. Bolus flush by syringe
b. Open flow of IV
10. Properly dispose of the syringe and needle assembly in an appropriate sharps container
Allow alcohol to dry for 30 seconds
for bacteria to be killed and to
minimize injecting alcohol with the
medication
IV. INTRAVENOUS ADMINISTRATION AND CARE
IMPORTANT POINTS
1. Maintain sterility of needles, ends of IV tubing and medication for injections
2. Utilize safety engineered devices to minimize risk of needle sticks (mandatory)
3. Always insure that all sharps are properly disposed of in a timely manner in an approved sharps disposal
container.
4. Assure the proposed site for cannulation is free of inflammation, swelling, infection and any skin lesions
5. Never recap used needles
6. When drawing up medication from a vial or ampule, draw up a little extra that can be wasted when
purging air bubbles
Revised: July 21, 2008
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State of Wisconsin – Standards & Procedures of Practical Skills
TEACHING POINTS
A. IV ADMINISTRATION SET PREPARATION
1. Select the appropriate solution
a. Inspect the solution
b. Open outer packaging by tearing pre-cut slit at either end of the bag
1) Recheck clarity
2. Select an appropriate IV administration set
3. Open the administration set
a. Check to be certain the end caps that preserve the sterile field of the administration set remain
in place
b. Uncoil the tubing in preparation for spiking the IV bag
c. If adjunct devices such as extensions or flow meters are to be used, they should be opened and
attached to the administration set at this time
4. Move the flow control clamp to a convenient location and close off the IV tubing by:
a. Rotating the control knob (roller clamp)
b. Sliding the clamp (slide clamp)
c. Pinching the clamp (pinch clamp)
5. Spike the IV bag
a. Method one
1) If not previously done, hang the IV bag with the tail ports extending downward
2) Grasp the IV port just above the plastic tab. With the other hand, pull the plastic tab from
the port. Be careful to maintain sterility of the port
3) Remove the protective cap from the IV tubing spike being careful to protect the sterile
field
4) Insert the IV tubing spike into the IV port by pushing and twisting the spike until it
punctures the seal of the port
5) Squeeze the drip chamber to fill it approximately half full of fluid
b. Method two
1) Holding the IV bag at its base, invert the bag so the tail ports extend upward
2) While continuing to hold the IV bag, grasp its IV port just below the plastic tab. With the
other hand, pull the plastic tab from the port. Be careful to maintain sterility of the port
3) Remove the protective cap from the IV tubing spike being careful to protect the sterile
field
4) Insert the IV tubing spike into the IV port by pushing and twisting the spike until it
Revised: July 21, 2008
Solution choice should be based on
patient condition and local protocols
A slight amount of moisture inside
the outer bag is normal and not cause
for concern
Choose between macro and micro
infusion sets based on patient
condition
Whenever possible, the IV bag
should be hung in a vertical position
to facilitate preparation
If too much fluid enters the drip
chamber, invert the bag and drip
chamber and squeeze some of the
fluid back into the bag
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State of Wisconsin – Standards & Procedures of Practical Skills
TEACHING POINTS
punctures the seal of the port
5) Invert the bag so it is in an upright position and hang the IV bag
6) Squeeze the drip chamber to fill it approximately half full of fluid
6. Place the end of the tubing in a convenient location while preserving sterility by keeping
protective cap in place
7. Open the flow control clamp and allow the IV fluid to completely fill the line. It is often
necessary to invert and “flick” med-ports with your fingers to remove larger air bubbles
8. Once the line is completely filled with fluid, and larger air bubbles removed, close the flow clamp
and place the “primed” line in position for use
B. INITIATING VENOUS ACCESS
1. Prepare IV administration system as previously described in this section
2. Prepare the necessary equipment and supplies
a. Sharps container
b. Tape and/or commercially available device for securing the IV
c. Alcohol prep pads or other suitable antiseptic swab
d. Gauze pads
e. Site dressing
f. Tourniquet (latex free)
g. Catheter(s)
h. Band-aid
4. Select a venipuncture area (hand, wrist, forearm or antecubital space)
5. Apply a venous tourniquet approximately 4 to 8 inches above the selected area
6. Select a vein for cannulation and cleanse the intended venipuncture site with an alcohol prep or
other suitable antiseptic swab in an outward circular motion for at least 2 inches
7. Based on the intent of the IV and the size of the vein selected, choose an appropriate size IV
catheter
8. Remove the catheter from its packaging and the protective plastic sheath
9. Being careful to maintain the sterility of the needle and catheter, visually inspect the end of each
for any defects, such as burred edges
10. Slightly twist the catheter on the needle to insure the catheter moves freely on the needle (optional
step)
11. Grasp the patient’s extremity near the area where the IV will be started using your non-dominant
Revised: July 21, 2008
Some fluid may be flushed into the
environment
Some protective caps do not allow
fluid to flow once they are wet. If
the protective cap needs to be
removed to complete priming,
maintain sterility and replace cap
when tubing is primed
If tape is used, it should be torn to
appropriate size and length prior to
beginning the procedure
Use antiseptics per local protocol
Allow alcohol to dry for 30 seconds
for bacteria to be killed and to
minimize discomfort of the insertion
Avoid placement that would shut off
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State of Wisconsin – Standards & Procedures of Practical Skills
hand in order to stabilize the vein at the venipuncture site. This may be accomplished by:
a. Pulling traction distal
b. Holding extremity circumferentially so area is taut
TEACHING POINTS
the blood supply and cause the vein
to collapse.
In order to maintain sterility while
placing IV, keep stabilizing hand and
fingers out of the way of the catheter
assembly
Revised: July 21, 2008
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State of Wisconsin – Standards & Procedures of Practical Skills
12. Insure the bevel of the needle is facing upward in relation to the patient’s skin
13. Holding the catheter assembly with fingers of your dominant hand, and in such a manner as to be
able to visualize the flash chamber, approach the injection site with the needle held at
approximately a 15 – 20 degree angle
14. Inform the patient they will feel a slight “pinch” as the needle enters their skin
15. While continuing to apply traction to the skin to hold the vein steady, quickly, but carefully,
enter the skin with the needle and continue until the needle tip is against the wall of the vein
itself. Maintain traction and vein stabilization until catheter is in the lumen of the vein
16. Slowly advance the needle through the vein wall and into the lumen of the vein
17. Once you have entered the vein, continue to advance the needle and catheter assembly slightly
(0.5 cm further) so the tip of the catheter enters the vein
18. When the catheter tip is within the lumen of the vein, slowly advance the catheter along the
needle until the hub meets the patient’s skin. Slide the catheter while holding the needle steady
19. After the catheter has been threaded into the vein, slightly pull back the needle from the catheter,
but DO NOT withdraw it completely
20. If not drawing blood via the IV catheter, release the tourniquet. If blood draws are to be made
using the IV catheter, leave the tourniquet in place and obtain blood samples before releasing
tourniquet
21. Palpate the end of the catheter beneath the patient’s skin and occlude the vein just proximal to
the end of the catheter with direct pressure
22. Remove the needle and activate any safety features before disposing of it in an approved sharps
container
23. With your free hand, remove the protective cap from the end of the IV tubing and attach it to the
catheter hub, making sure not to push the catheter further in or pull it out
24. Open the IV flow clamp and observe the flow of fluid into the drip chamber
a. If the IV does not flow:
1) Insure the tourniquet has been released
2) Carefully withdraw the catheter slightly while observing the drip chamber since the tip
may be occluded by a valve or the side of the vein
3) Determine if the IV is positional and troubleshoot as necessary
2) Begin the process anew using another site
b. With the IV running, and before securing the IV catheter in place, inspect the venipuncture site
for signs of infiltration
c. If an IV can not be made to flow properly or infiltration is observed, discontinue the IV
immediately
25. If the IV is observed to flow properly:
Revised: July 21, 2008
TEACHING POINTS
Consideration may be given to a
bevel down approach for pediatric
and geriatric patients with small
veins
A “pop” may be felt as the needle
enters the vein.
The flash chamber should fill with
blood when entering the vein.
Smaller catheters will be slower to
have a flash
Patients with poor perfusion may not
have a significant flash
No more than one-half the length of
the catheter should be below the skin
at the point the needle enters the vein
or only a small portion of the
catheter will actually be within the
vein for the finished IV
Review “luer lock” versus “slip tip”
connections
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State of Wisconsin – Standards & Procedures of Practical Skills
TEACHING POINTS
a. Using a gauze pad or alcohol prep pad as necessary, wipe away any fluid or blood that may be
present in order to dry the site sufficiently that tape will adhere
b. Secure the IV and the IV tubing in place; cover insertion site with a sterile dressing or
commercially available device
26. Secure the patient’s extremity as appropriate to maintain flow
27. Adjust the flow rate by closing flow clamp or other flow-metering device to the appropriate
setting
28. Continue to monitor the patient for:
a. Signs of a fluid overload
b. Other complications resulting from the IV
c. Appropriate flow rate
d. Infiltration
29. Continue to monitor the IV to insure appropriate flow rate is maintained and the venipuncture
does not infiltrate
Many taping methods and
commercial securing devices are
available. Follow local protocols
Consideration must be given to
maximum and/or ordered quantities
of fluids
C. CHANGING THE SOLUTION BAG OF AN ESTABLISHED IV
1. Select and inspect the IV solution
2. Open outer packaging by tearing pre-cut slit at either end of the bag
3. Shut off the flow clamp on the nearly empty IV bag to prevent air from entering the IV tubing as
the solution bag is being changed
4. Invert the nearly empty bag to prevent any remaining fluid from running out, and remove the IV
tubing spike from the bag
a. Use extreme care to ensure the IV tubing spike does not touch anything to contaminate the
sterile field
b. Follow one of the methods previously described in this section to puncture the bag
c. Discard the used solution bag after noting the approximate amount of any remaining fluid
4. Reestablish the IV flow rate
D. DISCONTINUING AN IV
Revised: July 21, 2008
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State of Wisconsin – Standards & Procedures of Practical Skills
TEACHING POINTS
1. Prepare the necessary materials
a. Gauze square(s)
b. Tape
c. Band-Aid
d. Disposal container
2. Close the flow clamp of the IV administration set
3. Gently remove the tape and/or securing device to expose the venipuncture site
4. Cover the venipuncture site with a gauze square and apply gentle pressure as you remove the IV
catheter
5. Inspect the catheter to insure it is complete, noting any abnormalities
6. Affix an adhesive bandage that will continue to apply pressure until bleeding has stopped
7. Properly dispose of all materials
8. Monitor venipuncture site for bleeding
Revised: July 21, 2008
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State of Wisconsin – Standards & Procedures of Practical Skills
TEACHING POINTS
– MANAGEMENT OF SOFT TISSUE INJURIES
OBJECTIVES:
1. To control external bleeding
2. To prevent further injury and reduce pain
3. To prevent further wound contamination and reduce the potential of subsequent infection
4. To secure dressings through the application of appropriate bandaging techniques
GENERAL PRINCIPLES:
1. Use appropriate body substance isolation precautions
2. Expose the wound site to determine the extent of injury
3. Control bleeding by using the following techniques as needed: direct pressure, pressure dressing,
elevation, pressure points, cold application and tourniquet
4. Use sterile dressings
5. Cover the entire wound site with the sterile surface of the dressing
6. Apply bandage snugly, making certain not to cut off circulation distal to injury site
7. Secure the dressing(s) with roller gauze or cravats applying gentle, even pressure over the wound site
8. Use the patient’s brow ridge, chin and occipital ridge as necessary to provide natural anchoring points for
bandaging
9. If the chin is used, monitor the patient carefully for airway problems. Cut bandage and fold flaps up if
bandage interferes with airway or causes patient discomfort
10. Immobilize the injury site as appropriate
11. Consider shock and prevent/treat as appropriate: oxygen, patient positioning, maintenance of body
temperature
12. CMS should be checked frequently and bandaging adjusted to maintain a pulse if necessary
13. Always consider the Mechanism of Injury (MOI)
14. Suspect cervical spine injury with significant MOI
I. HEAD
IMPORTANT POINTS:
1. Do not exert point pressure to scalp if underlying fracture is suspected
2.. Do not pack nose or ear to stop blood or cerebral spinal fluid (CSF) flow
Revised: July 21, 2008
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State of Wisconsin – Standards & Procedures of Practical Skills
TEACHING POINTS
SKILLS:
A. HEAD (side wound)
1. Open dressing to preserve sterile surface
2. Apply sterile surface to wound site and control bleeding
3. Anchor bandage securely under brow and occipital ridges
4. Cover dressing completely with bandage
5. Exert even pressure over entire wound site with finished bandage
6. Leave eyes uncovered; leave ears either completely covered or completely uncovered
B. HEAD (top wound)
1. Open dressing to preserve sterile surface
2. Apply sterile surface to wound site and control bleeding
3. Anchor bandage securely under brow and occipital ridges
4. Bring bandage over dressing and under chin and tighten down over dressing
5. Cover dressing completely and apply even pressure with bandage over area
6. Anchor bandage securely by making additional wraps around head, securing under brow ridge and
occipital ridge
7. Cut bandage under chin and fold ends up if it interferes with the airway
8. Make last few turns around brow, overlapping folded section
II. EYE
IMPORTANT POINTS:
1. If areas around eye are lacerated but the eyeball is not involved, use direct pressure to control bleeding
2. If eyeball injury is suspected, close eye and apply loose dressing
3. If chemical burn is involved, irrigate eye with normal saline continuously
4. If thermal burns are involved, apply dressing moistened with sterile saline solution
5. If light burns are involved, cover eyes with moist, lightproof pads
6. Cover both eyes when injury occurs as consensual eye movement may cause further injury
7. Never touch the globe or the penetrating object with your hand
8. The finished bandage should hold the eye and/or penetrating object in place
9. Maintain verbal and physical contact with the patient as you explain your actions
10. Always irrigate from the bridge of the nose outward in order to avoid infecting or contaminating the
uninjured eye
SKILLS:
Revised: July 21, 2008
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State of Wisconsin – Standards & Procedures of Practical Skills
TEACHING POINTS
A. EYE INJURY – Non-penetrating
1. Have patient close eyes
2. Apply sterile surface of dressing to injury(ies)
3. Secure bandage around head, anchoring under occipital ridge
a. Bandage snugly if eyeball is uninjured
b. Bandage loosely if injury to the globe is suspected
4. Cover both eyes with finished bandage; do not occlude mouth or nose
5. Restrain patient’s hands to keep from touching the eye area as needed
B. EYE INJURY – Penetrating
1. Surround injured eye with sterile padding
2. If penetrating object, cut hole in end of cup just large enough for object to pass through
3. Place cup or cone over eye, resting it on pads, but do not touch the eye
4. Secure the cup/cone to head with bandage wrapped around cup and then around head anchoring
on occipital ridge
5. Wrap bandage to cover uninjured eye, leaving the nose and mouth exposed
6. Restrain patient’s hands as necessary to prevent patient from touching the bandaged area
Do not cut a hole in dressings or
padding as it may leave small
particles of fabric in the eye
III. NECK
IMPORTANT POINTS:
1. Use an occlusive dressing to prevent air embolus from being sucked into jugular vein
2. DO NOT use a circumferential bandage around the neck
SKILL:
1. Place dressing over wound
2. Secure dressing in place by wrapping the bandage over the dressing and over the top of the opposite
shoulder, crossing under the axilla and back again to form a figure eight
3. Unless contraindicated, transport patient on left side in moderate Trendelenberg position
IV. TORSO
IMPORTANT POINTS:
1. Chest injuries can be life threatening and must be assessed and treated immediately
2. Penetrating objects should be left in place unless they interfere with the patient’s ability to breathe or
maintain an airway
Revised: July 21, 2008
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State of Wisconsin – Standards & Procedures of Practical Skills
TEACHING POINTS
3. Penetrating objects must be removed if CPR is necessary
4. All open or penetrating injuries to the chest or abdomen must be sealed with an occlusive dressing
5. Large penetrating objects should be shortened to facilitate transport or provide stabilization
6. Control bleeding with direct pressure around organs, never on top of them
7. Look for multiple entry/exit wounds with any form of penetrating trauma
8. Use sterile solution soaked dressings on protruding organs
9. Administer high flow oxygen and assist ventilations as appropriate
10. Transport patients rapidly to the closest appropriate medical facility
11. Consider ALS intercept early where available
SKILLS:
A. OPEN CHEST (SUCKING CHEST)
1. Immediately apply manual pressure to seal wound after patient forcibly exhales
2. Apply and secure an occlusive dressing,
3. Auscultate for breath sounds
4. Closely monitor patient for signs of deterioration
B. PENETRATING OBJECT
1. Stabilize object with hand(s)
2. If in chest, upper abdomen or neck area , apply occlusive dressing surrounding the base of the
object
3. Stack bulky dressings in alternating layers to stabilize object from all sides
4. Secure dressings with bandage to control bleeding and immobilize the object
5. Restrain patient’s hands as necessary to prevent patient from removing object
6. Transport rapidly in position of comfort
C. ABDOMINAL EVISCERATION
1. Cover exposed or protruding organs with a sterile dressing moistened with sterile saline
2. Cover with occlusive dressing to prevent moisture loss
3. Cover with bulky dressings to preserve body warmth
4. Secure dressings loosely in place
5. Transport patient in supine or lateral recumbent position with knees flexed
D. SHOULDER
IMPORTANT POINTS:
Revised: July 21, 2008
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State of Wisconsin – Standards & Procedures of Practical Skills
TEACHING POINTS
1. May be accompanied by fractures or dislocations
2. Suspect C-spine injury with significant MOI
SKILL:
1. Apply sterile dressing to wound and control bleeding with direct pressure
2. Check CMS distal to injury prior to applying bandages
3. Position forearm flexed across chest and bring upper arm along line of body
4. Wrap bandage around body, covering wounded arm and crossing under arm on the uninjured side to
secure dressing
5. Recheck CMS distal to injury
E. AXILLARY
IMPORTANT POINTS:
1. Dressing of axillary wounds can easily impair circulation. Check CMS often
SKILL:
1. Apply sterile surface of dressing to wound and control bleeding with direct pressure
2. Check CMS distal to injury prior to applying bandages
3. Add dressings over the first to achieve bulk as necessary
4. Bandage around injured armpit and shoulder
5. Position forearm flexed across chest, hand pointing toward opposite shoulder. Recheck CMS
6. Wrap bandage around body, over outside surface of arm on injured side and under opposite shoulder
7. Recheck CMS distal to injury
F. EXTERNAL GENITALIA
IMPORTANT POINTS:
1. Preserve the patient’s privacy
2. Expose genitalia only if wound is suspected
SKILL:
1. Apply sterile dressing to wound site and control bleeding
2. Secure the dressing by running a bandage over dressing, between legs and around pelvis.
Revised: July 21, 2008
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State of Wisconsin – Standards & Procedures of Practical Skills
TEACHING POINTS
V. EXTREMITIES
IMPORTANT POINTS:
1. Remove patient’s jewelry from the affected extremity
2. Elevate extremity to reduce pain and control bleeding, if circulation is present
3. Leave digits exposed whenever possible
SKILLS:
A. HAND
1. Check CMS
2. Apply sterile surface of dressing to wound and control bleeding
3. Place bandage roll or dressing in palm of hand to maintain position of function
4. Anchor bandage around wrist
5. Wrap hand to prevent release from position of function
6. Achieve some restriction of wrist joint movement with bandage
7. Place hand in elevated position
8. Recheck CMS distal to injury
Leave fingertips exposed to check
CMS
Consider use of splint to restrict
movement
B. AMPUTATION/AVULSION
IMPORTANT POINTS:
1. Save all amputated or avulsed parts. Transport with patient whenever possible
2. Wrap in a sterile dressing
3. Protect in watertight container
4. Keep part(s) cool during transport, but do not allow to freeze
Dry or moist dressing per local
protocol
SKILL:
1. Apply sterile dressing to wound and control bleeding with direct pressure
2. Wrap bandage around circumference of extremity and pass bandage several times across end of stump to
achieve pressure over bleeding area, then secure with several additional circumferential turns
3. Keep stump elevated, if possible
4. If partially attached:
a. Fold skin flap back over wound
b. Secure with sufficient pressure to control bleeding
c. Keep partial amputation cool
Revised: July 21, 2008
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State of Wisconsin – Standards & Procedures of Practical Skills
TEACHING POINTS
VI. BURNS
IMPORTANT POINTS:
1. Make certain the scene is safe to enter
2. Always take appropriate hazard precautions as well as body substance isolation precautions
3. Burns involving the hands, feet, face or genitalia should be considered critical burns
4. Any burns associated with respiratory injuries are critical injuries
5. Burn patients are especially susceptible to shock (hypoperfusion) and hypothermia.
6. Care must be taken to minimize the potential for infection when dealing with burn patients
7. Never use any type of ointment, lotion or antiseptic
8. Avoid breaking blisters
SKILLS:
A. THERMAL BURNS
1. Stop the burning process as rapidly as possible using water or saline
2. Remove jewelry and any easily removable clothing or debris from the affected area
3. Continually monitor the airway and breathing for signs of airway impairment or respiratory
distress
4. Prevent further contamination of the burned area
5. Cover the wound with a clean and dry dressing
6. Treat for shock
7. Transport
Avoid dressings that may leave
fragments in burn injuries
B. ELECTRICAL BURNS
1. Do not attempt to remove a patient from the electrical source unless trained to do so
2. Do not touch a patient unless you are certain s/he is no longer in contact with the electrical source
3. If appropriate, and after assuring no electrical threat remains, stop the burning process as rapidly
as possible using water or saline
4. Remove jewelry, and any easily removable clothing, or debris from the affected area
5. Continually monitor the airway and breathing for signs of airway impairment or respiratory
distress
6. Prevent further contamination of the burned area
7. Treat any soft tissue injuries or fractures associated with the burn. Look for multiple entry/exit
wounds
8. Cover any exposed burned area with a dry, sterile dressing
9. Treat for shock
Revised: July 21, 2008
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State of Wisconsin – Standards & Procedures of Practical Skills
TEACHING POINTS
10. Transport
C. CHEMICAL BURN
1. Always consider the potential impact of hazardous materials. Patient(s) should not be transported
until primary decontamination is completed
2. Brush dry powders off prior to flushing
3. Remove jewelry and any easily removable clothing or debris from the affected area
4. Flush the affected areas with large quantities of water or saline
5. Continue flushing the contaminated area(s) during transport
6. Do not contaminate uninjured or unaffected areas while flushing
7. Continually monitor the airway and breathing for signs of airway impairment or respiratory
distress
8. Prevent further contamination of the burned area
9. Treat any soft tissue injuries associated with the burn
10. Treat for shock
11. Transport
Revised: July 21, 2008
Refer to Emergency Response
Guidebook or other resources
8
State of Wisconsin – Standards & Procedures of Practical Skills
TEACHING POINTS
– PNEUMATIC ANTI-SHOCK GARMENT
OBJECTIVES:
1. To define the indications and contraindications for the use of the pneumatic compression trousers
2. To define the manner in which the PASG can be used to stabilize suspected pelvic fractures and apply
circumferential pressure to suspected intra-abdominal bleeding accompanied by signs of shock
IMPORTANT POINTS:
1. PASG may be applied without inflation to any patient having the potential to develop shock. A systolic
blood pressure of 90 mm HG or less, associated with signs and symptoms is generally regarded as a prime
indicator for inflation. However, protocols vary
2. Inflate the PASG based on protocol
3. The only absolute contraindication to inflation is pulmonary edema
4. There are relative contraindications to inflation of all three compartments
5. Inflation should be only to a level at which shock symptoms subside. Careful and frequent monitoring of
the vital signs after inflation is essential
6. Do not deflate in the field unless ordered to do so by medical control
NOTE: Extreme circumstances may arise when the PASG may be deflated in the field, but only under
authority of Medical Control. (Field deflation is not a generally accepted practice)
SKILL:
A. INFLATION
1. Assess patient for and record signs/symptoms of shock. If spinal injury is suspected, maintain
spinal stabilization
2. Determine and record the patient’s blood pressure
3. Leave deflated blood pressure cuff in place on patient
4. Auscultate breath sounds
5. Remove clothing from patient’s abdomen and lower extremities
6. Assess patient’s abdomen, pelvis and lower extremities for wounds or fractures. Record findings
7. Cover any open wounds with sterile dressings and bandage in place
8. Restore alignment of extremity fractures, if possible
9. Contact medical control, if required by local protocol, for permission to inflate garment. If
medical control contact is not required, proceed according to local protocol
10. Open and arrange anti-shock garment
Revised: July 21, 2008
Check for wet or dry breath sounds
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State of Wisconsin – Standards & Procedures of Practical Skills
TEACHING POINTS
11. Apply anti-shock garment
a. Method One:
1) Lift patient’s lower extremities and buttocks, sliding the garment beneath the patient
2) If spine injury is suspected, use orthopedic stretcher, log roll or straddle slide to position
patient
b. Method Two:
1) Loosely secure all three compartments
2) One rescuer puts pants over his/her arms from the foot end and grasps the patient’s ankles
3) Other rescuers pull garment onto patient like a pair of trousers
12. Verify that the superior edge of the garment is just inferior to the patient’s costal margin
13. Secure garment – legs then abdomen
14. Attach inflation pump lines to garment and open all in-line valves
15. Inflate garment until:
a. Patient’s clinical status improves satisfactorily, or
b. Velcro fasteners begin to crackle, indicating separation, or
c. Air escapes from relief valve(s)
16. Close all in-line valves
17. Leave inflation pump attached to garment during movement and transport
18. Reassess and record, immediately and at frequent intervals en route to the hospital, the patient’s:
a. Blood pressure
b. Pulse rate
c. Respiratory status
d. Level of consciousness
Open all in-line valves on garment
except if ordered otherwise by
medical control or in cases in which
protocol indicates that a specific
compartment is not to be inflated
Monitor respiratory status during
inflation. Stop inflation if
respiratory distress worsens
B. PASG DEFLATION PROCEDURE
NOTE: Extreme circumstances may arise when the PASG may be deflated in the field, but only
under authority of Medical Control. (Field deflation is not a generally accepted practice)
IMPORTANT POINTS:
1. Deflate the PASG only on the order of a physician who has examined the patient in the emergency
department
2. Deflate only after appropriate resuscitative and stabilization measures have been accomplished
3. Deflate only with direct physician supervision
SKILL:
1. Assure the patient has functioning IV lines
Revised: July 21, 2008
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State of Wisconsin – Standards & Procedures of Practical Skills
TEACHING POINTS
2. Assess and record the patient’s vital signs
3. Gradually deflate the abdominal section of the garment
a. Monitor blood pressure carefully
b. For each 4 - 6 mm Hg drop in the patient’s blood pressure, stop deflation and infuse fluids until
stabilized at baseline level
c. If blood pressure continues to drop despite infusion, re-inflate garment and reassess resuscitation
4. After abdominal deflation, gradually deflate each leg segment while monitoring blood pressure and
resuscitating as above
5. If blood pressure cannot be stabilized during deflation, garment inflation will be maintained into the
surgical setting
6. Following deflation of the garment, blood gases and electrolytes will be assessed and corrected as
necessary
Revised: July 21, 2008
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State of Wisconsin – Standards & Procedures of Practical Skills
TEACHING POINTS
– MUSCULOSKELETAL INJURIES
OBJECTIVES:
1. To immobilize suspected fractures and /or dislocations by adequate immobilization of skeletal structure
Movement to restore normal
distal and proximal to the injury site
circulation will depend upon local
2. To apply manual stabilization and utilize appropriate splinting techniques
protocol
3. To determine the presence or absence of circulation, movement and sensation distal to the injury site
4. To restore normal circulation distal to injury sites whenever possible and appropriate, with one attempt to
align with gentle traction before splinting
5. To reduce the potential of further injury to nerves, blood vessels and soft tissue surrounding the injury site
6. To reduce hemorrhage and pain at the injury site and thereby reduce and/or minimize the potential of
injury related shock
GENERAL PRINCIPLES:
1. Control external bleeding, as needed
2. Prevent further wound contamination and reduce the potential of subsequent infection by covering open
wounds with a sterile dressing
3. Assess circulation, movement and sensation (CMS) prior to and following splint application; loosen
splint, if necessary, to regain pulse
4. Prevent further injury and reduce pain by immobilizing the joint above and below the long bone injury
5. Prevent further injury and reduce pain by immobilizing the bone above and below the joint injury
6. Remove clothing from affected area prior to splinting
7. Pad as appropriate to prevent pressure and discomfort to patient
8. Consider application of cold packs to injury site to reduce swelling
9. Always consider the Mechanism of Injury (MOI)
10. Suspect cervical spine injury with significant MOI
11. Consider shock and prevent/treat as appropriate: oxygen, patient positioning, maintenance of body
temperature
12. Use of commercial splints should be in accordance with manufacturer’s directions
I. THORAX
IMPORTANT POINTS:
1. Provide oxygen and assist ventilations as necessary
2. Monitor patient closely for signs and symptoms of a pneumothorax
3. Stabilize chest wall injuries at the patient’s maximum point of exhalation
Revised: July 21, 2008
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State of Wisconsin – Standards & Procedures of Practical Skills
TEACHING POINTS
4. In injuries involving the shoulder girdle, it is important to immobilize the entire shoulder girdle
5. Immobilize in position found, or position where pulse is regained
SKILLS:
A. RIB INJURIES
1. Position forearm of injured side across chest, hand slightly elevated toward opposite shoulder and
secure with roller bandage or sling and swathe
2. If using a sling and swathe, place triangular bandage under and over arm with point at elbow and
two ends tied around patient’s neck. Knot should be to the side of the neck
3. Pin or tie end to form cup to support elbow
4. Transport in sitting or semi-sitting position, if patient’s condition allows
B. FLAIL CHEST
1. Immediately apply manual stabilization of the flail segment
2. Secure the flail segment with a bulky dressing
3. Place patient in the supine position or on injured side while maintaining spinal immobilization as
appropriate
4. Provide oxygen and assist ventilations as necessary
Encourage and facilitate deep
breathing
If circumferential wrap is used, care
should be taken to ensure adequate
tidal volume
C. SHOULDER INJURIES
1. Check CMS distal to the injury.
2. Splint the arm and shoulder in position found, or the position where a distal pulse is regained. Pad
void between arm and chest as appropriate
3. Wrap wide bandage around injured arm and body to serve as a swathe to pull shoulder back and
secure injured arm to body
4. Recheck CMS distal to injury
D. COLLAR BONE (Clavicle)
1. Sling and Swathe method
a. Check CMS in the extremity on the injured side
b. Position the forearm of the injured side across the chest, hand slightly elevated toward
opposite shoulder
c. Place triangular bandage under and over arm with point at elbow and ends tied around neck
d. Pin or tie pointed end to form a cup to support elbow
e. Leave fingers exposed to facilitate circulation check
f. Wrap wide bandage around injured arm and body as swathe to pull injured shoulder back and
Revised: July 21, 2008
Knot should be placed at side of neck
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State of Wisconsin – Standards & Procedures of Practical Skills
TEACHING POINTS
secure extremity to body
g. Recheck CMS in the extremity on the injured side
h. Transport in sitting or semi-sitting position, if patient’s condition permits
2. Figure of Eight technique
a. Check CMS in the extremity on the injured side
b. Begin bandage on top of injured shoulder and carry diagonally downward across shoulder
blades to opposite armpit
c. Continue through and around armpit, over shoulder and down across shoulder blades to armpit
on injured side
d. Proceed through armpit and up, over shoulder, to starting point
e. Repeat procedure for three or more additional turns, overlapping the preceding turn by onethird its width
f. Hold shoulders up and back with finished bandage, immobilizing fracture
g. Recheck CMS in the extremity on the injured side
h. Transport in sitting or semi-sitting position, if patient’s condition permits
E. SHOULDER BLADE (Scapula)
1. Check CMS in the extremity on the injured side
2. Immobilize with sling and swathe as for clavicle fracture
3. Recheck CMS in the extremity on the injured side
4. Transport in sitting or semi-sitting position, if patient’s condition permits
II. EXTREMITIES
IMPORTANT POINTS: (Upper extremities)
1. Apply and maintain manual stabilization of the extremity until the splinting process is complete
2. Align severely angulated fractures with gentle traction unless resistance is felt
3. Do not attempt to replace protruding bone ends into the wound, if present
4. Injuries involving joints should be immobilized in the position found
5. Make one attempt to restore circulation distal to an injury site
6. Avoid applying pressure to the injury site, whenever possible
7. Remove jewelry from injured extremities, place hands in position of function
8. Transport patient in sitting or semi-sitting position, as patient’s condition permits
Revised: July 21, 2008
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State of Wisconsin – Standards & Procedures of Practical Skills
TEACHING POINTS
SKILLS:
A. ARM (Humerus)
1. Check CMS distal to injury site
2. Stabilize manually proximal and distal to injury site
3. First EMT will straighten any severe angulation with gentle traction above and below the fracture
site
4. Place a rigid splint on the lateral aspect of the arm to maintain alignment and secure in place
5. Apply wrist sling and swathe to the injured arm to hold the arm in place, elevating the hand and
immobilizing the shoulder
6. Recheck CMS distal to injury site
B. ELBOW
1. Check CMS distal to injury site
2. Stabilize manually proximal and distal to injury site
3. Immobilize elbow joint, upper arm and forearm with rigid splint
4. Secure in place
5. Recheck CMS distal to injury site
Slings should support the hand and
wrist, but should not encompass the
elbow
Apply a sling and swathe for support
and immobilization, as needed
C. FOREARM (Radius and Ulna)
1. Check CMS distal to injury site
2. Stabilize manually proximal and distal to injury site
3. Place a rigid splint on the entire anterior aspect of the forearm to maintain alignment and secure in
place
4. Wrap splint and forearm with bandage leaving finger tips exposed
5. Apply sling and swathe to keep elbow immobilized and hand pointing slightly upward toward
opposite shoulder
6. Recheck CMS distal to injury site
D. WRIST
1. Check CMS distal to injury site
2. Stabilize manually proximal and distal to injury site
3. Immobilize wrist with hand in position of function
4. Secure splint and forearm with bandage leaving wrist and finger tips exposed
5. Recheck CMS distal to injury site
Apply a sling and swathe for support
and immobilization, as needed
Capillary refill may be best option
for determining circulation for wrist
Revised: July 21, 2008
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State of Wisconsin – Standards & Procedures of Practical Skills
TEACHING POINTS
and hand injuries
E. HAND
1. Check CMS distal to injury site
2. Stabilize manually proximal and distal to injury site
3. Immobilize hand in position of function
4. Place a rigid splint on the entire anterior aspect of the forearm to maintain alignment and secure in
place, leaving finger tips exposed
5. Keep hand elevated
6. Recheck CMS distal to injury site
IMPORTANT POINTS: (Lower Extremities)
1. Apply and maintain manual stabilization of the extremity until the splinting process is complete
2. Align severely angulated fractures with gentle traction unless resistance is felt
3. Do not attempt to replace protruding bone ends into the wound, if present
4. Injuries involving joints should be immobilized in the position found
5. Make one attempt to restore circulation distal to an injury site
6. Avoid applying pressure to the injury site, whenever possible
7. Watch for the development of hypovolemic shock due to internal hemorrhage associated with pelvic, hip
and femur fractures
F. PELVIC INJURIES
1. Check CMS in both lower extremities
2. Immobilize legs by tying knees and ankles together with bandages, padding between thighs and
knees, unless this increases patient’s pain
3. Lift and/or slide the patient as a unit on to a long spinal immobilization device or use orthopedic
stretcher. DO NOT log roll patient
4. Flex the patient’s knees with pillows underneath for comfort, if possible, and secure patient to
long spineboard or orthopedic stretcher
5. Recheck CMS in both lower extremities
Revised: July 21, 2008
Place PASG on long spinal
immobilization device before
positioning patient
Do not log roll patient when moving
to a rigid support device
PASG may be used as a splinting
device as well as an anti-shock
device per local protocol.
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State of Wisconsin – Standards & Procedures of Practical Skills
TEACHING POINTS
G. HIP INJURIES
1. Check CMS in both lower extremities
2. Lift and/or slide the patient as a unit onto a long spinal immobilization device or use an orthopedic
stretcher. DO NOT log roll patient
3. Support the extremity in the position found using blankets, pillows or similar materials.
4. Secure the patient to the long spinal immobilization device
5. Recheck CMS in both lower extremities
H. THIGH INJURIES (Femur)
TRACTION SPLINT (Hare style)
First EMT:
1. Take position at injured extremity out of the way of person applying splint
2. Check CMS distal to injury site
3. The ankle hitch may be applied at this time
4. Grasp and support the calf with one hand. With the other hand, grasp ankle, or ankle hitch strap, in
preparation for lifting
5. Apply traction sufficient to stabilize the injured thigh until traction can be assumed by splint
Revised: July 21, 2008
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State of Wisconsin – Standards & Procedures of Practical Skills
TEACHING POINTS
Second EMT:
1. Adjust the length of the splint by measuring against the length of the uninjured leg and lock
securely in place
2. Position leg support straps on splint with two proximal to the knee, one distal to the knee and one
just proximal to the ankle hitch
3. Release traction mechanism and extend traction strap
4. Position splint under injured extremity
5. Extend or attach heel stand to support splint
6. Verify the ischial pad is firmly against the ischial tuberosity
7. Firmly secure groin strap using care not to pinch the external genitalia
8. If not previously done, apply ankle hitch to patient’s ankle so as to maintain foot at right angle to
leg when traction is applied
9. Attach traction mechanism to ankle hitch
10. Tighten traction mechanism until:
a. First EMT reports mechanical traction equals manual traction
b. Patient acknowledges pain relief
11. Readjust leg support straps if necessary with two proximal to the knee, one distal to the knee and
one proximal to the ankle hitch
12. Secure leg support straps
13. Recheck CMS distal to injury site
14. Secure patient and splint to long spinal immobilization device
Do not place support strap over
fracture site
TRACTION SPLINT (Sager style)
1. Check CMS distal to injury site
2. Adjust length of splint
3. Slide groin strap under injured leg. NOTE: Splint may be applied to either the lateral or medial
aspect of the leg
4. Secure the groin strap using sufficient padding to insure patient comfort
5. Estimate the size of the ankle and fold down the number of pads needed
6. Apply the ankle harness snugly around the patient’s ankle
7. Extend the inner shaft of the splint by holding the shaft lock in the open position and pulling the
inner shaft out until the desired amount of traction, per manufacturer’s recommendations, is noted
on the calibrated wheel
8. Apply the longest strap as high up on the thigh as possible
9. Apply the second longest strap as low as possible on the thigh
10. Apply the shortest strap over the ankle harness and lower leg
Revised: July 21, 2008
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State of Wisconsin – Standards & Procedures of Practical Skills
TEACHING POINTS
11. Apply figure eight strap around both ankles by slipping the strap under the ankles. Cross strap
over the heel and secure buckle snugly
12. Recheck CMS distal to injury site
TRACTION SPLINT (Kendrick Traction Device)
1. Check CMS distal to injury site
2. Apply ankle hitch tightly around the leg, slightly above the ankle
3. Tighten stirrup by pulling the green tabbed strap, until snug under patient’s heel
4. Apply upper thigh system by sliding the pronged portion of buckle under the leg, at the knee, and
seesaw upward until positioned in groin area. Secure buckle
5. Cinch the groin strap until traction pole receptacle is positioned in line with the iliac crest
6. Extend the traction pole
7. Place traction pole along the lateral aspect of the injured leg, extending approximately eight (8)
inches (one pole section) beyond the bottom of the foot
8. Insert pole end(s) into traction pole receptacle
9. Secure yellow elastic strap around knee
10. Place yellow tab end of blue cinch strap (located on ankle hitch) over the dart end of traction pole
11. Apply traction by pulling the red tab end of cinch strap until patient comfort improves
12. Apply upper (red) elastic strap and lower (green) elastic strap around patient’s leg and traction
pole
13. Recheck CMS distal to injury site
Check manufacturer’s instructions
I. KNEE INJURIES
1. Check CMS distal to injury site
2. Splint the knee in the position found
3. Immobilize knee joint with rigid splints
4. Recheck CMS distal to injury site
J. LEG INJURIES (Tibia and/or Fibula)
1. Check CMS distal to injury site
2. Stabilize manually proximal and distal to the injury site.
3. Immobilize with rigid splint(s)
4. Secure in place
5. Recheck CMS distal to injury site
Revised: July 21, 2008
When using board splints, apply one
medial and one lateral to the leg
If using one board splint, apply to the
posterior aspect of the leg
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State of Wisconsin – Standards & Procedures of Practical Skills
TEACHING POINTS
K. ANKLE AND FOOT INJURIES
1. Check CMS distal to injury site
2. Stabilize manually proximal and distal to injury site
3. Immobilize with pillow, blanket, or appropriate commercial splinting device, leaving toes exposed
4. Elevate foot and ankle to reduce edema
5. Recheck CMS proximal and distal to injury site.
Revised: July 21, 2008
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State of Wisconsin – Standards & Procedures of Practical Skills
TEACHING POINTS
– SPINAL INJURIES
OBJECTIVES:
1. To provide initial manual stabilization to the entire spinal column and head to facilitate a patent airway
2. To restore and maintain normal anatomical alignment of the spinal column and head through application
of manual stabilization until appropriate stabilization and immobilization is assumed by a mechanical
device
3. To provide total immobilization of the entire spinal column and head through the proper positioning and
securing of a spinal injury or suspected spinal injury patient to a mechanical movement/stabilization
device
4. To provide stabilization and immobilization of the spinal column and head from the time at which manual
stabilization is first initiated and neutral positioning achieved through all patient handling, packaging and
transport procedures
5. To determine the presence or absence of circulation, movement and sensation in the patient’s extremities
.
IMPORTANT POINTS:
1. One rescuer is responsible for stabilization of the head, neck and maintenance of the airway
2. Rescuer maintaining manual stabilization directs patient movement.
3. Restoring spinal alignment may be appropriate during the spinal stabilization and immobilization process.
However, if resistance to movement of the neck or spine is felt, or the patient experiences an increase in
pain, stabilize the patient in the position found
4. In general, a cervical collar should be used during the stabilization/immobilization process. A cervical
collar alone is not adequate for protecting the cervical spine
5. Stabilization and immobilization are the only adequate protection for suspected spinal injuries
6. Once immobilization has been completed, the device may be positioned to assist in maintaining a patent
airway
7. Patients may be immobilized to a long or short immobilization device using straps, tape, cravats, Velcro
closures, commercial devices, etc. Appropriate padding such as blankets, towels, dressings, etc, may be
needed to prevent movement of the patient in or on the immobilization device
8. Consider padding board for patient comfort
Revised: July 21, 2008
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State of Wisconsin – Standards & Procedures of Practical Skills
TEACHING POINTS
SKILLS:
I. SPINAL INJURIES
A. KENDRICK EXTRICATION DEVICE (KED)
First rescuer
1. Stabilize and support the head in a neutral position
2. Maintain stabilization until patient’s head is secured to KED
Second rescuer
1. Check CMS in all four extremities
2. Assist in repositioning the patient’s body to a neutral position, as necessary
3. Select and apply an appropriately sized cervical collar
4. Prepare and position KED behind patient (Request additional help in positioning patient if
necessary)
5. Secure KED with center and bottom chest straps. Assure firm contact of device with lower back
and armpits
6. Pad any void between patient’s head and the device to preserve neutral alignment as is necessary
7. Secure head to device; first strap over forehead, second strap over chin
NOTE: The chin strap may be omitted or removed if airway compromise exists
8. First EMT may now release manual stabilization
9. Recheck CMS in all four extremities
Both rescuers
1. Secure groin and top chest straps, if not done previously
2. Tie hands together and lower extremities together, if necessary
3. Position long immobilization device adjacent to patient
4. Slide and pivot patient; support patient at thighs and with device handles
5. Lower patient to long immobilization device; maintain legs in flexed position
6. Move patient to head of long immobilization device
7. Release groin straps and lower the patient’s legs to the long immobilization device. Loosen top
chest strap as necessary to facilitate breathing and patient comfort
8. Secure patient to long immobilization device at chest, pelvis, thighs, and below knees, padding as
necessary
9. Recheck CMS in all four extremities
B. SPINAL INJURY – XP-ONE (XP-1)
Revised: July 21, 2008
It is permissible for rescuers to
exchange positions while providing
immobilization
Depending on the style of C-collar in
use, the chinstrap may be more
appropriately placed on the C-collar
below the chin
Groin strap must be properly
positioned under the mid-line of each
buttock to properly secure device to
patient
Reassess head, strap placement and
tension
(Optional)
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State of Wisconsin – Standards & Procedures of Practical Skills
TEACHING POINTS
First rescuer
1. Stabilize and support the head in a neutral position
2. Maintain stabilization until patient’s head is secured to XP-1
Second rescuer
1. Check CMS in all four extremities
2. Assist in repositioning the patient’s body to a neutral position, as necessary
3. Apply Med-Spec extrication collar
4. Prepare and position XP-1 behind patient (Request additional help in positioning patient if
necessary)
5. Secure XP-1 with center and bottom chest straps. Assure firm contact of device with lower back
and armpits
6. Secure head to device, choose appropriate tabs and attach them to the Velcro on both sides of the
collar. Place forehead pad on patient and attach tabs
Both rescuers
1. Secure groin straps
2. Apply top chest strap; draw shoulder straps down, loop Velcro around top on top and middle chest
straps and secure in place
3. Position long immobilization device adjacent to patient
4. Slide and pivot patient; support patient at thighs and with device handles
5. Lower patient to long immobilization device; maintain legs in flexed position
6. Move patient to head of long immobilization device
7. Release groin straps and lower the patient’s legs to the long immobilization device. Loosen top
chest strap as necessary to facilitate breathing and patient comfort
8. Remove chin strap, if needed, to assure an airway
9. Secure patient to long immobilization device at chest, pelvis, thighs, and below knees, padding as
necessary
10. Recheck CMS in all four extremities
Revised: July 21, 2008
It is permissible for rescuers to
exchange positions while providing
manual stabilization
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State of Wisconsin – Standards & Procedures of Practical Skills
TEACHING POINTS
C. LONG SPINEBOARD - Standing Patient
IMPORTANT POINTS:
1. A standing patient with a potential spinal injury must be moved to a supine position as soon as possible
2. Manual stabilization of the patient’s head and neck can be maintained from either the front or the back of
the patient depending on the rescuer’s height. Shorter rescuers may need to stabilize from the front of the
patient
3. While holding manual stabilization from the rear, communicate with team members as your view of the
patient will be obstructed by the immobilization device
SKILL:
1. Maintain manual stabilization of the patient’s head, neck and spine
2. Check CMS in all four extremities
3. Select and apply a cervical collar
4. Position the long spinal immobilization device behind the patient being certain it is centered directly
behind the mid-line of the patient
5. Two rescuers face the patient and stand on either side
6. The two rescuers place their arms that are closest to the patient, under the patient’s arms and grasp the
device just above the patient’s armpit
7. The two rescuers, with their free hand, grasp the patient’s arm at the elbow or the board to maintain a
secure grip as the device is tilted backward
8. The device is then tilted backward to the ground
9. The patient’s torso and lower extremities are secured to the device, followed by the patient’s head,
padding as necessary to maintain neutral alignment
10. Recheck CMS in all four extremities
D. SLING AND LONG SPINEBOARD
First rescuer
1. Stabilize and support the head in a neutral position
Second rescuer
1. Check CMS in all four extremities
2. Select and apply an appropriately-sized cervical collar
3. Position sling across chest and under armpits of patient and tighten around body
4. Secure patient’s hands together if possible
5. Position long spineboard at slight elevation to patient’s longitudinal axis. Support at this angle
while pulling patient
Revised: July 21, 2008
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State of Wisconsin – Standards & Procedures of Practical Skills
TEACHING POINTS
6. On command, pull patient slowly onto board keeping sling close to board at all times as First
rescuer guides patient’s body and maintains stabilization of the head
7. As first rescuer approaches head of board, lower board gently and move back as pull is completed
8. Secure patient to long immobilization device at chest, pelvis, thighs, and below knees, padding as
necessary
9. Secure patient’s head to long spineboard, padding as necessary
10. First rescuer may then release manual stabilization
11. Recheck CMS in all four extremities
E. LOG ROLL AND LONG IMMOBILIZATION DEVICE (Patient Supine – 3 Rescuers)
First Rescuer
1. Stabilize and support the head in a neutral position
2. Maintain stabilization until patient’s head is secured to long immobilization device
Second and Third Rescuers
1. Check CMS in all four extremities
2. Select and apply an appropriately-sized cervical
3. Tie patient’s lower extremities together
4. Second rescuer raises patient’s near arm over patient’s head to prevent arm from obstructing roll or places
arm along patient’s side with hand against thigh
6. Second and third rescuer s reach across patient and place their hands along patient’s body evenly
spaced between shoulder and knees
7. On signal from first rescuer, second and third rescuer s roll patient toward them, maintaining
spinal alignment
8. Second and third rescuer s each use hand closest to patient’s feet to position the long
immobilization device on the floor next to the patient’s back
9. On signal from first rescuer, all roll the patient back onto long immobilization device and lower
arm to side
10. If centering of the patient is necessary; on signal from first rescuer, slide patient with gentle even
motion while maintaining spinal alignment
11. Third rescuer secures patient to long immobilization device at chest, pelvis, thighs, and below
knees, padding as necessary
12. Second rescuer secures patient’s head to long immobilization device, padding as necessary to
maintain neutral alignment
13. First rescuer may then release manual stabilization
14. Recheck CMS in all four extremities
Revised: July 21, 2008
Hand spacing may be adjusted to
accommodate patient’s weight and
height
The patient may be centered through
the use of either direct lateral
movement or the “Z” method, which
combines longitudinal and lateral
movement
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State of Wisconsin – Standards & Procedures of Practical Skills
TEACHING POINTS
F. LOG ROLL AND LONG IMMOBILIZATION DEVICE (Patient Prone or on side – 3 Rescuers)
First Rescuer
1. Stabilize head, neck and spine in position found
Second and Third Rescuers
1. Check CMS in all four extremities
2. Secure patient’s lower extremities together
3. Place long spinal immobilization device parallel to the patient so the back of the patient’s head is
next to the board
4. Both rescuers kneel on board facing the patient with second rescuer at the patient’s chest and third
rescuer at the patient’s thighs
5. Second rescuer raises patient’s arm nearest the device and positions it over the patient’s head or
along side the patient’s body with the hand against the thigh
6. Second and third rescuer s reach across patient and place their hands along patient’s body evenly
spaced between shoulder and knees
7. On signal from first rescuer, second and third rescuer s roll patient toward them onto long
immobilization device
8. As patient is rolled, first rescuer brings head into neutral position, if possible, achieving spinal
alignment (If resistance is felt, head is stabilized at that point)
9. If centering of the patient is necessary; on signal from first rescuer, slide patient with gentle even
motion while maintaining spinal alignment
10. Third rescuer secures patient to long immobilization device at chest, pelvis, thighs, and below
knees, padding as necessary
11. Second rescuer selects and applies an appropriately-sized cervical collar, then secures patient’s
head to long immobilization device, padding as necessary to maintain neutral alignment
12. First rescuer may then release manual stabilization
13. Recheck CMS in all four extremities
G. ORTHOPEDIC STRETCHER (Two Rescuers – Patient Supine)
First Rescuer
1. Stabilize head and neck in neutral position
Second EMT
1. Check CMS in all four extremities
2. Select and apply cervical collar
3. Adjust stretcher to height of patient
4. Place one half of stretcher on each side of patient
5. Slide stretcher halves under patient and latch head end together
Revised: July 21, 2008
Hand spacing may be adjusted to
accommodate patient’s weight and
height
The patient may be centered through
the use of either direct lateral
movement or the “Z” method, which
combines longitudinal and lateral
movement
Stretcher should remain closed when
length is adjusted
6
State of Wisconsin – Standards & Procedures of Practical Skills
6. Close foot end of stretcher being careful not to pinch patient
7. Secure patient to long immobilization device at chest, pelvis, thighs, and below knees, padding as
necessary
8. Secure patient’s head to orthopedic stretcher, padding as necessary to maintain neutral alignment
9. First EMT may then release manual stabilization
10. Recheck CMS in all four extremities
11. Place and secure patient to a long board
TEACHING POINTS
A bystander may be used to gently
lift patient to help avoid pinching
when closing stretcher halves
H. STRADDLE SLIDE (4 Rescuer minimum)
First Rescuer
1. Stabilize head, neck and spine in neutral position
Second, Third and Fourth Rescuer s
1. Check CMS in all four extremities
2. Select and apply an appropriately-sized cervical collar
3. Second and third rescuer s straddle patient facing first rescuer
a. Second rescuer bends and places hands under patient’s chest below the shoulders
b. Third rescuer bends and places hands under patient’s pelvis
4. Fourth rescuer positions long spineboard lengthwise at the patient’s head or feet
5. At signal from the first rescuer, second and third rescuers lift patient just enough to allow the long
spineboard to pass under the patient’s body
6. Fourth rescuer slides long spineboard under patient in one smooth, unbroken movement
7. On signal from first rescuer, second and third rescuers lower patient on the long spineboard
8. If centering of the patient is necessary; on signal from first rescuer, slide patient with gentle even
motion while maintaining spinal alignment
9. Third rescuer secures patient to long immobilization device at chest, pelvis, thighs, and below
knees, padding as necessary
10. Second rescuer secures patient’s head to long spineboard, padding as necessary to maintain neutral
alignment
11. First rescuer may then release manual stabilization
12. Recheck CMS in all four extremities
J. HELMET REMOVAL
IMPORTANT POINTS:
1. The ability to maintain an airway is of ultimate importance when managing helmeted patients
2. Stabilization and immobilization are the only adequate protection for suspected spinal injuries
Revised: July 21, 2008
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State of Wisconsin – Standards & Procedures of Practical Skills
TEACHING POINTS
3. Consideration should be given to leaving a well fitting helmet, which allows ready access to perform all
necessary airway maneuvers, in place
4. Proper immobilization of patients wearing helmets and other protective equipment often requires the
patient’s body or head to be padded to maintain appropriate neutral position
SKILL:
1. Open faced helmets/half helmets
a. From the cephalic position, first EMT provides manual stabilization by placing one hand on each side
of the helmet with the fingers on the mandible
b. Second EMT removes the face shield, then and unfastens the restraining strap
c. Second EMT places one hand on each side of the patient’s neck with thumbs resting against the angle
of the jaw and the fingers extending behind the occiput to support the patient’s head and maintain
manual stabilization
d. First EMT then removes the helmet by grasping the straps or edges of the helmet to spread it as it is
gently pulled along the long axis of the body and tilted slightly forward
e. Throughout the removal process, the second EMT maintains manual stabilization of the patient’s head
and neck
f. First EMT resumes control of manual stabilization
g. The second EMT selects and applies an appropriately-sized cervical collar in preparation for moving
the patient to a long immobilization device
h. EMTs move patient to long immobilization device using appropriate technique as previously
described in this section
Glasses, microphones, head-sets or
other obstructions must be removed
before attempting to remove the
helmet
If the patient is wearing other
protective equipment, once the
helmet is removed, care must be
taken to pad between the occiput and
the immobilization device to
maintain the head in a neutral
alignment
2. Closed face (full face) helmet - (Minimum of three rescuers) Assumes a well fitted helmet and no
immediate life-threat due to airway obstruction or respiratory arrest
a. Patient is positioned on long spineboard using appropriate technique as described previously in this
section
b. While maintaining manual stabilization, the head end of the long immobilization device is elevated
approximately three inches from the horizontal and firmly blocked in that position
c. While the First EMT maintains manual stabilization from the cephalic position, the Second and Third
EMTs straddle the patient and the long spineboard
d. Second EMT grasps the patient under the armpits while Third EMT grasps patient at the pelvis
e. On signal from the First EMT, the patient is moved up the long spineboard until the lower rim of the
helmet is just beyond the top edge of the board
f. While the Third EMT continues to stabilize the patient’s body, the Second EMT places one hand on
Revised: July 21, 2008
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State of Wisconsin – Standards & Procedures of Practical Skills
TEACHING POINTS
each side of the patient’s neck with thumbs resting against the angle of the jaw and the fingers
extending behind the occiput to support the patient’s head and maintain manual stabilization
g. Second EMT assumes manual stabilization of patient’s head and cervical spine
h. When advised by Second EMT that s/he has assumed manual stabilization, First EMT slowly releases
manual stabilization
i. First EMT insures that any objects which could obstruct helmet removal (glasses, microphones,
headset, etc) have been removed from the patient and/or helmet, then loosens and unfastens the
helmet restraining strap
j. First EMT then removes the helmet by grasping the straps or edges of the helmet to spread it as it is
gently pulled along the long axis of the body and tilted slightly rearward to clear the patient’s nose
k. Once the lower edge of the helmet has cleared the patient’s nose, the helmet is tilted slightly forward
and removed
l. First EMT resumes manual stabilization of the patient’s head and cervical spine
m. Second EMT grasps patient under armpits
n. On signal from First EMT, all EMTs slide the patient down the long spineboard until s/he is properly
positioned
o. C-collar is applied and patient is secured to long spineboard using appropriate technique as previously
described in this section
3. Football Helmet (Patient supine)
a. First EMT provides manual stabilization by placing one hand on each side of the helmet with the
fingers on the mandible
b. Second EMT removes the face shield by using paramedic shears to cut the nylon straps holding the
shield in position
c. Second EMT then unfastens chin strap(s) at the side snaps, removing it completely
d. Using the closed trauma shears as a lever, the second EMT pries the lower lateral interior pads from
the helmet and removes them
e. If the helmet is equipped with an air bladder, the second EMT releases the air valve of the helmet and
deflates the bladder
f. Second EMT places one hand on each side of the patient’s neck with the thumbs resting against the
angle of the jaw and the fingers extending behind the occiput to support the patient’s head and
maintain neutral alignment
g. First EMT then removes the helmet by grasping it’s edges to
spread it as it is gently pulled
along the long axis of the body and tilted slightly forward
h. Throughout the removal process the second EMT maintains
manual stabilization of the
patient’s head and neck
i. First EMT resumes control of manual stabilization
Revised: July 21, 2008
Second EMT may continue to
straddle the patient or may move off
to one side when assuming C-spine
stabilization
Depending on the style of helmet
being worn, it may be necessary to
use a closed face helmet procedure to
remove the helmet
Coaching or trainer staff may be able
to assist with equipment removal
Shoulder pads may elevate the
patient’s body to an extent that
traditional immobilization devices
will no longer provide adequate
immobilization
If the patient is wearing other
protective equipment, extreme care
must be taken to insure spinal
alignment is maintained both during
9
State of Wisconsin – Standards & Procedures of Practical Skills
j. Second EMT selects and applies an appropriately sized cervical collar in preparation for moving the
patient to a long immobilization device
k. EMTs move the patient to a long immobilization device using appropriate technique as previously
described in this section
l. The second EMT pads as necessary under the patient’s head to maintain neutral alignment
m. Patient is secured to long immobilization device using appropriate technique as previously described
in this section
Revised: July 21, 2008
TEACHING POINTS
the log roll and once the helmet is
removed
Additional care must be taken to pad
between the occiput and the
immobilization device to maintain
the head in a neutral position
10
State of Wisconsin – Standards & Procedures of Practical Skills
Glossary of Common Abbreviations
ABCs....................Airway Breathing & Circulation
AED .....................Automated External Defibrillator or Defibrillation
AHA.....................American Heart Association
ALS ......................Advanced Life Support
ARC .....................American Red Cross
ASA......................Aspirin
AVPU ..................Alert, Verbal, Painful, Unresponsive
BLS ......................Basic Life Support
BP ........................Blood Pressure
BSA ......................Body Surface Area
BSI .......................Body Substance Isolation
BVM ....................Bag-valve Mask
CC ........................Chief Complaint
cc ..........................Cubic Centimeter
CO2 ......................Carbon Dioxide
C-spine ................Cervical Spine
CID/HID..............Cervical Immobilization Device/Head Immobilization Device
CMS .....................Circulation, Movement & Sensation
CNS......................Central Nervous System
CPR .....................Cardiopulmonary Resuscitation
CSF ......................Cerebral Spinal Fluid
DCAP/BTLS .......Deformities, Contusions, Abrasions, Penetrations, Burns,
Tenderness, Lacerations, Swelling
dL.........................Deciliter
EMS .....................Emergency Medical Services
EMT ....................Emergency Medical Technician
ET ........................Endotracheal
ETC .....................Esophageal Tracheal Combitube
IM ........................Intramuscular
IV .........................Intravenous
IVP.......................Intravenous push
KED .....................Kendrick Extrication Device
kg .........................kilogram
11
State of Wisconsin – Standards & Procedures of Practical Skills
KTD .....................Kendrick Traction Device
lbs.........................Pounds
LOC .....................Level of Consciousness
lpm .......................Liters per Minute
MAST ..................Medical (or Military) Anti-Shock Trousers
mg ........................Milligram
mL........................Milliliter
mmHg ..................Millimeters of Mercury
MOI .....................Mechanism of Injury
NOI ......................Nature of Illness
NPO .....................Nothing by Mouth
NTG .....................Nitroglycerine
O2 ........................Oxygen
OB ........................Obstetrics
OPQRST .............Onset, Provocation, Quality, Radiation, Severity, Time
PASG ...................Pneumatic Anti-Shock Garment
PO ........................By mouth
prn .......................as needed, as desired, as necessary
PSI .......................Pounds per square inch
pt ..........................patient
SAMPLE .............Signs & Symptoms, Allergies, Medications, Past pertinent medical
history, Last oral Intake, Events preceding incident
SC ........................Subcutaneous
SIDS.....................Sudden Infant Death Syndrome
SL.........................Sublingual
SQ ........................Subcutaneous
SOB......................Shortness of Breath
SpO2.....................Saturation percentage of oxygen
S/S ........................Signs & Symptoms
USP ......................United States Pharmacopia
VS ........................Vital Signs
> ...........................Greater than
< ...........................Less than
12
State of Wisconsin – Standards & Procedures of Practical Skills
WISCONSIN EMSC
EMERGENCY MEDICAL SERVICES
FOR CHILDREN
BLS PREHOSPITAL CARE
GUIDELINE
13
State of Wisconsin – Standards & Procedures of Practical Skills
WISCONSIN EMSC
INITIAL ASSESSMENT PROTOCOL: BLS PREHOSPITAL CARE GUIDELINE
Pre -arrival preparation:
 Plan sc ene size
-up
 Prepare pediatric equipment,
based on dis patc h information
_
Review ÒChild AlertÓ
information in ambulanc e
or dispatch center
Yes
Child with s pec ial
medic al needs?
No
Scene size -up. Assess:
_
Safety hazards to patient, c aregiver, EMT
_
Mec hanism of injury /nature of illness
_
Environment
_
Universal precautions assured
Initial patient assessment
_
Pediatric Assessment Triangle
Ğ Appearance
Ğ Work of breathing
Ğ Circulation to the skin
_
Primary survey
Ğ Airway
Ğ Breathing
Ğ Circulation
Ğ Disability ( AVPU)
Ğ E xposure (c hildren cool quic kly)
_
Vital signs 1
Severity of
phy siologic abnormality?
Stable or none
_
_
_
Detailed phy sic al exam
Focused his tory ( SAMPLE)
Ğ Signs/sy mptoms
Ğ Allergies
Ğ Medic ations
Ğ Pas t pertinent medic al history
Ğ Las t oral intak e
Ğ E vents leading to call
Refer to appropriate protocols:
Ğ Altered Level of Consciousness
Ğ Anaphylaxis/Allergic E mergency
Ğ Burns
Ğ Child Abuse/Neglect Suspected
Ğ Drowning
Ğ Environmental Hyperthermia
Ğ Hypotherm ia
Ğ Pediatric Tracheostom y with
Respiratory Distress
Ğ Poisoning/Toxic Exposure
Ğ Respiratory Distress
Ğ Safe P lace for Newborns
Ğ Trauma
Unstable
_
Critic al
Refer to appropriate protoc ols:
Ğ Altered Level of Consciousness
Ğ Anaphylaxis/Allergic E mergency
Ğ Bradycardia
Ğ Burns
Ğ Child Abuse/Neglect Suspected
Ğ Drowning
Ğ Environmental Hyperthermia
Ğ Hypotherm ia
Ğ Neonatal Resuscitation
Ğ Pediatric Tracheostom y with
Respiratory Distress
Ğ Poisoning/Toxic Exposure
Ğ Respiratory Distress
Ğ Safe P lace for Newborns
Ğ Seizures
Ğ Shock
Ğ Trauma
NOTES:
1. Refer to bac k of page for age
appropriate vital signs
-
_
Refer to appropriate protoc ols:
Ğ Anaphylaxis/Allergic E mergency
Ğ Bradycardia
Ğ Burns
Ğ Child Abuse/Neglect Suspected
Ğ Drowning
Ğ Environmental Hyperthermia
Ğ Hypotherm ia
Ğ Neonatal Resuscitation
Ğ Poisoning/Toxic Exposure
Ğ Pediatric Pulseless Arrest
Ğ Respiratory Arrest
Ğ Safe P lace for Newborns
Ğ Seizures
Ğ Shock
Ğ Trauma
Document:
_
Clinic al ass ess ment and V S
_
Key historic al features
Wisconsin EMS for Children, Rev. 7/2002
14
State of Wisconsin – Standards & Procedures of Practical Skills
WISCONSIN EMSC
ALTERED LEVEL OF CONSCIOUSNESS PROTOCOL: BLS CARE GUIDELINE

Initial Assessment Protocol
Seizure in progress?
Yes

Refer to Seizure Protocol
No
Spontaneous breathing?
No

Refer to Respiratory Arrest Protocol

Open airway, with C-spine stabilization
if trauma suspected
– Jaw thrust
– Suction
– Nasopharyngeal airway
Yes

Position patient on side
if trauma not suspected
Airway adequate?
No
Yes


Yes
Administer 100% oxygen
Pulse oximetry, if available
Airway adequate?
No
Patient cyanotic, or
pulse oximetry reading < 90%?
Yes

Assist ventilation with BVM and
100% oxygen at age-appropriate rate
No

Check blood glucose
Yes
Circulation adequate?
No
No
No
IV skills?
Glucose < 60 mg/dl?1

ALS intercept, if possible
Yes
Yes

EMT-B
 Per medical control, Glucagon
– 0.1 mg/kg IM/SQ
– Max. 1.0 mg
EMT- B/IV
 Glucagon, as above, or
 Glucose 0.5 gm/kg IV
diluted for age2






Start IV
Give fluid bolus NS/LR
10 - 20 ml/kg
Contact medical control
Support the ABC’s as needed
Rapid transport
Continued monitoring
Focused history and detailed exam
en route
Document:
 Level of consciousness ( AVPU scale),
motor activity and pupillary size, symmetry,
reaction to light
 Respiratory impairment if present
 Vital signs and pulse oximetry
 Therapy employed and response to it
 Communication with medical control
NOTES:
1. If unable to determine blood glucose
contact medical control for local protocol
2. D50W: 1 ml/kg for children > 2 yr.
D25W: 2 ml/kg for infants, children < 2 yr.
(dilute D50W 1:1 with sterile water)
D12.5W: 4 ml/kg for neonates < 28 days
(dilute D50W 1:3 with sterile water)
Special Considerations:
 Intubation may be necessary to protect
the airway. ALS-capable assistance needed
if intubation is not within scope of practice.
 A non-visualized airway can be used in children
of sufficient height:
– Regular Combitube ® if pt. Taller than 5’.
– Small Combitube ® if pt. Between 4’8” and 5’.
 In the focused history, consider the possible
causes of altered level of consciousness,
AEIOU – TIPPS:
Alcohol
Epilepsy, endocrine (diabetes), electrolytes
Insulin
Opiates and other drugs
Uremia (kidney failure)
Trauma, temperature
Infection
Psychogenic
Poison
Shock, stroke, space occupying lesion,
subarachnoid hemorrhage
 In the case where any of the above causes is
identified, refer to the appropriate protocol
Wisconsin EMS for Children, Rev. 7/2002
15
State of Wisconsin – Standards & Procedures of Practical Skills
WISCONSIN EMS-C
ANAPHYLAXIS/ALLERGIC EMERGENCY PROTOCOL: BLS CARE GUIDELINES
Initial Assessment Protocol
Administer 100% O2
Assess vital signs



Cardiorespiratory
compromise?
Respiratory distress,
or poor perfusion
without hypotension
None

If related to insect sting,
apply ice to site

Severe respiratory distress,
respiratory arrest, and/or
hypotensive shock
Epinephrine 1:1000 SQ/IM1,2
– 0.01 mg/kg (0.01 ml/kg)
– Maximum single dose: 0.3 - 0.5 mg





Nebulized Albuterol 2.5 mg in 3 ml NS
Q 15 min PRN for wheezing
Pulse oximetry, if available
Secure airway PRN
Support ventilation with BVM
at age-appropriate rate PRN
Nebulized Albuterol 2.5 mg in 3 ml NS
Q15 minutes PRN for wheezing
ALS intercept, if possible
Epinephrine 1:1000 IM1,2
– 0.01 mg/kg (0.01 ml/kg)
– Maximum single dose: 0.3 - 0.5 mg
– May repeat x3 Q 5 min PRN
Shock position if tolerated



No
IV skills?
Yes


Start IV
Give NS/LR bolus 20 ml/kg
Yes
Improved?
No




Contact medical control
Support ABCs
Keep Warm
Monitor & transport


Cardiac monitor
Pulse oximetry, if available
NOTES:
1. Vigorously massage injection site for
30-60 seconds.
2. If Epipen® is used to administer
epinephrine:
– Use the “Jr.” size (0.15 mg) for
children who weigh < 20 kg (44 lb),
blue color on the Broselow® tape
– Use the adult size (0.3 mg) for
children who weigh ≥ 20 kg (44 lb)

Give bolus NS/LR 20ml/kg, to a
maximum of 60 ml/kg PRN for shock
Document:




Clinical assessment and VS
Resuscitative measures and response
Meds given and response to each
Communication with medical control
Wisconsin EMS for Children, Rev. 7/2002
16
State of Wisconsin – Standards & Procedures of Practical Skills
WISCONSIN EMSC
BRADYCARDIA PROTOCOL: BLS CARE GUIDELINE
Initial Assessment Protocol
Administer 100% O2
Assess vital signs



HR < 100 BPM and severe
cardiorespiratory compromise?
 Poor perfusion
 Hypotension
 Respiratory distress
No

Yes


Yes
Secure airway
Support ventilation with BVM
at age-appropriate rate
Pulse oximetry, if available
Increased HR and/or
improved circulation?
No
Heart rate ≥ 60/min ?
Yes
No




Start IV
Give fluid bolus NS/LR 10 - 20 ml/kg
Perform chest compressions
Continue as indicated by HR
Yes
IV skills?
No
Yes
Increased HR and/or
improved circulation?
No

EMT-B
 Per medical control, Glucagon
– 0.1 mg/kg IM/SQ
– Max. 1.0 mg
EMT- B/IV
 Glucagon, as above, or
 Glucose 0.5 gm/kg IV
diluted for age2
Increased HR and/or
improved circulation?
Yes
Check blood glucose
Glucose < 60 mg/dl?1
No
No

ALS intercept, if possible

Refer to Pulseless Arrest
ProtocolPRN
Yes







Contact medical control
Support ABC’s
Observe
Keep warm
Transport
Detailed physical exam (en route)
Focused history (en route)
Document:
 Clinical assessment and VS
 Resuscitative measures and response
 Meds given and response to each
 Communication with medical control
NOTES:
1. If unable to determine blood glucose contact
medical control for local protocol
2. D50W: 1 ml/kg for children > 2 yr.
D25W: 2 ml/kg for infants, children < 2 yr.
(dilute D50W 1:1 with sterile water)
D12.5W: 4 ml/kg for neonates < 28 days
(dilute D50W 1:3 with sterile water)
17
Special Considerations:
 Hypoglycemia may cause bradycardia in
infants
 Special conditions may apply for severe
hypothermia. See Hypothermia Protocol
Wisconsin EMS for Children, Rev. 7/2002
State of Wisconsin – Standards & Procedures of Practical Skills
WISCONSIN EMSC
BURN PROTOCOL: BLS CARE GUIDELINE




Initial Assessment Protocol
Secure airway as appropriate
Give 100% O2
Stop the burning process
Thermal Burn



Chemical Burn
Remove clothing
Expose burned area
Remove metal or
constricting items



If dry chemical, brush off
before flushing
Flush area with water for
at least 10-15 min
No
Special Considerations:
 Pulse oximetry will give a falsely high reading
in presence of carbon monoxide or cyanide inhalation.
 Intubation may be necessary to protect
the airway. ALS-capable assistance needed
if intubation is not within scope of practice.
 A non-visualized airway can be used in children
of sufficient height:
– Regular Combitube ® if pt. Taller than 5’.
– Small Combitube ® if pt. Between 4’ 8” and 5’.
 Consider possibility of child abuse.
 Patients are NEVER hypotensive from acute
burns. Fluid shifts take hours to occur.
 It is important to prevent hypothermia due to cooling of
uncovered burn, and removal of clothing.
Start IV
Contact Medical Control
for fluid resuscitation
guidelines



No
If patient is in shock, see
Shock Protocol
Cover burn with dry sterile,
preferably non-stick,
dressing
Indications of
Inhalation Injury?2
Yes



Assess wounds,
Cover with sterile dressing
IV skills?
Yes


Document:
 BSA burned
 Depth of burn
 Location of burns
 Signs of inhalation injury
 Contact with Medical Control
Total BSA with
2° or 3° burns > 5%
Yes
ALS intercept,
if possible

Estimate Total Body Surface
Area (BSA) involved, 1
and depth of burn
No

Electrical Injury
Consider early intubation or
ALS intercept
Refer to Respiratory
Distress or Respiratory
Failure Protocol
Rapid transport to appropriate
facility, preferably a burn
center, when available, 3
for all critical4 burns
Notes:
1. The “rule of nines” does not apply to children because of relati vely
larger heads and smaller lower extremities. BSA can be estimated
using the table on the back of this sheet. Small burn areas can be
estimated by: the area of the child’s palm between wrist and fingers
is 1% of BSA.
2. Inhalation injury is suggested by:
Enclosed space fire
Respiratory distress or failure
Stridor or hoarse cry
Soot around nose or mouth
Singed nasal hair or eyebrows
Carbonaceous sputum
3. When transfer to a burn center may be indicated, consult Medical
Control for recommendation for helicopter transport vs. secondary
interfacility transport from local hospital
4. Critical burn: 2° or 3° burn >15% BSA, any burn accompanied by
inhalation injury or associated with major trauma, or any burn to the
face, hands, feet or genitalia.
Wisconsin EMS for Children, Rev. 7/2002
18
State of Wisconsin – Standards & Procedures of Practical Skills
WISCONSIN EMSC
CHILD ABUSE SUSPECTED: BLS PREHOSPITAL CARE GUIDELINE


_
Initial Assessm ent Protocol
Reassure patient that s/he is safe
Be alert to immediate sc ene and
ac curately doc ument y our observations
and c onversation with patient and caregiver
Phy siologic abnormality?
Yes
_
Refer to appropriate protocol
No
Suspec ted
sexual abuse
Suspec ted
physic al abuse
Crew member of same sex
may relate better to patient
_
_
_
Do not disturb any
evidenc e, including
victimÕ
s c lothing, unles s
nec essary to treat patient
_
_
Do not leave patient
unattended at any time to
preserve the Òc hain of evidenceÓ
_
Assess and document
appearanc e of injuries inc luding:
Ğ Ty pe of injury
Ğ Loc ation(s)
Ğ Ac uity of injury
Ğ Presence of multiple injuries
Ğ Unusual patterns of injury,
inc luding injuries resembling
objec ts
Note als o:
Ğ Mental status of the patient
Ğ Interac tion of patient and
caretaker(s)
Suspec ted
neglect
_
Note and doc ument:
_ Features of the sc ene which may
sugges t neglec t, i.e.,
Ğ Unsanitary surroundings
Ğ Lac k of food available
Ğ Responsible caretaker is a child
_ State of nutrition of the patient
_ State of cleanlines s of the patient
_ Presenc e or absenc e of patientÕ
s
prescription medic ations
_ Absenc e of identified medical aids, i.e.,
Eyeglasses
Hearing aid
Suc tioning equipment
Report all c ases of suspec ted abus e
to the County Department of Soc ial
Servic es and/or local law enforc ement
Special Consideratons :
_ Child abus e is the leading c aus e of injury
related death in infants under 1 y ear old.
_ Consider the possibility of child abuse:
Ğ Whenever a child is injured
Ğ Whenever an infant presents with
seizures or altered mental status.
_ EMTs and P aramedics are mandated by
law to report s uspec ted child abuse, and
are protec ted from civil s uit if they report
in good faith.
_ If the sc ene is unsafe, or the patient is
uns table physiologic ally , complete the
detailed examination in the ambulanc e
during transport
Document:
_ Observations
fac tually , i.e.,
ÒThe patient had a 1/2 inc h c irc ular
burn on the palm of the left handÓ,
not ÒThe patient had a c igarette burn
on the palm of the lef t handÓ.
_ Direct quotes from the patient or
c aretaker.
_ Observations,
not c onc lusions, i.e.,
ÒThere was a pile of dirty diapers
lying in the corner of the roomÓ,
not
ÒThe room was unsanitaryÓ.
-
Wisconsin EMS for Children, Rev. 7/2002
19
State of Wisconsin – Standards & Procedures of Practical Skills
WISCONSIN EMSC
DROWNING PROTOCOL: BLS CARE GUIDELINE
Initial Assessment Protocol

Is airway patent?
No
Yes
Yes
C-spine stabilization
Jaw thrust


No
No
Suspect C-spine
injury?

Head tilt, chin lift
Spontaneous
respiratory effort?
Yes




Give 100% O2
Support ventilation with BVM
at age-appropriate rate
Refer to Respiratory Arrest
Protocol
Consider use of PEEP1 if patient
is intubated



Give 100% O2
Assess ventilation
Assist breathing with BVM PRN
Does patient have
a pulse?2
No

Refer to Pulseless Arrest
Protocol
Yes
No
Signs of respiratory
distress?
No
Is the patient
in shock?
Yes
Yes


Nebulized Albuterol (2.5 mg in 3ml NS)
Refer to Respiratory Distress
Protocol









Refer to Shock Protocol
Remove wet clothing and
dry the patient
Assess for other signs
of trauma
Notes:
1. PEEP (positive end expiratory pressure)
applied to bag-valve-tube ventilation is likely
to improve oxygenation and lung compliance.
PEEP of 4 to 6 cm H20 is often helpful.
2. If severe hypothermia, refer to Hypothermia
Protocol
Contact medical control
Support ABCs PRN
Pulse oximetry, if available
Focused history
Keep warm
Monitor & transport
Document:
 Duration of immersion
 Type of liquid involved
 Temp of water
 CPR prior to EMS arrival
Wisconsin EMS for Children, Rev. 7/2002
20
State of Wisconsin – Standards & Procedures of Practical Skills
WISCONSIN EMSC
ENVIRONMENTAL HYPERTHERMIA PROTOCOL: BLS CARE GUIDELINE






Yes
No
Able to tolerate
Oral liquids?
Initial Assessment Protocol
Assess vital signs
Assess for signs of hyperthermia 1
Assess for environmental risk factors
Place in cool environment
Remove or loosen clothing as indicated
Severe cardiorespiratory compromise?
 Respiratory distress
 Poor perfusion
 Hypotension
Yes
Adequate
respiratory effort?
No
No

Secure airway
Support ventilation with BVM
at age-appropriate rate
Refer to Respiratory Arrest
Protocol

Give cool liquids


No

IV skills?
No
ALS intercept, if possible
Cardiac monitor
Pulse oximetry, if available
Initiate cooling measures:
– Spray with tepid water
– Fan body to evaporate
and cool



IV skills?
Yes
Yes

Yes
Start IV
Give fluid bolus NS/LR 20 ml/kg



Start IV
Give fluid bolus NS/LR 20 ml/kg
Improved?
Yes
No






Contact medical control
Support ABCs PRN
Pulse oximetry, if available
Focused history en route
Monitor & transport
Check blood glucose

Give additional NS/LR bolus
20 ml/kg to total 60 ml/kg
PRN

Cardiac monitor
Pulse oximetry, if available
Initiate cooling measures:
– Spray with tepid water
– Manually fan body to
evaporate and cool
No
Glucose < 60 mg/dl?2
Yes

EMT-B
 Per medical control, Glucagon
– 0.1 mg/kg IM/SQ
– Max. 1.0 mg
EMT- B/IV
 Glucagon, as above, or
 Glucose 0.5 gm/kg IV
diluted for age2
NOTES:
1. Signs and symptoms of hyperthermia include:
• Hot, dry, flushed or ashen skin
• Profound weakness and fatigue
• Tachycardia
• Vomiting, diarrhea
• Tachypnea
• Hypoperfusion
• Sweating (early), no sweating (late) • Muscle cramps
• Diminished level of consciousness
2. If unable to determine blood glucose contact medical control for local protocol
3. D50W: 1 ml/kg for children > 2 yr.
D25W: 2 ml/kg for infants, children < 2 yr.
(dilute D 50W 1:1 with sterile water)
D12.5W: 4 ml/kg for neonates < 28 days
(dilute D 50W 1:3 with sterile water)

No
Seizure in progress?
Yes

Refer to Seizure Protocol
Document:
 Clinical assessment
 Vital signs and pulse oximetry
 Therapy employed and response to it
 Communication with medical control
Wisconsin EMS for Children, Rev. 7/2002
21
State of Wisconsin – Standards & Procedures of Practical Skills
WISCONSIN EMS-C
HYPOTHERMIA PROTOCOL: BLS CARE GUIDELINES







Initial Assessment Protocol
Administer 100% 02, warmed if available
Assess vital signs
Complete initial assessment1
Assess for environmental risk factors
Remove from cold environment
Remove wet clothing, dry gently and
cover with blankets
No
Clinical Hypothermia?1
Yes
Warm patient by placing warm
packs to axillae and groin,
taking care to avoid direct skin
contact
Maintain horizontal position
Handle patient gently
Contact medical control
Support ABCs
Pulse oximetry, if possible5
Observe
Transport rapidly to the closest
appropriate medical facility








Severe cardiorespiratory
compromise?
 Respiratory distress
 Poor perfusion
 Hypotension
No
No

Yes



Secure airway, as indicated
Support ventilation with BVM
at age-appropriate rate PRN
Handle patient gently
ALS intercept, if available
Yes
IV skills?
Pulse palpable?2
Yes


No
NOTES:
1. Signs and Symptoms of clinical hypothermia include:
 Altered mental status
 Low or absent blood pressure
 Dilated, sluggish pupils
 Dysrhythmias
 Decreased reflexes
 Cyanosis (after oxygen)
 May appear dead
 Fast or slow respiratory rate
 Shivering
 Weak or absent pulses
2. In the case of severe hypothermia the pulse rate may be extremely
slow (< 30/min), and shivering may be absent .
3. “Pediatric capable” refers to an AED capable of an energy setting
of ≤ 50 joules.
4. If possible, set monophasic AED to deliver 200 J for the first and
second shock, and 300 J for the third shock. Do not deliver more
than 3 shocks until active rewarming is accomplished.
5. Pulse oximetry is likely to be inaccurate if the displayed heart rate
is significantly different from the actual measured heart rate.
6. Helicopter transport to a facility with pediatric cardiopulmonary
bypass capability is indicated in this case.
Perform chest
compressions

Establish vascular access
Give fluid bolus NS/LR
20 ml/kg (preferably warmed)
Patient ≥ 8 yrs. old
and ≥ 25 kg (55 lb)?
No
“Pediatric capable”
AED available?3
Yes

No
Yes
Apply AED
4

AED indicates
V -fib?
Apply AED
No
Yes

Shock up to 3 times
Yes
Pulse palpable?2
No

Continue chest
compressions
Special Considerations






No
Hypothermic heart is unlikely to respond to
resuscitation drugs, pacemaker stimulation
and defibrillation.
Drugs may be ineffective and may accumulate to
toxic levels.
Shivering stops when body temperature < 86° F.
Frostbitten areas should not be massaged; avoid
refreezing after rewarming.
Oxygen and IV fluids should be warmed, if
possible.
Do not apply heat directly to skin.
IV skills?
Yes





Document
 Clinical assessment and VS
 Resuscitation measures and response
 Meds given and response to each
 Communication with medical control
Establish vascular access
Give fluid bolus NS/LR
20 ml/kg (preferably warmed)
Contact medical control
Continue CPR
Transport rapidly to closest
appropriate medical facility 6
Wisconsin EMS for Children, Rev. 7/2002
22
State of Wisconsin – Standards & Procedures of Practical Skills
WISCONSIN EMSC
NEONATAL RESUSCITATION: BLS CARE GUIDELINE










Prepare field
Deliver head
Suction nose, mouth, and (gently) posterior
pharynx with 6 Fr catheter, or bulb syringe
Deliver body 1
Clamp and cut cord

Dry
Stimulate
Cover head
Keep warm
Spontaneous good
respiratory effort?
Infant crowning
No


Visualize and suction hypopharynx
ALS intercept, if possible
Perform deep suction
BVM ventilate between suctioning
attempts PRN to stabilize
Position airway
Support ventilation with BVM
and 100% oxygen @ 40-60
breaths/min for 30 sec

No

Yes
Thick particulate
meconium present?2

Yes
Heart rate?
< 60/min




60 -100/min
Support ventilation with
BVM and 100% oxygen

Continue ventilation @ 40-60/min
Chest compressions @ 120/min
Compressions:ventilations 3:1
ALS intercept, if possible
Heart rate > 100/min?
No

Contact medical control
Continue to support ABCs
Keep warm
Rapid transport
No
Yes
IV skills?

Give 100% O2
Yes


NOTES:
1. Maintain newborn at or below the level of the
mother’s perineum until the cord is clamped
2. Small amounts of meconium may merely discolor
the amniotic fluid without visible particles. In this
case no special management is necessary.
Meconium management is indicated for amniotic
fluid that is “pea soup” in appearance, or contains
visible meconium particles.
3. D12.5W: 4 ml/kg for neonates
(dilute D50W 1:3 with sterile water)
4. APGAR score, described with the table of normal
values, reflects the success of resuscitation.
Reassess RR and effort
Evaluate color
APGAR4 at 1 and 5 min
Continue support with
BVM and 100% oxygen
Cardiac monitor




No
IV skills?


Yes

Yes

> 100/min
Cyanotic?
No
Start IV with NS/LR @ TKO
Per medical control, consider:
– Naloxone 0.1 mg/kg IV/SQ/ET
– Glucose 0.5 gm/kg IV3
– Fluid bolus 10 - 20 ml/kg NS/LR
Document:
 Position and orientation of infant at
delivery
 Character of amniotic fluid, and presence
of meconium
 Cardiorespiratory impairment, if present
 Vital signs and pulse oximetry
 Therapy employed and response to it
 APGAR score at 1 and 5 min.
 Communication with medical control
23





Contact medical control
Continue to support ABCs
Keep warm
Observe
Transport
Special Considerations:
 The newborn’s pulse can be palpated
readily by feeling the umbilical stump
 Choices for vascular access are:
1. Peripheral vein, including scalp vein
2. Intraosseous
Wisconsin EMS for Children, Rev. 7/2002
State of Wisconsin – Standards & Procedures of Practical Skills
WISCONSIN EMSC
PEDIATRIC TRACHEOSTOMY WITH RESPIRATORY DISTRESS PROTOCOL:
BLS PREHOSPITAL CARE GUIDELINE




Special Considerations:
 Most pediatric tracheostomy
obstruction results from thickened
or dried secretions blocking the
narrow lumen of the tracheostomy
tube.
 Another cause, for children who
are dependent on mechanical
ventilation, is dysfunction of the
ventilator or/and oxygen source.
Initial Assessment Protocol
Ascertain that patient has a tracheostomy
Disconnect patient from mechanical
ventilator, if present
Support ventilation with resuscitator bag
and 100% oxygen connected directly to
the tracheostomy tube adapter at ageappropriate rate
Yes
Is the tracheostomy tube
positioned correctly?

Yes


No
Is the patient breathing
spontaneously and effectively?
Yes
No
NOTES:
1. Obstruction to ventilation can be
recognized by:
– Tachypnea or apnea
– Increased resistance to bagging,
– Diminished or absent chest rise,
– Poor breath sounds bilaterally,
– Cyanosis despite 100% oxygen.
2. Techniques for suctioning the tracheostomy
tube include:
– Attempt to bag via tracheostomy
tube with 100% oxygen.
– Select correct suction catheter (the
child’s caregiver will usually know),
a 3 mm ID tracheostomy tube will accept
a 6 Fr or 8 Fr suction catheter.
– Instill 1.0 to 2.0 ml NS into the trach
tube to loosen secretions.
– Insert the suction catheter 2 to 3 inches
or until the patient coughs. Do not force
the catheter against resistance. Do not
apply suction while inserting the catheter.
– Apply suction, no more than 100 mm Hg,
for 3 to 5 seconds while slowly removing
the suction catheter.
3. Techniques for replacing a tracheostomy
tube include:
– Use a tube the same size or smaller than
the tube being replaced.
– If the new tube has an obturator, leave it
in place.
– Moisten or lubricate the tip of the tube with
water, saline, or sterile lubricant.
– Gently insert the tube with a curving
motion, posteriorly then downward,
applying slight traction to the skin above
and below the stoma.
– To facilitate placement, a suction catheter
can be inserted through the tracheostomy
tube and used as a guide.
– Remove obturator, give bagged breaths.
– Check for proper placement by noting:
Bilateral chest rise with bagging
Bilateral breath sounds
Lack of high resistance to ventilation
Improvement in patient condition
– If a new tracheostomy tube is not available,
an endotracheal tube of the same outer
diameter can be used, inserted the same
length as the tracheostomy tube.
No
Is there obstruction to
ventilation?1

Suction the tracheostomy tube2
Attempt to support ventilation with
resuscitator bag


Is the tracheostomy tube
still obstructed?
Provide supplemental
oxygen with mask applied
to tracheostomy tube
Pulse oximetry, if available
Assist/provide ventilation
with resuscitator bag
to tracheostomy tube
Pulse oximetry, if available
No
Is perfusion adequate?
No
Yes
Yes


Suction the tracheostomy tube a
second time2
Attempt to support ventilation with
resuscitator bag



Communicate with medical control
Rapid transport
Close monitoring en route with
pulse oximetry, if available
No
Is the tracheostomy tube
still obstructed?
Yes




Cut or untie the tracheostomy ties
Remove the tracheostomy tube
Replace the tracheostomy tube3
Attempt to ventilate through the
new tracheostomy tube
Is the airway
still obstructed?

Refer to Shock Protocol
No
Yes



ALS intercept, if possible
Consider:
– BVM ventilation with mask over nose
and mouth, and a sterile occlusive
dressing over the tracheostomy stoma
– BVM ventilation with infant mask over
the tracheostomy stoma
– Orotracheal intubation
– Intubation with endotracheal tube
through the tracheostomy stoma
Communicate with medical control
Document:
 Patient’s clinical condition and VS
 Actions taken and response to them
 Communication with medical control
Wisconsin EMS for Children, Rev. 7/2002
24
State of Wisconsin – Standards & Procedures of Practical Skills
WISCONSIN EMSC
PEDIATRIC PULSELESS ARREST PROTOCOL: BLS CARE GUIDELINE




Initial Assessment Protocol
Establish unresponsiveness
– Position airway
Determine breathlessness
– Ventilate with BVM and
100% oxygen
Determine pulselessness
– Perform chest compressions
ALS intercept, if possible
Patient ≥ 8 yrs. old
and ≥ 25 kg (55 lb)?
No
“Pediatric capable”
AED available?1
Yes
Yes
Apply AED
2


Yes
Shock up to 3 times
No

Apply AED
AED indicates
V -fib?
No



Convert to pulseproducing rhythm?
No
Yes


Continue chest compressions
Consider intubation3,4,5
Identify and treat possible causes:
– Hypoxemia
– Hypovolemia
– Hypothermia
– Hyper-/hypokalemia, acidosis
– Tension pneumothorax
– Tamponade
– Toxins/poisons/drugs
Yes
Consider intubation3,4,5
Ventilate with 100% oxygen
Convert to pulseproducing rhythm?
No
No
IV skills?

Ventilate with 100% oxygen
Yes

IV skills?
Start IV
No
Yes







Refer to appropriate protocol PRN:
– Bradycardia
– Shock
Contact Medical Control
Support ABC’s
Complete initial assessment
Observe
Keep warm
Transport



Start IV
Contact medical control for
recommendation for continued
resuscitation
Initiate rapid transport if indicated
Document:
 Clinical assessment
 AED readings
 Resuscitative measures and response,
including changes in cardiac rhythm
 Meds given and response to each
 Communication with medical control
NOTES:
1. “Pediatric capable” refers to an AED
capable of an energy setting of ≤ 50 joules.
2. If possible, set monophasic AED to deliver
200 J for the first and second shock, and
300 J for the third shock.
3. The decision for tracheal intubation vs.
continued BVM ventilation depends on
several factors, including:
– Local protocol and medical control
instructions,
– Anticipated transport time,
– Adequacy of BVM ventilation,
– Need to protect the airway.
4. ALS-capable assistance needed
if intubation is not within scope of practice.
5. A non-visualized airway can be used in
children of sufficient height:
– Regular Combitube ® if pt. taller than 5’.
– Small Combitube ® if pt.≥ 4’8” and ≤ 5’.
Special Considerations:
 Most pediatric pulseless
arrests are consequent
upon respiratory arrest.
 If resuscitative efforts are
unsuccessful, reevaluate
oxygenation and ventilation.
 When sudden unexpected death
of an infant occurs:
– Contact Medical Control for
possibility that body should
remain at scene for Coroner
investigation.
– Compassionate interaction
with a grieving family may be
helpful to them.
Wisconsin EMS for Children, Rev. 7/2002
25
State of Wisconsin – Standards & Procedures of Practical Skills
WISCONSIN EMSC
POISONING/TOXIC EXPOSURE PROTOCOL: BLS CARE GUIDELINE

Initial Assessment Protocol
Refer to appropriate protocols:
– Altered Level of Consciousness
– Anaphylaxis
– Bradycardia
– Child Abuse/Neglect Suspected
– Pulseless Arrest
– Respiratory Arrest
– Respiratory Distress
– Seizures
– Shock

Route(s) of exposure?
Inhalation





Skin, eye or mucous
membrane
Ingestion
If hazard of inhaled poison or toxin
is still present DO NOT ENTER
SCENE without PPE1
Remove patient to fresh air
Administer 100% oxygen
Consider additional routes of
exposure (skin, eye)
Identify substance(s) involved;
bring container or label to
hospital, if possible



Look for source of poison or toxin
Identify and estimate amount of
substance ingested
Collect containers or medication
bottles and take with patient







Special Considerations:
 The national and Wisconsin Poison
Center phone number is 800-222-1222
anywhere in the state.
 Most important to stabilize the patient
 Because it is sometimes difficult to determine exactly how much of a substance
a child has taken, special attention is
needed in obtaining the history.
 Determine infant/child’s weight and estimated amount of poison ingested to
help determine appropriate treatment.
 Generally, do not induce vomiting,especially if corrosive ingestion is suspected
 Anticipate possible vomiting, seizures,
respiratory and CNS depression, and
dysrhythmias, and refer to appropriate
protocols.
 Contact medical control or a Poison
Control Center for specific information
about individual toxic exposures and
treatments.


If hazard of spilled poison or toxin
is still present, avoid crosscontamination
Remove patient from contaminated
area and remove contaminated
clothing and/or jewelry
If eyes are involved check for and
remove contact lenses
Identify substance involved
Flush copiously with tap water or
normal saline. If toxin is a powder,
brush off before flushing.
Bring container or label with patient
Estimate timing and duration of exposure
Contact medical control and/or a Poison
Control Center immediately and provide
exposure information
Treat as per medical/poison center
direction2 and transport
Document:
 Nature of exposure to poison/toxin
 Clinical assessment and VS
 Resuscitation measures and response
 Meds given and response to each
 Communication with medical control
and/or Poison Control Center
NOTES:
1. PPE is personal protective equipment
2. Medications which may be given
under medical control and/or Poison
Control Center advice include:
– Activated charcoal 1gm/kg PO to a
maximum of 50 gm. Caution for risk of
vomiting and aspiration. Shake well
before administration.
– Syrup of ipecac 10-30 ml PO, based
on age of patient, with vomiting 10-20
minutes after administration
Wisconsin EMS for Children, Rev. 7/2002
26
State of Wisconsin – Standards & Procedures of Practical Skills
WISCONSIN EMSC
RESPIRATORY ARREST PROTOCOL: BLS CARE GUIDELINE

Initial Assessment Protocol
Perform airway manuever, maintaining
in-line C-spine stabilization PRN
– Jaw thrust or chin lift
– Suction
– Oropharyngeal airway

Administer 100% oxygen
Support ventilation with BVM
at age-appropriate rate
ALS intercept, if possible


Refer to Respiratory Distress
Protocol
Yes
Spontaneous breathing
restored?
No







Reposition and reassess
Relieve upper airway obstruction
Consider back blows, chest/abdominal
thrusts (age dependent)
Direct laryngoscopy, foreign body removal
with Magill forcepsPRN (if so trained)
Secure airway as appropriate1,2,3
No
No
Adequate chest rise?
Yes
Yes
Adequate chest rise?


Continue BVM ventilation at age-appropriate rate PRN
Secure airway as appropriate1,2,3
Yes
IV skills?

Obtain IV access,
NS/LR @ TKO rate
No

No
Refer to Shock Protocol, or
Pulseless Arrest Protocol
Normal perfusion?
Yes
NOTES:
1. The decision for tracheal intubation vs.
continued BVM ventilation depends on
several factors, including:
– Local protocol and medical control
instructions,
– Anticipated transport time,
– Adequacy of BVM ventilation,
– Need to protect the airway.
2. ALS-capable assistance needed
if intubation is not within scope of
practice.
3. A non-visualized airway can be used in
children of sufficient height:
– Regular Combitube ® if pt. taller than 5’.
– Small Combitube ® if pt.≥ 4’8” and ≤ 5’.
4. If unable to determine blood glucose
contact medical control for local protocol
5. D50W: 1 ml/kg for children > 2 yr.
D25W: 2 ml/kg for infants, children < 2 yr.
(dilute D50W 1:1 with sterile water)
D12.5W: 4 ml/kg for neonates < 28 days
(dilute D50W 1:3 with sterile water)
EMT-B
 Per medical control, Glucagon
– 0.1 mg/kg IM/SQ
– Max. 1.0 mg
EMT- B/IV
 Glucagon, as above, or
 Glucose 0.5 gm/kg IV
diluted for age5
 Per Medical Control, consider
Naloxone IV:
< 20 kg: 0.1 mg/kg
> 20 kg: 2mg dose

Check blood glucose
Yes
Glucose < 60 mg/dl?4
No










Special Considerations:
 Respiratory arrest may be a sign of a
toxic ingestion or metabolic disorder.
Consider naloxone or glucose per
medical control.
Contact Medical Control
Support ABCs
If patient is seizing, refer to
Seizure Protocol
Detailed physical exam
Cardiac monitor
Pulse oximetry, if available
Continue to monitor & observe
Focused history (en route)
Keep warm
Monitor and transport
Document:
 Clinical assessment and VS
 Resuscitative measures and response
 Meds given and response to each
 Communication with medical control
Wisconsin EMS for Children, Rev. 7/2002
27
State of Wisconsin – Standards & Procedures of Practical Skills
WISCONSIN EMSC
RESPIRATORY DISTRESS PROTOCOL: BLS PREHOSPITAL CARE GUIDELINE





Initial Assessment Protocol
Administer 100% Oxygen
Detailed physical exam
Pulse oximetry, if available
Refer to PediatricTracheostomy
with Respiratory Distress Protocol PRN
Lower vs. upper
airway disease?
Reactive (Lower) Airway Disease
 Wheezing
 Grunting
 Retractions/nasal flaring
 Tachypnea
 Decreased breath sounds
 Central cyanosis
 Tachycardia/bradycardia
 Decreasing level of
consciousness
Yes
Partial (Upper) Airway Obstruction:
 Suspected FBAO, croup, or
epiglottitis
 Stridor
 Choking
 Drooling
 Hoarseness
 Retractions/Acc. muscle use
 Tripod position
Known history of
reactive airway disease?
No
Poor perfusion?
Yes

Refer to Shock Protocol
No




Position of comfort with caregiver
Nebulized bronchodilator(s):
– Albuterol (2.5 mg/3ml NS)
– For EMT-B/IV:
Ipratroprium (0.5 mg/3 ml NS)
added to the initial albuterol
treatment only
Cardiac monitor






Contact medical control
Support ABCs PRN
Pulse oximetry, if available
Focused history
Keep warm
Monitor & transport





Yes
Distress/obstruction
relieved?
No
Avoid agitation
Position of comfort with caregiver
Assess tolerance to O2 administration
Do not look in the throat
Do not attempt intubation or IV access

Refer to Respiratory Arrest
Protocol
Document:
 Severity of respiratory distress
 Signs of upper or lower airway disease
 Vital signs and pulse oximetry
 Changes in VS and pulse oximetry
when O2 given
 Therapy employed and response to it
 Communication with medical control
Wisconsin EMS for Children, Rev. 7/2002
28
State of Wisconsin – Standards & Procedures of Practical Skills
WISCONSIN EMSC
SAFE PLACE FOR NEWBORNS1: BLS CARE GUIDELINE
Parent calls 911 or brings infant
to law enforcement or EMT


Yes
Initial Assessment Protocol
for newborn infant2
Infant clinically stable?
No


Yes Reasonable cause to suspect
infant is victim of abuse?
Refer to Child Abuse/
Neglect Suspected Protocol
No

Offer to provide needed
care for infant, including
transport, but decline to
accept legal custody
Yes
Refer to appropriate protocol:
– Altered Mental Status Protocol
– Bradycardia Protocol
– Pediatric Pulseless Arrest Protocol
– Respiratory Arrest Protocol
– Respiratory Distress Protocol
– Seizure Protocol
– Shock Protocol
– Trauma Protocol
Is it reasonable to believe
the infant is more than
72 hours old?
No





Accept legal custody of the newborn.
Assure anonymity and confidentiality
for the parent and anyone assisting
the parent.
Offer care to the parent, if female, but do
not induce her to reveal her identity.
All information obtained must remain
confidential except to attending physician
and County Social Service staff.
Make available to the parent the Maternal
and Child Health toll free number,
1-800-722-2295, for resources and referral
information. The parent has the right to
refuse the information.




Special Considerations:
 More information can be obtained from
the internet web site:
www.safeplacefornewborns.org
NOTES:
1. This protocol is based on Wis 2001 Act 2,
Safe Place for Newborns legislation, enacted
on April 3, 2001, intended to provide a safe
place for unwanted newborn infants rather than
abandonment, injury or death. The goal is to
provide anonymous, confidential protective
shelter, medical care and treatment in a hospital
setting for babies reasonably believed to be less
than or equal to 72 hours old. The parent
relinquishing custody of the child has the right
to remain anonymous.
2. In applying the Pediatric Assessment Triangle two
elements of the “Appearance” must be modified to
account for the newborn age:
– Interactiveness: responds to voice or touch vs.
agitated vs. lethargic
– Look/gaze: blinks to light vs. glassy-eyed stare
Contact medical control
Pulse oximetry, if available
Transport to an emergency
department which can provide
appropriate care and referral to
County Social Service within
24 hours
Monitor closely during transport
Document:
 Clinical condition of infant, including
initial assessment, VS and pulse oximetry
 Any therapies provided and the response to them
 Communication with medical control
 DO NOT attempt to ascertain or document
the identity or location of parent or person assistin parent unless:
– Child abuse is suspected
– It appears that the person assisting the parent
is coercing her/him to relinquish custody
Wisconsin EMS for Children, Rev. 7/2002
29
State of Wisconsin – Standards & Procedures of Practical Skills
WISCONSIN EMSC
SEIZURE PROTOCOL: BLS CARE GUIDELINE






Contact medical control
Support the ABC’s as needed
Rapid transport
Continued monitoring
Focused history and detailed exam
en route
Initial Assessment Protocol
No
Seizure in progress?
Yes
No
Spontaneous breathing?
Refer to Respiratory Arrest
Protocol

Yes


Position patient on side
if trauma not suspected
Protect against injury
Open airway with C-spine
stabilization if trauma suspected
– Jaw thrust
– Suction1
– Nasopharyngeal airway

No
Airway adequate?
Yes


Yes
Administer 100% oxygen
Pulse oximetry, if available
Airway adequate?
No
Patient cyanotic, or
pulse oximetry reading < 90%?
Yes

Assist ventilation with BVM and
100% oxygen
No
No
IV skills?
Circulation adequate?

No
Yes

No

Yes
Start IV
Give fluid bolus NS/LR
10 - 20 ml/kg
ALS intercept, if possible
Seizure still in progress, or
Status epilepticus?2
Yes

NOTES:
1. Do not force suction device between teeth.
2. Status epilepticus is defined as a seizure
that lasts for more than 30 minutes, or a
series of seizures over 30 minutes during
which full consciousness is not regained.
3. If unable to determine blood glucose,
contact medical control for local protocol.
4. D50W: 1 ml/kg for children > 2 yr.
D25W: 2 ml/kg for infants, children < 2 yr.
(dilute D50W 1:1 with sterile water)
D12.5W: 4 ml/kg for neonates < 28 days
(dilute D50W 1:3 with sterile water)
Glucose < 60 mg/dl?3
No

ALS intercept, if possible
Yes
EMT-B
 Per medical control, Glucagon
– 0.1 mg/kg IM/SQ
– Max. 1.0 mg
EMT- B/IV
 Glucagon, as above or
 Glucose 0.5 gm/kg IV
diluted for age4
No
Seizure stopped?
Yes


Document:
 Presence, type and duration of seizure
 Respiratory impairment if present
 Vital signs and pulse oximetry
 Therapy employed and response to it
 Communication with medical control
Check blood glucose



Contact medical control after
glucagon or glucose given
Support the ABC’s as needed
Rapid transport
Continued monitoring
Focused history and detailed
exam en route
Special Considerations:
 Do not attempt intubation while
patient is actively seizing
Wisconsin EMS for Children, Rev. 7/2002
30
State of Wisconsin – Standards & Procedures of Practical Skills
WISCONSIN EMSC
SHOCK PROTOCOL: BLS CARE GUIDELINE


_
_
_
Initial Assessm ent Protocol
Secure airway as appropriate
Give 100% O 2
Cardiac monitor
Supine position
Etiology
of shoc k?
Hypovolemic shock
(Suspec ted dehy dration,
3 rd spac ing,
hemorrhage)
No
IV skills?
_
No
ALS intercept,
if possible
IV skills?
_
Anaphy laxis
suspec ted?
No
Glucose < 60 mg/dl?
Yes
Repeat boluses of 20 ml/kg
PRN to maximum 60 ml/k g
Improved?
Repeat boluses of 20 ml/kg
PRN to maximum 60 ml/k g
_
No
EMT -B
_
Per medic al c ontrol, Glucagon
Ğ 0.1 mg/k g IM/S Q
Ğ Max. 1.0 mg
EMT - B/IV
_
Glucagon , as above or
_
Glucose 0.5 gm/k g IV
diluted for age 3
No
No
2
Yes
Yes
No
Heart rate < 100/min
with poor perfusion?
ALS interc ept, if possible
Start IV
Give fluid bolus NS/ LR 20 ml/kg
_
Yes
Improved?
_
_
Yes
Start IV
Give fluid bolus NS/ LR 20 ml/kg
_
Cardiogenic shoc k
(History of congenital heart
disease or surgery ,
rhy thm dis turbance,
hy pogly c emia, post
cardiac arrest)
Distributive shoc k
(Suspec ted sepsis,
anaphy laxis)
Yes
_
1
Yes
Yes
_
Improved?
Refer to Bradycardia Protocol
_
Refer to Allergic Reaction/
Anaphylaxis Protocol
No
No
IV skills?
Yes
_
_
_
_
_
_
_
_
Contac t Medic al Control
Support ABCÕ
s
Pulse oximetry if available
Rapid transport
Observe
Keep warm
Detailed physic al exam (en route)
Foc used his tory (en route)
NOTES:
1. Tension pneumothorax can produc e shock.
Refer to Traum a Protocol
2. If unable to determine blood glucose
contact medical control for local protocol
3. D 5 0 W: 1 ml/kg for c hildren > 2 y r.
D 2 5 W: 2 ml/kg for infants, c hildren < 2 y r.
(dilute D 5 0 W 1:1 with s terile water)
D 1 2 .5 W: 4 ml/kg for neonates < 28 days
(dilute D 5 0 W 1:3 with s terile water)
_
_
Special Considerations:
_ Assessment for improved s tatus s hould
include evaluation of the ABCÕ
s and
lung sounds
_ Fluid should be given c autiously in
c ardiogenic shock
Start IV
Give fluid bolus NS/ LR 10 ml/kg
Document:
_
Clinic al assessment and V S
_
Resusc itative measures and res ponse
_
Meds given and response to each
_
Communic ation with medic al c ontrol
Wisconsin EMS for Children, Rev. 7/2002
31
State of Wisconsin – Standards & Procedures of Practical Skills
WISCONSIN EMSC
TRAUMA PROTOCOL: BLS PREHOSPITAL CARE GUIDELINE

Initial Assessm ent Protocol
Special features of pediatric trauma

_
_
_
_
_
_
Airway:
Obstruction c ommon
in head injury
Open with jaw thrus t
C-spine stabilization
E xpec t vomiting
Suction P RN
Advanced airway
management - BVM
vs. intubation 2
_
_
_
1
_
_
Breathing:
Give 100% O 2
BVM assis ted breath ing PRN
ALS interc ept for
suspec ted tension
pneumothorax 3
Three-sided dressing
for suc king chest
wound
_
_
_
_
NOTES:
_
1. Indications for spinal immobilization inc lude:
Mechanism of injury likely to involve head or spine
Altered level of c onsc iousness
Signs or sy mptoms of weakness or numbness
E vidence of trauma to head, neck, chest or spine
Spinal pain
Maintain neck in neutral position by plac ing padding
beneath shoulders, bac k and hips on s pine board.
2. Advanc ed airway management:
Fac tors favoring BV M airway support
Combativeness, s trong gag reflex
Spas m of jaw muscles
Short on -sc ene and transport times
Fac tors favoring endotrac heal intubation ( if so trained) Unresponsive child
Absent gag reflex
Apnea, poor muscle tone
Long extrication or transport time
Limited pers onnel available during trans port
3. Suspec t tension pneumothorax when the following are pres ent:
Blunt or penetrating c hest injury
Respiratory distress
Hy poxia
Hy poperfusion
4. MAS T trousers are not indic ated for hy potension, exc ept
possibly in the patient with clinic ally uns table pelvic fracture
.
5. Normal ventilatory rate (breaths/ min):
30 for infants < 1 y r., 20 for toddlers and c hildren
 ventilatory rate:
35 for infants < 1 y r., 25 for toddlers and c hildren
6. ÒMajorÓtrauma is defined as one or more of the following:
Patient unresponsive to voic e
Sy stolic blood pressure (mm Hg):
< 60 (0 -6 mos.), < 70 (6 mos. -5 yr.), < 80 (> 5 yr.)
Respiratory rate (breaths/ min):
> 60 (0 -1 y r.), > 40 (> 1 yr.), or inadequate or
ineffec tive respiratory effort,
stridor , grunting
Penetrating injuries to head, neck, torso, or extremities
proximal to the elbow or knee
Flail c hest
Two or more proximal long bone frac tures (
humerus , femur)
Unstable pelvic fractures
New onset paraly sis
Amputation injuries proximal to the wrist or ank le
Burns (2¡ or 3¡) c overing > 15% of body surface area
7. ÒPotentially majorÓtrauma is defined as one or more of:
Any physiologic abnormality or severe pain
Ejection from automobile during c rash
Death of another person in the same auto
E xtric ation time > 20 min.
Vic tim of rollover auto crash
Vic tim of high speed c rash (impac t speed > 40 mph, major
auto deformity, intrusion of damage into passenger spac e)
Auto -pedes trian/auto -bic ycle injury with signific ant impac t
Motorc yc le crash > 20 mph, or separation of rider from bike
Falls > 10 ft.
Circulation: 4
E xternal hemorrhage
c ontrol
Shock position if no
head injury
Splint fractured ex tremity (traction
splint for femur to
reduce pain or re store c irculation or
sens ation)
If shoc k present, ALS
interc ept, if possible
(refer to Shock
Protocol )
_
_
ABCDEÕ
s
_
_
_
_
_
Disability:
Assess with AVPU
scale and pupillary
size, equality and
response to light
For patients in ÒPÓor
ÒUÓcategories,as sist
ventilation PRN
If pupils equal and
reactive to light us e
normal ventilatory
rate 5
If pupils dilated, un equal, unreactive
to light, or c hild is
pos turing, use 
ventilatory rate 5
Immediate transport (c onsider
aeromedic al transport) to a
Pediatric Trauma Center, if possible
Clos e monitoring during transport
_
_
_
Exposure:
E xamine bac k while
immobilizing
Keep c hild warm c over infantÕ
s head
(not the fac e)
Yes
Is this ÒmajorÓtrauma?
No
_
_
Contac t Medic al Control and consider
trans port to a Pediatric Trauma Center
Clos e monitoring during transport
Yes
Is this Òpotentially
majorÓtrauma?
7
No
_
_
Foc used history and
exam at the sc ene
Transport to E.D. with
close monitoring
Special Considerations:
_ Head injury is the leading killer of children
_ The head injured pediatric patient of ten dis plays:
Ğ Airway obstruc tion due to
 musc le tone
Ğ Vomiting and as piration
Ğ Seizures
_ Head injured patients may experienc e
 intra c ranial pressure during intubaion unless rapid
sequence intubation technique is us ed. BV M
ventilation may be safer for such patients.
_ Shock in the pediatric trauma vic tim is mos t
often due to blood loss, usually in the abdomen,
or thigh (with a femur frac ture).
_ Consider the possibility of child abuse in all
pediatric trauma victims, and all infants with
altered mental status (refer to
Child Abuse/
Neglect Suspected Protocol )
Wisconsin EMS for Children, Rev. 7/2002
32
6
State of Wisconsin – Standards & Procedures of Practical Skills
WISCONSIN EMSC
EMERGENCY MEDICAL SERVICES
FOR CHILDREN
ALS PREHOSPITAL CARE
GUIDELINE
33
State of Wisconsin – Standards & Procedures of Practical Skills
WISCONSIN EMSC
INITIAL ASSESSMENT PROTOCOL: ALS PREHOSPITAL CARE GUIDELINE
Pre-arrival preparation:
 Plan scene size-up
 Prepare pediatric equipment,
based on dispatch information

Review “Child Alert”
information in ambulance
or dispatch center
Yes
Child with special
medical needs?
No
Scene size-up. Assess:
 Safety hazards to patient, caregiver, EMT
 Mechanism of injury/nature of illness
 Environment
 Universal precautions assured
Initial patient assessment
 Pediatric Assessment Triangle
– Appearance
– Work of breathing
– Circulation to the skin
 Primary survey
– Airway
– Breathing
– Circulation
– Disability (AVPU)
– Exposure (children cool quickly)
 Vital signs
Severity of
physiologic abnormality?
Stable or none



Detailed physical exam
Focused history (SAMPLE)
– Signs/symptoms
– Allergies
– Medications
– Past pertinent medical history
– Last oral intake
– Events leading to call
Refer to appropriate protocols:
– Altered Level of Consciousness
– Anaphylaxis
– Burns
– Child Abuse/Neglect Suspected
– Drowning
– Environmental Hyperthermia
– Hypothermia
– Pediatric Tracheostomy with
Respiratory Distress
– Poisoning/Toxic Exposure
– Respiratory Distress
– Safe Place for Newborns
– Tachycardia with Adequate
Perfusion
– Trauma
Unstable

Refer to appropriate protocols:
– Altered Level of Consciousness
– Anaphylaxis
– Bradycardia
– Burns
– Child Abuse/Neglect Suspected
– Drowning
– Environmental Hyperthermia
– Hypothermia
– Neonatal Resuscitation
– Pediatric Tracheostomy with
Respiratory Distress
– Poisoning/Toxic Exposure
– Respiratory Distress
– Safe Place for Newborns
– Seizures
– Shock
– Tachycardia with Poor Perfusion
– Trauma
NOTES:
1. Refer to back of page for ageappropriate vital signs
Critical

Refer to appropriate protocols:
– Anaphylaxis
– Bradycardia
– Burns
– Child Abuse/Neglect Suspected
– Drowning
– Environmental Hyperthermia
– Hypothermia
– Neonatal Resuscitation
– Poisoning/Toxic Exposure
– Pediatric Pulseless Arrest
– Respiratory Arrest
– Safe Place for Newborns
– Seizures
– Shock
– Trauma
Document:
 Clinical assessment and VS
 Key historical features
Wisconsin EMS for Children, Rev. 1/2002
34
State of Wisconsin – Standards & Procedures of Practical Skills
WISCONSIN EMSC
ALTERED LEVEL OF CONSCIOUSNESS PROTOCOL: ALS CARE GUIDELINE
Initial Assessment Protocol

Seizure in progress?
Yes

Refer to Seizure Protocol
No
Spontaneous breathing?
No
Refer to Respiratory Arrest Protocol

Yes

Position patient on side
if trauma not suspected

Airway adequate?
No
Yes
Yes
Administer 100% oxygen
Pulse oximetry, if available


Open airway, with C-spine stabilization
if trauma suspected
– Jaw thrust
– Suction
– Nasopharyngeal airway
Airway adequate?
No
Patient cyanotic, or
pulse oximetry reading < 90%?

Yes

Maintain airway
Assist ventilation with BVM and
100% oxygen
No

Yes
Check blood glucose
Circulation adequate?
No
Glucose < 60 mg/dl?1
No


Yes







Start IV/IO
Give fluid bolus NS/LR
10 - 20 ml/kg
Glucagon 0.1 mg/kg IM/SQ
(max 1 mg), or
Glucose 0.5 gm/kg IV/IO,
diluted for age2
Contact medical control
Support the ABC’s as needed
Rapid transport
Continued monitoring
Focused history and detailed exam
en route
Document:
 Level of consciousness ( AVPU scale),
motor activity and pupillary size, symmetry,
reaction to light
 Respiratory impairment if present
 Vital signs and pulse oximetry
 Therapy employed and response to it
 Communication with medical control
NOTES:
1. If unable to determine blood glucose
contact medical control for local protocol
2. D50W: 1 ml/kg for children > 2 yr.
D25W: 2 ml/kg for infants, children < 2 yr.
(dilute D50W 1:1 with sterile water)
D12.5W: 4 ml/kg for neonates < 28 days
(dilute D50W 1:3 with sterile water)
Special Considerations:
 Intubation may be necessary to protect
the airway. Confirmation tracheal intubation by
exhaled CO2 determination, when possible.
 In the focused history, consider the possible
causes of altered level of consciousness,
AEIOU – TIPPS:
Alcohol
Epilepsy, endocrine (diabetes), electrolytes
Insulin
Opiates and other drugs
Uremia (kidney failure)
Trauma, temperature
Infection
Psychogenic
Poison
Shock, stroke, space occupying lesion,
subarachnoid hemorrhage
 In the case where any of the above causes is
identified, refer to the appropriate protocol
Wisconsin EMS for Children, Rev. 1/2002
35
State of Wisconsin – Standards & Procedures of Practical Skills
WISCONSIN EMS -C
ANAPHYLAXIS/ALLERGIC EMERGENCY PROTOCOL: ALS CARE GUIDELINES


_
Initial Assessm ent Protocol
Administer 100% O 2
Assess vital signs
Cardiorespiratory
c ompromise?
Respiratory distress,
or poor perfusion
without hy potension
None

If related to insec t sting,
apply ice to site
Epinephrine S Q 1:1000
 0.01 mg/kg (0.01 ml/k g)
 Maximum single dose: 0.3
Severe respiratory distress,
respiratory arrest, and/or
hy potensive shoc k


- 0.5 mg



Nebulized Albutero l 2.5 mg in 3 ml NS
Q 15 min P RN for wheezing


Sec ure airway PRN
Support ventilation with B VM at age
appropriate rateP RN
Start IV/I0
Epinephrine IV/ IO 1:10,000
Ğ 0.01 mg/kg (0.1 ml/kg)
Ğ maximum single dos e 0.1 mg
Give NS/LR bolus 20 ml/kg
Nebulized Albutero l 2.5 mg in 3 ml NS
Q15 minutes P RN for wheezing
Yes
Improved?
No
¥
¥
¥
¥

Contact medical control
Support ABCs
Keep Warm
Monitor & transport


Cardiac monitor
Pulse oximetry , if available

Special Considerations:
 If prolonged transport consider
Diphenhydram ine (Benadryl) IV/IO 1 mg/kg
(0.l ml/kg) slow push over 2
-3 minutes
 Simple hives do not require field treatment
other than ic e pack at site of ins ec t sting
Epinephrine IV/ I0 1:10,000
Ğ 0.01 mg/kg ( 0.l ml/kg) Q5 min P RN
Ğ Maximum single dos e: 0.1 mg
Give bolus NS/LR 20ml/kg, to a
maximum of 60 ml/k g P RN for shock
Document:




Clinical ass ess ment and V S
Resusc itative measures and res ponse
Meds given and response to eac h
Communic ation with medical control
Wisconsin EMS for Children, Rev. 1/2002
36
State of Wisconsin – Standards & Procedures of Practical Skills
WISCONSIN EMSC
BRADYCARDIA PROTOCOL: ALS CARE GUIDELINE



Initial Assessment Protocol
Administer 100% O2
Assess vital signs
HR < 100 BPM and severe
cardiorespiratory compromise?
 Poor perfusion
 Hypotension
 Respiratory distress
No
Secure airway
Support ventilation with BVM
at age-appropriate rate
Pulse oximetry, if available

Yes


Yes
Increased HR and/or
improved circulation?
No
Yes
Heart rate ≥ 60/min ?
No
Perform chest compressions
Continue as indicated by HR






Glucagon 0.1 mg/kg IM/SQ
(max 1 mg), or
Glucose 0.5 gm/kg IV/IO,
diluted for age2
Start IV/IO with NS/LR @ TKO
Check blood glucose
Yes
Glucose < 60 mg/dl?1
No
Increased HR and/or
improved circulation?
No
Epinephrine
 IV/IO: 0.01 mg/kg (0.1 ml/kg 1:10,000)
 ET: 0.1 mg/kg (0.1 ml/kg 1:1,000)
 Repeat Q 3-5 min if no response
Yes
Special Considerations:
 Hypoglycemia may cause
bradycardia in infants
 Special conditions may apply for
severe hypothermia. Refer to
Hypothermia Protocol
NOTES:
1. If unable to determine blood glucose
contact medical control for local protocol
2. D50W: 1 ml/kg for children > 2 yr.
D25W: 2 ml/kg for infants, children < 2 yr.
(dilute D50W 1:1 with sterile water)
D12.5W: 4 ml/kg for neonates < 28 days
(dilute D50W 1:3 with sterile water)
Yes
Increased HR and/or
improved circulation?
No
Atropine 0.02 mg/kg
 Minimum dose 0.1 mg
 Maximum single dose:
– 0.5 mg for child
– 1.0 mg for adolescent
 May be repeated once







Contact medical control
Support ABC’s
Observe
Keep warm
Transport
Detailed physical exam (en route)
Focused history (en route)
Document:
 Clinical assessment and VS
 Resuscitative measures and response
 Meds given and response to each
 Communication with medical control
Yes
Increased HR and/or
improved circulation?
No

Refer to Pulseless Arrest Protocol
as indicated
Wisconsin EMS for Children, Rev. 1/2002
37
State of Wisconsin – Standards & Procedures of Practical Skills
WISCONSIN EMSC
BURN PROTOCOL: ALS CARE GUIDELINE




Initial Assessment Protocol
Secure airway as appropriate
Give 100% O2
Stop the burning process
Thermal Burn



Chemical Burn
Remove clothing
Expose burned area
Remove metal or
constricting items


Electrical Injury
If dry chemical, brush off
before flushing
Flush area with water for
at least10-15 min



Assess wounds
Cover with sterile dressing
ECG monitor for dysrhythmia
No
Dysrhythmia present?

Estimate Total Body Surface
Area (BSA) involved, 1 and
depth of burn
Yes
Refer to appropriate
dysrhythmia protocol
No
Total BSA with
2° or 3° burns > 5%
Yes



Start IV/IO
Contact Medical Control
for fluid resuscitation
guidelines
If patient is in shock, see
Shock Protocol
Cover burn with dry sterile,
preferably non-stick, dressing
Refer to local pain management
guidelines


No
Special Considerations:
 Pulse oximetry will give a falsely high
reading in presence of carbon
monoxide or cyanide inhalation.
 Consider possibility of child abuse.
 Patients are NEVER hypotensive
from acute burns. Fluid shifts take
hours to occur.
 Potential for hypothermia from cooling
of uncovered burn.
Notes:
1. The “rule of nines” does not apply to children because of relati vely
larger heads and smaller lower extremities. BSA can be estimated
using the table on the back of this sheet. Small burn areas can be
estimated by: the area of the child’s palm between wrist and fingers
is 1% of BSA.
2. In the absence of local guidelines, effective pain control can usually
be acfhieved with Morphine sulfate 0.1 mg/kg IV, not IM.
3. Inhalation injury is suggested by:
Enclosed space fire
Respiratory distress or failure
Stridor or hoarse cry
Soot around nose or mouth
Singed nasal hair
Carbonaceous sputum
4. When transfer to a burn center is indicated, but would require
excessively long transport time, consult Medical Control for
recommendation for helicopter transport vs. secondary interfacility
transport from local hospital
5. Critical burn: 2° or 3° burn >15% BSA, any burn accompanied by
inhalation injury or associated with major trauma, or any burn to the
face, hands, feet or genitalia.
Indications of
Inhalation Injury?3
Yes



Document:
 BSA burned
 Depth of burn
 Location of burns
 Signs of inhalation injury
 Contact with Medical Control
 Pain medication employed
Consider early intubation
Refer to Respiratory
Distress or Respiratory
Failure Protocol
Rapid transport to appropriate
facility, preferably a burn
center, when available, 4 for
all critical5 burns
Wisconsin EMS for Children, Rev. 1/2002
38
State of Wisconsin – Standards & Procedures of Practical Skills
WISCONSIN EMSC
CHILD ABUSE SUSPECTED: ALS PREHOSPITAL CARE GUIDELINE


Initial Assessment Protocol
Reassure patient that s/he is safe
Be alert to immediate scene
and accurately document your observations
and conversation with patient and caregiver
Yes
Physiologic abnormality?
Refer to appropriate protocol
No
Suspected
sexual abuse
Crew member of same sex
may relate better to patient




Suspected
physical abuse

Do not disturb any
evidence, including
victim’s clothing, unless
necessary to treat patient
Do not allow patient to
bathe or wash

Suspected
neglect
Assess and document
appearance of injuries including:
– Type of injury
– Location(s)
– Acuity of injury
– Presence of multiple injuries
– Unusual patterns of injury,
including injuries resembling
objects
Note also:
– Mental status of the patient
– Interaction of patient and
caretaker(s)

Note and document:
– Features of the scene which may
suggest neglect, i.e.,
Unsanitary surroundings
Lack of food available
Responsible caretaker is a child
– State of nutrition of the patient
– State of cleanliness of the patient
– Presence or absence of patient’s
prescription medications
– Absence of identified medical aids, i.e.,
Eyeglasses
Hearing aid
Suctioning equipment
Do not leave patient
unattended at any time to
preserve the “chain of evidence”

Report all cases of suspected abuse
to the County Department of Social
Services and/or local law enforcement
Special Consideratons:
 Child abuse is the leading cause of injuryrelated death in infants under 1 year old.
 Consider the possibility of child abuse:
– Whenever a child is injured
– Whenever an infant presents with
seizures or altered mental status.
 EMT’s and Paramedics are mandated by
law to report suspected child abuse, and
are protected from civil suit if they report
in good faith.
 If the scene is unsafe, or the patient is
unstable physiologically, complete the
detailed examination in the ambulance
during transport
Document:
 Observations factually, i.e.,
“The patient had a 1/2 inch circular
burn on the palm of the left hand”,
not “The patient had a cigarette burn
on the palm of the left hand”.
 Direct quotes from the patient or
caretaker.
 Observations, not conclusions, i.e.,
“There was a pile of dirty diapers
lying in the corner of the room”, not
“The room was unsanitary”.
Wisconsin EMS for Children, Rev. 1/2002
39
State of Wisconsin – Standards & Procedures of Practical Skills
WISCONSIN EMSC
DROWNING PROTOCOL: ALS CARE GUIDELINE

Initial Assessment Protocol
Is airway patent?
No
Yes
Yes


No
No
Suspect C-spine
injury?
C-spine stabilization
Jaw thrust

Head tilt, chin lift
Spontaneous
respiratory effort?
Yes





Give 100% O2
Support ventilation with BVM
at age-appropriate rate
Refer to Respiratory Arrest
Protocol
Consider use of PEEP2 if patient
is intubated



Give 100% O2
Assess ventilation
Assist breathing with BVM
PRN
Consider use of CPAP1
Does patient have
a pulse?3
No

Refer to Pulseless Arrest
Protocol
Yes
No
No
Signs of respiratory
distress?
Is the patient
in shock?
Yes


Nebulized albuterol (2.5 mg/3ml NS)
Refer to Respiratory Distress
Protocol



Refer to Shock Protocol
Remove wet clothing and
dry the patient
Assess for other signs
of trauma
Patient comatose
(“P” or “U” category)?
Notes:
1. CPAP (continuous positive airway pressure)
may be useful in this circumstance. Pressure
of 4 to 6 cm H2 0 is often helpful.
2. PEEP (positive end expiratory pressure)
applied to bag-valve-tube ventilation is likely
to improve oxygenation and lung compliance.
PEEP of 4 to 6 cm H20 is often helpful.
3. If severe hypothermia, refer to Hypothermia
Protocol.
4. If head trauma is suspected, place OG tube,
not NG tube.
No
Yes







Place NG or OG tube4
Document:
 Duration of immersion
 Type of liquid involved
 Temp of water
 CPR prior to arrival
Contact medical control
Support ABCs PRN
Pulse oximetry, if available
Focused history
Keep warm
Monitor & transport
Wisconsin EMS for Children, Rev. 1/2002
40
State of Wisconsin – Standards & Procedures of Practical Skills
WISCONSIN EMSC
ENVIRONMENTAL HYPERTHERMIA PROTOCOL: ALS CARE GUIDELINE






Yes
Able to tolerate
Oral liquids?
No
Initial Assessment Protocol
Assess vital signs
Assess for signs of hyperthermia1
Assess for environmental risk factors
Place in cool environment
Remove or loosen clothing as indicated
Severe cardiorespiratory compromise?
 Respiratory distress
 Poor perfusion
 Hypotension
Yes
Adequate
respiratory effort?
No
No
Secure airway
Support ventilation with BVM
at age-appropriate rate
Refer to Respiratory Arrest
Protocol

Give cool liquids




Cardiac monitor
Pulse oximetry, if available
Initiate cooling measures:
– Spray with tepid water
– Manually fan body to
evaporate and cool




Start IV/IO
Give fluid bolus NS/LR 20 ml/kg







Contact medical control
Support ABCs PRN
Pulse oximetry, if available
Focused history en route
Monitor & transport
Yes
No
Start IV/IO
Give fluid bolus NS/LR 20 ml/kg
Improved?
No

Give additional NS/LR bolus
20 ml/kg to total 60 ml/kg
PRN

Cardiac monitor
Pulse oximetry, if available
Initiate cooling measures:
– Spray with tepid water
– Manually fan body to
evaporate and cool
Check blood glucose

Glucose < 60 mg/dl?
2

Yes


Yes
Glucagon 0.1 mg/kg IM/SQ
(max 1 mg), or
Glucose 0.5 gm/kg IV/IO,
diluted for age2
No
Seizure in progress?
Yes
NOTES:
1. Signs and symptoms of hyperthermia include:
• Hot, dry, flushed or ashen skin
• Profound weakness and fatigue
• Tachycardia
• Vomiting, diarrhea
• Tachypnea
• Hypoperfusion
• Sweating (early), no sweating (late) • Muscle cramps
• Diminished level of consciousness
2. If unable to determine blood glucose contact medical control for local protocol
3. D50W: 1 ml/kg for children > 2 yr.
D25W: 2 ml/kg for infants, children < 2 yr.
(dilute D50W 1:1 with sterile water)
D12.5W: 4 ml/kg for neonates < 28 days
(dilute D50W 1:3 with sterile water)

Refer to Seizure Protocol
Document:
 Clinical assessment
 Vital signs and pulse oximetry
 Therapy employed and response to it
 Communication with medical control
Wisconsin EMS for Children, Rev. 1/2002
41
State of Wisconsin – Standards & Procedures of Practical Skills
WISCONSIN EMS-C
HYPOTHERMIA PROTOCOL: ALS CARE GUIDELINES
Initial Assessment Protocol
Administer 100% 02, warmed if available
Assess vital signs
Complete initial assessment1
Assess for environmental risk factors
Remove from cold environment
Remove wet clothing, dry gently and
cover with blankets







No
Clinical Hypothermia?1
Yes
No



Severe cardiorespiratory compromise?
 Respiratory distress
 Poor perfusion
 Hypotension
Yes
Warm patient by placing warm
packs to axillae and groin, taking
care to avoid direct skin contact
Maintain horizontal position
Handle patient gently




Secure airway, as indicated
Support ventilation with BVM
at age-appropriate rate PRN
Handle patient gently
Cardiac monitor and pulse
oximetry, if available
Asystole or
V - fib?
No
Yes








Contact medical control
Support ABCs
Observe
Keep Warm
Transport rapidly to the most
appropriate medical facility
Perform chest compressions
Defibrillate @ 2 J/kg
May repeat immediately X 2 @ 4 J/kg


Start IV/IO
Give fluid bolus NS/LR 20 ml/kg
Special Considerations






The hypothermic heart is unlikely to respond to
resuscitation drugs, pacemaker stimulation
and defibrillation
Drugs may be ineffective and may accumulate to
toxic levels
Shivering stops when body temperature < 86° F
Frostbitten areas should not be massaged; avoid
refreezing after rewarming
Oxygen and IV fluids should be warmed, if
possible
Do not apply heat directly to skin
NOTES:
1. Signs and Symptoms of clinical hypothermia include:
 Altered mental status
 Dilated, sluggish pupils
 Cyanosis (after oxygen)
 Fast or slow respiratory rate
 Weak or absent pulses
 Low or absent blood pressure
 Dysrhythmias
 Decreased reflexes
 May appear dead
 Shivering
Document
 Clinical assessment and VS
 Resuscitation measures and response
 Meds given and response to each
 Communication with medical control
Wisconsin EMS for Children, Rev. 1/2002
42
State of Wisconsin – Standards & Procedures of Practical Skills
WISCONSIN EMSC
NEONATAL RESUSCITATION: ALS CARE GUIDELINE






Infant crowning
Prepare field
Deliver head
Suction nose, mouth, and (gently)
posterior pharynx with 6 Fr
catheter, or bulb syringe
Deliver body
Clamp and cut cord






Dry
Stimulate
Cover head
Keep warm
Spontaneous good
respiratory effort?
No

Yes
Thick particulate
meconium present?1


Yes
Visualize and suction hypopharynx
Intubate
Perform deep suction
Repeat until suctioned material
is free of meconium
Ventilate between suctioning
attempts PRN to stabilize
Heart rate?
No


Position airway
Support ventilation with BVM
and 100% oxygen @ 40-60
breaths/min for 30 sec
< 60/min




60 -100/min
Continue ventilation @ 40-60/min
Chest compressions @ 120/min
Compressions:ventilations 3:1
Secure airway as appropriate

No
> 100/min
Support ventilation with
BVM and 100% O2
Heart rate > 100/min?

Yes








Epinephrine ET 0.03 mg/kg
(0.3 ml/kg of 1:10,000 sol’n)
May repeat Q3-5 min PRN

Establish vascular access IV/IO
with NS/LR @ TKO
Chest compressions @ 120/min
Compressions:ventilations 3:1
Secure airway as appropriate


Continue support with
BVM and 100% O2
Start IV/IO with NS/LR @ TKO
Cardiac monitor

Give 100% O2
Yes
Cyanotic?
No

NOTES:
1. Small amounts of meconium may merely discolor
the amniotic fluid without visible particles. In this
case no special management is necessary.
Meconium management is indicated for amniotic
fluid that is “pea soup” in appearance, or contains
visible meconium particles.
2. D12.5W: 4 ml/kg for neonates
(dilute D50W 1:3 with sterile water)
3. APGAR score, described with the table of normal
values, reflects the success of resuscitation.
Reassess RR and effort
Evaluate color
APGAR3 at 1 and 5 min
Per medical control, consider:
– Naloxone 0.1 mg/kg IV/IO/ET/SQ
– Glucose 0.5 gm/kg IV/IO2
– Fluid bolus 10 - 20 ml/kg NS/LR
Document:
 Position and orientation of infant at
delivery
 Character of amniotic fluid, and presence
of meconium
 Cardiorespiratory impairment, if present
 Vital signs and pulse oximetry
 Therapy employed and response to it
 APGAR score at 1 and 5 min.
 Communication with medical control
43





Contact medical control
Support ABCs
Keep warm
Observe
Transport
Special Considerations:
 Remember to maintain the newborn at or
the level of the mothers perineum until
the cord is clamped and cut
 Choices for vascular access are:
1. Peripheral vein, including scalp vein
2. Intraosseous
3. Umbilical vein, if within scope of
practice
Wisconsin EMS for Children, Rev. 1/2002
State of Wisconsin – Standards & Procedures of Practical Skills
WISCONSIN EMSC
PEDIATRIC TRACHEOSTOMY WITH RESPIRATORY DISTRESS PROTOCOL:
ALS PREHOSPITAL CARE GUIDELINE




Special Considerations:
 Most pediatric tracheostomy
obstruction results from thickened
or dried secretions blocking the
narrow lumen of the tracheostomy
tube.
 Another cause, for children who
are dependent on mechanical
ventilation, is dysfunction of the
ventilator or/and oxygen source.
NOTES:
1. Obstruction to ventilation can be
recognized by:
– Tachypnea or apnea
– Increased resistance to bagging,
– Diminished or absent chest rise,
– Poor breath sounds bilaterally,
– Cyanosis despite 100% oxygen.
2. Techniques for suctioning the tracheostomy
tube include:
– Attempt to bag via tracheostomy
tube with 100% oxygen.
– Select correct suction catheter (the
child’s caregiver will usually know),
a 3 mm ID tracheostomy tube will accept
a 6 Fr or 8 Fr suction catheter.
– Instill 1.0 to 2.0 ml NS into the trach
tube to loosen secretions.
– Insert the suction catheter 2 to 3 inches
or until the patient coughs. Do not force
the catheter against resistance. Do not
apply suction while inserting the catheter.
– Apply suction, no more than 100 mm Hg,
for 3 to 5 seconds while slowly removing
the suction catheter.
3. Techniques for replacing a tracheostomy
tube include:
– Use a tube the same size or smaller than
the tube being replaced.
– If the new tube has an obturator, leave it
in place.
– Moisten or lubricate the tip of the tube with
water, saline, or sterile lubricant.
– Gently insert the tube with a curving
motion, posteriorly then downward,
applying slight traction to the skin above
and below the stoma.
– To facilitate placement, a suction catheter
can be inserted through the tracheostomy
tube and used as a guide.
– Remove obturator, give bagged breaths.
– Check for proper placement by noting:
Bilateral chest rise with bagging
Bilateral breath sounds
Lack of high resistance to ventilation
Improvement in patient condition
– If a new tracheostomy tube is not available,
an endotracheal tube of the same outer
diameter can be used, inserted the same
length as the tracheostomy tube.
– Confirm correct placement by exhaled CO2
determination, when possible.
Initial Assessment Protocol
Ascertain that patient has a tracheostomy
Disconnect patient from mechanical
ventilator, if present
Support ventilation with resuscitator bag
and 100% oxygen connected directly to
the tracheostomy tube adapter at ageappropriate rate
No
Is there obstruction to
ventilation?1
Yes
No
Yes

Is the tracheostomy tube
positioned correctly?
Yes



Suction the tracheostomy tube2
Attempt to support ventilation with
resuscitator bag


Is the tracheostomy tube
still obstructed?

Provide supplemental
oxygen with mask applied
to tracheostomy tube
Pulse oximetry, if available
Assist/provide ventilation
with resuscitator bag
to tracheostomy tube
Pulse oximetry, if available
No
Is perfusion adequate?
Yes

No
Is the patient breathing
spontaneously and effectively?
No
Yes
Suction the tracheostomy tube a
second time2
Attempt to support ventilation with
resuscitator bag



Communicate with medical control
Rapid transport
Close monitoring en route with
pulse oximetry, if available
No
Is the tracheostomy tube
still obstructed?
Yes




Cut or untie the tracheostomy ties
Remove the tracheostomy tube
Replace the tracheostomy tube3
Attempt to ventilate through the
new tracheostomy tube
Is the airway
still obstructed?

Refer to Shock Protocol
No
Yes


Consider:
– BVM ventilation with mask over nose
and mouth, and a sterile occlusive
dressing over the tracheostomy stoma
– BVM ventilation with infant mask over
the tracheostomy stoma
– Orotracheal intubation
– Intubation with endotracheal tube
through the tracheostomy stoma
Communicate with medical control
Document:
 Patient’s clinical condition and VS
 Actions taken and response to them
 Communication with medical control
Wisconsin EMS for Children, Rev. 1/2002
44
State of Wisconsin – Standards & Procedures of Practical Skills
WISCONSIN EMSC
POISONING/TOXIC EXPOSURE PROTOCOL: ALS CARE GUIDELINE

Initial Assessment Protocol
Refer to appropriate protocols:
– Altered Level of Consciousness
– Anaphylaxis
– Bradycardia
– Cardiac Arrest
– Respiratory Arrest
– Respiratory Distress
– Seizures
– Shock
– Suspected Child Abuse/Neglect
– Tachycardia with Poor Perfusion

Route(s) of exposure?
Inhalation





Skin,eye, or mucous
membrane
Ingestion
If hazard of inhaled poison or toxin
is still present DO NOT ENTER
SCENE without PPE1
Remove patient to fresh air
Administer 100% oxygen
Consider additional routes of
exposure (skin, eye)
Identify substance(s) involved;
bring container or label to
hospital, if possible



Look for source of poison or toxin
Identify and estimate amount of
substance ingested
Collect containers or medication
bottles and take with patient







Special Considerations:
 The national and Wisconsin Poison
Center phone number is 800-222-1222
anywhere in the state.
 Most important to stabilize the patient
 Because it is sometimes difficult to determine exactly how much of a substance
a child has taken, special attention is
needed in obtaining the history.
 Determine infant/child’s weight and estimated amount of poison ingested to
help determine appropriate treatment.
 Generally, do not induce vomiting,especially if corrosive ingestion is suspected
 Anticipate possible vomiting, seizures,
respiratory and CNS depression, and
dysrhythmias, and refer to appropriate
protocols.
 Contact medical control or a Poison
Center for specific information about
individual toxic exposures and
treatments.


If hazard of spilled poison or toxin
is still present, avoid crosscontamination
Remove patient from contaminated
area and remove contaminated
clothing and/or jewelry
If eyes are involved check for and
remove contact lenses
Identify substance involved
Flush copiously with tap water or
normal saline. If toxin is a powder,
brush off before flushing.
Bring container or label with patient
Estimate timing and duration of exposure
Contact medical control and/or a Poison
Center immediately and provide exposure
information
Treat as per medical/poison center
direction2 and transport
Document:
 Nature of exposure to poison/toxin
 Clinical assessment and VS
 Resuscitation measures and response
 Meds given and response to each
 Communication with medical control
and/or Poison Center
NOTES:
1. PPE is personal protective equipment
2. Medications which may be given
under medical control and/or Poison
Center advice include:
– Activated charcoal 1gm/kg PO to a
maximum of 50 gm. Caution for risk of
vomiting and aspiration. Shake well
before administration.
– Syrup of ipecac 10-30 ml PO, based
on age of patient, with vomiting 10-20
minutes after administration
Wisconsin EMS for Children, Rev. 1/2002
45
State of Wisconsin – Standards & Procedures of Practical Skills
WISCONSIN EMSC
PEDIATRIC PULSELESS ARREST PROTOCOL: ALS CARE GUIDELINE




Initial Assessment Protocol
Establish unresponsiveness
– Position airway
Determine breathlessness
– Ventilate with BVM and 100%
oxygen at age-appropriate rate
Determine pulselessness
– Perform chest compressions
– Cardiac monitor
Cardiac rhythm?
Ventricular fibrillation, or
pulseless ventricular
tachycardia






Continue chest compressions
Intubate the airway
Ventilate with 100% oxygen
Start IV/IO, but do not delay
defibrillation
Defibrillate 2 J/kg
May repeat immediately x 2
@ 4 J/kg as indicated
Convert to pulseproducing rhythm?
Pulseless electrical
activity (PEA)





Continue chest compressions
Intubate the airway
Ventilate with 100% oxygen
Start IV/IO
Identify and treat causes
– Hypoxemia
– Hypovolemia
– Hypothermia
– Hyper-/hypokalemia, acidosis
– Tension pneumothorax
– Tamponade
– Toxins/poisons/drugs
Yes
Convert to pulseproducing rhythm?
No
Yes




Epinephrine (2nd and subsequent doses)
 IV/IO/ET: 0.1 mg/kg (0.1ml 1:1000)
(IV/IO doses up to 0.2 mg/kg may be effective)
 May be repeated Q 3 - 5 min.
 Defibrillate 4 J/kg 30 - 60 sec after each dose
Consider antiarrhythmics:
 Amiodarone 5 mg/kg IV/IO bolus, or
 Lidocaine 1 mg/kg IV/IO bolus
 Defibrillate 4 J/kg 30 - 60 sec after each dose
 If arrest prolonged (more than 10 min), or hyperkalemia suspected, consider:
 Sodium bicarbonate:2 1 meq/kg IV/IO (1 ml/kg
of the 8.4% solution), may repeat 0.5 meq/kg
Q 10 min during CPR



Continue chest compressions
Intubate the airway
Ventilate with 100% oxygen
Start IV/IO
Epinephrine (1st dose)
 IV/IO: 0.01 mg/kg (0.1 ml/kg 1:10,000)
 ET: 0.1 mg/kg (0.1 ml/kg 1:1000)
Epinephrine (2nd and subsequent doses)
 IV/IO/ET: 0.1 mg/kg (0.1ml 1:1000)
(IV/IO doses up to 0.2 mg/kg may be
effective)
 Repeat Q 3 - 5 min.
No

No
No

Yes
Epinephrine (first dose)
 IV/IO: 0.01 mg/kg (0.1 ml/kg 1:10,000)
 ET: 0.1 mg/kg (0.1 ml/kg 1:1000)
 Defibrillate 4 J/kg after 30-60 seconds
Convert to pulseproducing rhythm?
Asystole


Refer to appropriate protocol PRN:
– Bradycardia
– Shock
– Tachycardia with Adequate Perfusion
– Tachycardia with Poor Perfusion
Contact Medical Control
Support ABC’s
Complete initial assessment
Observe
Keep warm
Transport
NOTES:
1. Confirm tracheal intubation by exhaled
CO2 determination, when possible
2. Sodium bicarbonate should be used only
when good ventilation is established
Document:
 Clinical assessment
 Initial cardiac rhythm
 Resuscitative measures and response,
including changes in cardiac rhythm
 Meds given and response to each
 Communication with medical control
Convert to rhythm?
Yes
Yes
Rhythm generating
a pulse?
No
Special Considerations:
 Most pediatric pulseless arrests
are consequent upon respiratory
arrest
 If resuscitative efforts are
unsuccessful, reevaluate
oxygenation and ventilation
 When sudden unexpected death
of an infant occurs:
– Contact Medical Control for
possibility that body should
remain at scene for Coroner
investigation
– Compassionate interaction
with a grieving family may be
helpful to them
Wisconsin EMS for Children, Rev. 1/2002
46
State of Wisconsin – Standards & Procedures of Practical Skills
WISCONSIN EMSC
RESPIRATORY ARREST PROTOCOL: ALS CARE GUIDELINE









Perform airway manuever, maintaining
in-line C-spine stabilization PRN
– Jaw thrust or chin lift
– Suction
– Oropharyngeal airway
Yes
Refer to Respiratory Distress
Protocol
Initial Assessment Protocol
No
Spontaneous breathing
restored?


Reposition and reassess
Relieve upper airway obstruction
Consider back blows, chest/abdominal
thrusts (age dependent)
Direct laryngoscopy, foreign body removal
with Magill forceps as indicated
Secure airway as appropriate
Consider needle cricothyrotomy
No
Adequate
chest rise?
No
Adequate
chest rise?
Yes

Yes



Administer 100% oxygen
Support ventilation with BVM
at age-appropriate rate
Continue ventilatory support at age-appropriate rate PRN
Secure airway as appropriate1
Start IV/IO with NS/LR @ TKO rate
No
Refer to Shock Protocolor
Pulseless Arrest Protocol
Normal
perfusion?
Yes





Glucagon 0.1 mg/kg IM/SQ (max 1 mg), or
Glucose 0.5 gm/kg IV/IO diluted for age3
Per Medical Control, consider Naloxone IV/IO:
< 20 kg: 0.1 mg/kg
> 20 kg: 2mg dose
If patient is seizing, refer to Seizure Protocol
No








Special Considerations:
 Respiratory arrest may be a sign of a
toxic ingestion or metabolic disorder.
Consider naloxone or flumazenil per
medical control.
Glucose < 60 mg/dl?2
Yes

NOTES:
1. If intubation is indicated, confirm tracheal
placement by exhaled CO2 monitor, if
possible.
2. If unable to determine blood glucose
contact medical control for local protocol
3. D50W: 1 ml/kg for children > 2 yr.
D25W: 2 ml/kg for infants, children < 2 yr.
(dilute D50W 1:1 with sterile water)
D12.5W: 4 ml/kg for neonates < 28 days
(dilute D50W 1:3 with sterile water)
Check blood glucose
Contact Medical Control
Support ABCs
Detailed physical exam
Cardiac monitor
Pulse oximetry, if available
Continue to monitor & observe
Focused history (en route)
Keep warm
Monitor and transport
Document:
 Clinical assessment and VS
 Resuscitative measures and response
 Meds given and response to each
 Communication with medical control
Wisconsin EMS for Children, Rev. 1/2002
47
State of Wisconsin – Standards & Procedures of Practical Skills
WISCONSIN EMSC
RESPIRATORY DISTRESS PROTOCOL: ALS PREHOSPITAL CARE GUIDELINE





Initial Assessment Protocol
Administer 100% Oxygen
Detailed physical exam
Pulse oximetry, if available
Refer to PediatricTracheostomy
with Respiratory Distress Protocol PRN
Upper vs. lower
airway disease?
Reactive (Lower) Airway Disease
 Wheezing
 Grunting
 Retractions/nasal flaring
 Tachypnea
 Decreased breath sounds
 Central cyanosis
 Tachycardia/bradycardia
 Decreasing level of
consciousness
Yes
Partial Airway Obstruction:
 Suspected FBAO, croup, or
epiglottitis
 Stridor
 Choking
 Drooling
 Hoarseness
 Retractions/Acc. muscle use
 Tripod position
Known history of
reactive airway disease?
No
Poor perfusion?
Yes

Refer to Shock Protocol
No




Position of comfort with caregiver
Nebulized bronchodilator(s):
– Albuterol (2.5 mg/3ml NS)
– Ipratropium (500 mcg/2.5 ml NS)
with first albuterol only
Cardiac monitor






Contact medical control
Support ABCs PRN
Pulse oximetry, if available
Focused history
Keep warm
Monitor & transport





Yes
Distress/obstruction
relieved?
No
Avoid agitation
Position of comfort with caregiver
Assess tolerance to O2 administration
Per medical control - consider nebulized
epinephrine inhalation
Do not look in the throat
Do not attempt intubation or IV access

Refer to Respiratory Arrest
Protocol
Document:
 Severity of respiratory distress
 Signs of upper or lower airway disease
 Vital signs and pulse oximetry
 Changes in VS and pulse oximetry
when O2 given
 Therapy employed and response to it
 Communication with medical control
Special Considerations:
 Severe upper airway obstruction due to
croup may be relieved with inhaled
nebulized epinephrine (3 ml of 1:1000
epi, undiluted) per medical control.
Wisconsin EMS for Children, Rev. 1/2002
48
State of Wisconsin – Standards & Procedures of Practical Skills
WISCONSIN EMSC
SAFE PLACE FOR NEWBORNS1: ALS CARE GUIDELINE
Parent calls 911 or brings infant
to law enforcement or EMT


Yes
Initial Assessment Protocol
for newborn infant2
Infant clinically stable?
No


Yes Reasonable cause to suspect
infant is victim of abuse?
Refer to Child Abuse/
Neglect Suspected Protocol
No

Offer to provide needed
care for infant, includiing
transport, but decline to
accept legal custody
Yes
Is it reasonable to believe
the infant is more than
72 hours old?
Refer to appropriate protocol:
– Altered Mental Status Protocol
– Bradycardia Protocol
– Pediatric Pulseless Arrest Protocol
– Respiratory Arrest Protocol
– Respiratory Distress Protocol
– Seizure Protocol
– Shock Protocol
– Tachycardia with Adequate Perfusion Protocol
– Tachycardia with Poor Perfusion Protocol
– Trauma Protocol
No





Accept legal custody of the newborn.
Assure anonymity and confidentiality
for the parent and anyone assisting
the parent.
Offer care to the parent, if female, but do
not induce her to reveal her identity.
All information obtained must remain
confidential except to attending physician
and County Social Service staff.
Make available to the parent the Maternal
and Child Health toll free number,
1-800-722-2295, for resources and referral
information. The parent has the right to
refuse the information.




Special Considerations:
 More information can be obtained from
the internet web site:
www.safeplacefornewborns.org
NOTES:
1. This protocol is based on Wis 2001 Act 2,
Safe Place for Newborns legislation, enacted
on April 3, 2001, intended to provide a safe
place for unwanted newborn infants rather than
abandonment, injury or death. The goal is to
provide anonymous, confidential protective
shelter, medical care and treatment in a hospital
setting for babies reasonably believed to be less
than or equal to 72 hours old. The parent
relinquishing custody of the child has the right
to remain anonymous.
2. In applying the Pediatric Assessment Triangle two
elements of the “Appearance” must be modified to
account for the newborn age:
– Interactiveness: responds to voice or touch vs.
agitated vs. lethargic
– Look/gaze: blinks to light vs. glassy-eyed stare
Contact medical control
Pulse oximetry, if available
Transport to an emergency
department which can provide
appropriate care and referral to
County Social Service within
24 hours
Monitor closely during transport
Document:
 Clinical condition of infant, including
initial assessment, VS and pulse oximetry
 Any therapies provided and the response to them
 Communication with medical control
 DO NOT attempt to ascertain or document
the identity or location of parent or person assistin parent unless:
– Child abuse is suspected
– It appears that the person assisting the parent
is coercing her/him to relinquish custody
Wisconsin EMS for Children, Rev. 1/2002
49
State of Wisconsin – Standards & Procedures of Practical Skills
WISCONSIN EMSC
SEIZURE PROTOCOL: ALS CARE GUIDELINE






Contact medical control
Support the ABC’s as needed
Rapid transport
Continued monitoring
Focused history and detailed exam
en route
Initial Assessment Protocol
No
Seizure in progress?
Yes
Spontaneous breathing?
No
Refer to Respiratory Arrest Protocol

Yes

Position patient on side

Airway adequate?
No
Yes


Open airway with C-spine stabilization
if trauma suspected
– Jaw thrust
– Suction1
– Nasopharyngeal airway
Yes
Administer 100% oxygen
Pulse oximetry, if available
Airway adequate?
No
Patient cyanotic, or
pulse oximetry reading < 90%?

Yes

Maintain airway
Assist ventilation with BVM and
100% oxygen
No
Circulation adequate?

No

Start IV/IO
Give fluid bolus NS/LR
10 - 20 ml/kg
Yes
No
Seizure still in progress, or
Status epilepticus?2
Yes

Special Considerations:
 Do not attempt intubation while patient is
actively seizing
 Use paralyzing agents only under medical
control
 Initiate rapid transport immediately after
first dose of anticonvulsants

Glucose < 60 mg/dl?3
Yes

No

NOTES:
1. Do not force suction device between teeth.
2. Status epilepticus is defined as a seizure that
lasts for more than 30 minutes, or a series of
seizures over 30 minutes during which full
consciousness is not regained
3. If unable to determine blood glucose contact
medical control for local protocol
4. D50W: 1 ml/kg for children > 2 yr.
D25W: 2 ml/kg for infants, children < 2 yr.
(dilute D50W 1:1 with sterile water)
D12.5W: 4 ml/kg for neonates < 28 days
(dilute D50W 1:3 with sterile water)
5. Rapid administration of diazepam or lorazepam
may produce temporary respiratory depression,
requiring assisted BVM ventilation. This usually
resolves after a few minutes.
Check blood glucose





Treat the seizure:
– Diazepam:5
Rectally 0.5 mg/kg
(may repeat in 10-15 min. x 1)
IV/IO 0.2 mg/kg
(may repeat Q 10–15 min. x 3)
– Lorazepam: 0.1 mg/kg IV/IO/PR
(may repeat in 10-15 min. x 1)
Contact medical control after first
dose of glucose or diazepam
Support the ABC’s as needed
Rapid transport
Continued monitoring
Focused history and detailed exam
en route
No
Glucagon 0.1 mg/kg IM/SQ
(max 1 mg), or
Glucose 0.5 gm/kg IV/IO,
diluted for age4
Seizure stopped?
Yes
Document:
 Presence, type and duration of seizure
 Respiratory impairment if present
 Vital signs and pulse oximetry
 Therapy employed and response to it
 Communication with medical control
Wisconsin EMS for Children, Rev. 1/2002
50
State of Wisconsin – Standards & Procedures of Practical Skills
WISCONSIN EMSC
SHOCK PROTOCOL: ALS CARE GUIDELINE


_
_
_
_
Initial Assessm ent Protocol
Secure airway as appropriate
Give 100% O 2
Cardiac monitor
Supine position
Start IV/IO
Etiology
of shoc k?
Hypovolemic shock
(Suspec ted dehy dration,
3 rd spac ing,
hemorrhage)
_
Cardiogenic shoc k
(History of congenital heart
disease or surgery ,
rhy thm dis turbance,
hy pogly c emia, post
cardiac arrest)
Distributive shoc k
(Suspec ted sepsis,
anaphy laxis)
Give fluid bolus NS/ LR 20 ml/kg
Give fluid bolus NS/ LR 20 ml/kg
_
Yes
Anaphy laxis
suspec ted?
Improved?
No
_
1
Yes
Yes
No
No
Repeat boluses of 20 ml/kg
PRN to maximum 60 ml/k g
Yes
Rhythm
disturbance?
Gluc ose < 60 mg/dl
or canÕ
t determine?
No
Improved?
Yes
No
Brady c ardia < 100/min
With poor perfusion?
No
Glucose
 0.5 gm/k g IV/IO diluted for age
Yes
Yes
_
Refer to Bradycardia Protocol
_
Refer to Allergic Reaction/
Anaphylaxis Protocol
_
_
_
_
_
_
_
Contac t Medic al Control
Support ABCÕ
s
Pulse oximetry if available
Detailed physical exam
Observe
Keep warm
Transport
Foc used history (en route)
NOTES:
1. Tension pneumothorax c an produc e shoc k.
Refer to Traum a Protocol
2. If unable to determine blood glucose c ontac t
medic al c ontrol for local protoc ol
3. D 5 0 W: 1 ml/kg for children > 2 y r.
D 2 5 W: 2 ml/kg for infants, children < 2 y r.
(dilute D 5 0 W 1:1 with sterile water)
D 1 2 .5 W: 4 ml/kg for neonates < 28 day s
(dilute D 5 0 W 1:3 with sterile water)
4. Dopamine infusion using 0.8 mg/ml solution:
Drug dose (mc g/kg/ min) =
13.3 x drip rate (ml/hr) / Wt (kg)
_
Refer to appropriate
Protocol
Improved?
No
_
_
2
Repeat boluses of 20 ml/kg
PRN to maximum 60 ml/k g
_
Give fluid bolus NS/ LR 10 ml/kg
Dysrhythm ia
Yes
Improved?
No
_
Special Considerations:
_ Assessment for improved s tatus s hould
include evaluation of the ABCÕ
s and
lung sounds
_ Fluid should be given c autiously in
c ardiogenic shock
_ Dopamine mus t be administered by IV
pump
Consider dopam ine 5-20 mcg/kg/ min
Document:
_
Clinic al assessment and V S
_
Resusc itative measures and res ponse
_
Meds given and response to each
_
Communic ation with medic al c ontrol
Wisconsin EMS for Children, Rev. 1/2002
51
3
State of Wisconsin – Standards & Procedures of Practical Skills
WISCONSIN EMSC
TACHYCARDIA WITH ADEQUATE PERFUSION PROTOCOL: ALS CARE GUIDELINE
_
Rapid heart rate with evidence of adequate perfusion


_
_
_
Initial Assessm ent Protocol
Administer 100% O 2
Ensure effec tive ventilation
Cardiac monitor
Keep warm
QRS duration?
Normal for age
(approx. ² 0.08 sec)
Wide for age
(approx. > 0.08 sec)
Heart rate and rhy thm?
_
Probable sinus tac hc ardia
 Rate: usually < 220 for infants
usually <180 for c hildren
 P waves present and normal
 Variable RR with constant P R







Identify and treat possible c auses
Ğ Fever
Ğ Shoc k
Ğ Pain
Ğ Hy povolemia
Ğ Hy poxia
Ğ Drug ingestions
Ğ Pneumothorax
Ğ Cardiac tamponade
Refer to appropriate protocol
Monitor VS & patient as ses sment
Continue to assess ABCÕ
s
Detailed exam and foc used his tory
en route
Keep warm
Transport
Probable s upraventric ular tachy cardia
 Rate:
usually > 220 for infants
usually > 180 for children
 P waves absent or abnormal
 Abrupt rate c hange to or from normal
Start IV/IO






Adenosine 1 0.1 mg/kg
May double adenosine dose
and repeat once as needed
Maximum dose: 12 mg
Yes
Treat as presumptive
ventricular tachycardia
Start IV/IO
Identify and treat reversible
2 , or
causes, I.e., drug toxic ity
elec trolyte imbalanc es
Antiarrhythmics :
Ğ Am iodarone 5mg/kg IV/IO over
20 - 60 min, or
Ğ Procainamide 15 mg/k g IV/IO over
30 - 60 min (DO NOT adm inister
am iodarone and procainam ide
together) , or
Ğ Lidocaine 1 mg/kg IV/IO bolus
May repeat lidocaine twic e PRN
Termination of
the arrhy thmia?
No


Consult medic al c ontrol
Consider other drugs
NOTES:
1. For succ ess, adenosine requires a
prec ise adminis tration technique:
Ğ Record rhythm strip during adminstration
Ğ Inject as rapidly as possilble
Ğ Follow with rapid NS 2 to 5
mL bolus using two sy ringe technique
2. If tric yclic antidepressant poisoning is sus pected,
sodium bicarbonate 1 meq /kg (1 ml/kg 8.4% sol ution ) can be given. If QRS complex narrows in
response to the dose, it may be repeated P RN
Document:
_ Clinic al ass ess ment and V S
_ Resuscitative measures and response
_ Meds given and res ponse to eac h
_ Communic ation with medic al c ontrol
Wisconsin EMS for Children, Rev. 1/2002
52
State of Wisconsin – Standards & Procedures of Practical Skills
WISCONSIN EMSC
TACHYCARDIA WITH POOR PERFUSION PROTOCOL: ALS CARE GUIDELINE
_
Rapid heart rate with evidence of poor perfusion


_
_
_
Initial Assessm ent Protocol
Administer 100% O 2
Ensure effec tive ventilation
Cardiac monitor
Keep warm
QRS duration?
Normal for age
(approx. ² 0.08 sec)
Wide for age
(approx. > 0.08 sec )
Heart rate and rhy thm?
Probable sinus tac hcardia
 Rate:
usually < 220 for infants
usually <180 for c hildren
 P waves present and normal
 Variable RR with c onstant P R
_
Probable s upraventric ular tachy cardia
 Rate:
usually > 220 for infants
usually > 180 for children
 P waves absent or abnormal
 Abrupt rate c hange to or from normal
IV/IO ac cess
Immediately or rapidly
A vailable?
No


Identify and treat possible c auses
Ğ Fever
Ğ Shock
Ğ Pain
Ğ Hy povolemia
Ğ Hy poxia
Ğ Drug inges tions
Ğ Pneumothorax
Ğ Cardiac tamponade
Refer to appropriate protocol



Immediate Synchroniz ed
Cardioversion 0.5 - 1.0 J /kg
May inc rease to 2.0 J /kg if initial
dose ineffec tive
Use sedation if possible, but do
not delay cardiversion for
sedation






Adenosine 1 0.1 mg/k g
May double adenosine dose
and repeat onc e as needed
Maximum dose: 12 mg

Yes
No


-

Document:
_ Clinic al assessment and V S
_ Resuscitative measures and response
_ Meds given and res ponse to eac h
_ Communication with medic al c ontrol
Termination of
the arrhy thmia?




Consult medic al c ontrol
Consider other drugs
Immediate Synchroniz ed
Cardioversion 0.5 - 1.0 J /kg
Us e sedation if possible, but do
not delay cardiversion for
sedation
Yes

NOTES:
1. For succ ess, adenosine requires a
prec ise adminis tration tec hnique:
Ğ Record rhythm strip during adminstration
Ğ Injec t as rapidly as possilble
Ğ Follow with rapid NS 2 to 5 ml bolus using two
sy ringe technique
2. If tric yclic antidepressant poisoning is suspected,
sodium bicarbonate 1 meq /kg (1 ml/kg 8.4% sol
ution ) c an be given. If QRS complex narrows in,
response to the dose, it may be repeated P RN
Treat as presumptive
ventricular tachycardia
Start IV/IO
Termination of
the arrhythmia?
Yes
No
Identify and treat reversible
2
causes, i.e., drug toxicity
, or
electroly te imbalanc es
Antiarrhythmics :
Ğ Am iodarone 5mg/kg IV/IO over
20 - 60 min, or
Ğ Procainamide 15 mg/kg IV/IO over
30 - 60 min (DO NOT adm inister
am iodarone and procainam ide
together) , or
Ğ Lidocaine 1 mg/kg IV/IO bolus
May repeat lidocaine twic e PRN
Monitor VS & patient assessment
Continue to assess ABCÕ
s
Detailed exam and focused his tory
en route
Keep warm
Transport
Wisconsin EMS for Children, Rev. 1/2002
53
State of Wisconsin – Standards & Procedures of Practical Skills
WISCONSIN EMSC
TRAUMA PROTOCOL: ALS PREHOSPITAL CARE GUIDELINE

Initial Assessm ent Protocol
Special features of pediatric trauma
Airway:
 Obstruction c ommon
in head injury
 Open with jaw thrus t
 C-spine stabilization
 E xpec t vomiting
 Suction P RN
 Advanced airway
management - BVM
vs. intubation 2
1
Breathing:
 Give 100% O
2
 BVM assis ted breath
ing PRN
 Needle thoracos tomy
for tension pneumo thorax 3
 Three-sided dressing
for suc king chest
wound
Circulation: 4
 E xternal hemorrhage
c ontrol
 Shock position if no
head injury
 Splint fractured ex
tremity (traction
splint for femur to
reduce pain or re store c irculation or
sens ation)

If shoc k present, re susc itate with NS
or LR in bolus es of
20 ml/kg and repeat
PRN (refer to Shock
Protocol )
NOTES:
1. Indications for spinal immobilization inc lude:
Mechanism of injury likely to involve head or spine
Altered level of c onsc iousness
Signs or sy mptoms of weakness or numbness
E vidence of trauma to head, neck, chest or spine
Spinal pain
Maintain neck in neutral position by plac ing padding
beneath shoulders, back and hips on spine board.
2. Advanc ed airway management:
Fac tors favoring BV M airway support
Combativeness, s trong gag reflex
Spas m of jaw muscles
Short on -sc ene and transport times
Fac tors favoring endotrac heal intubation Unresponsive child
Absent gag reflex
Apnea, poor muscle tone
Long extrication or transport time
Limited pers onnel available during trans port
A vailability of rapid sequenc e intubation
3. Suspec t and c onsider treating tension
pneumothorax
with needle thoracostomy when the following are present::
Blunt or penetrating c hest injury
Respiratory distress
Hy poxia
Hy poperfusion
4. MAS T trousers are not indic ated for hy potension, exc ept
possibly in the patient with clinic ally uns table pelvic fracture
.
5. Normal ventilatory rate (breaths/ min):
30 for infants < 1 y r., 20 for toddlers and c hildren
 ventilatory rate:
35 for infants < 1 y r., 25 for toddlers and c hildren
6. ÒMajorÓtrauma is defined as one or more of the following:
Patient unresponsive to voic e
Sy stolic blood pressure (mm Hg):
< 60 (0 -6 mos.), < 70 (6 mos. -5 yr.), < 80 (> 5 yr.)
Respiratory rate (breaths/ min):
> 60 (0 -1 y r.), > 40 (> 1 yr.), or inadequate or
ineffec tive respiratory effort,
stridor , grunting
Penetrating injuries to head, neck, torso, or extremities
proximal to the elbow or knee
Flail c hest
Two or more proximal long bone frac tures (
humerus , femur)
Unstable pelvic fractures
New onset paraly sis
Amputation injuries proximal to the wrist or ank le
Burns (2¡ or 3¡) c overing > 15% of body surface area
7. ÒPotentially majorÓtrauma is defined as one or more of:
Any physiologic abnormality or severe pain
Ejection from automobile during c rash
Death of another person in the same auto
E xtric ation time > 20 min.
Vic tim of rollover auto crash
Vic tim of high speed c rash (impac t speed > 40 mph, major
auto deformity, intrusion of damage into passenger spac e)
Auto -pedes trian/auto -bic ycle injury with signific ant impac t
Motorc yc le crash > 20 mph, or separation of rider from bike
Falls > 10 ft.


ABCDEÕ
s
Disability:
 Assess with
AVPU
sc ale and pupillary
size, equality and
response to light
 For patients in Ò
PÓor
ÒUÓc ategories,assist
ventilation PRN
 If pupils equal and
reac tive to light us e
normal ventilatory
rate 5
 If pupils dilated, un
equal, unreac tive
to light, or c hild is
pos turing, use 
ventilatory rate 5
Immediate transport to a Pediatric
Trauma Center if possible
Clos e monitoring during transport
Exposure:
 E xamine bac k while
immobilizing
 Keep c hild warm
cover infantÕ
s head
(not the face)
Yes
Is this ÒmajorÓtrauma?
No


Contac t Medic al Control and consider
Transport to a P ediatric Trauma Center
Clos e monitoring during transport
Yes
Is this Òpotentially
majorÓtrauma?
7
No


Foc used history and
exam at the sc ene
Transport to E.D. wit
close monitoring
Special Considerations:
 Head injury is the leading killer of c hildren
 The head injured pediatric patient of ten display s:
Ğ Airway obstruction due to  muscle tone
Ğ Vomiting and as piration
Ğ Seizures
• Head injured patients may experience  intra cranial pressure during intubation unless rapid
sequenc e intubation tec hnique is us ed. BV M
ventilation may be s afer for suc h patients.
• Shoc k in the pediatric trauma victim is mos t
often due to blood loss, us ually in the
abdomen, or thigh (with a femur fracture)
• Fractures can be extremely painful. Pain from
orthopedic injuries without abdominal or head
injury can be treated with morphine sulfate
0.1 mg/kg IV, not IM.
• Consider the possibility of c hild abuse in all
pediatric trauma vic tims, and all infants with
altered mental s tatus (refer to
Child Abuse/
Neglect Suspected Protocol ).
Wisconsin EMS for Children, Rev. 1/2002
54
6
State of Wisconsin – Standards & Procedures of Practical Skills
Respiratory system ............................................ II-1
Assessment, initial (EMSC) ALS ............................ 32
Associated symptoms (HPI) .................................. II-8
Asthma ................................................................. III-3
Asystole ..................................................... IV-2, X-21
Ativan ..................................... I-41, II-13, II-15, V-14
Atropine .. I-10, I-48, II-11, IV-2, IX-38, X-21, XI-13,
XI-22
Atrovent .......................... I-24, II-11, III-3, III-4, III-7
Automated External Defibrillator ....................... X-13
Automatic External Defibrillator ........................ X-27
Aut-pulse CPR device ........................................ X-30
1
12 Lead ECG ...................................................... X-17
A
Abbreviations, acceptable charting ........................ II-4
Abdominal pain, problems.................................... V-1
Abdominal thrusts................................................ III-1
Abuse, substance ................................................ V-12
Abuse/assault ....................................................... VI-1
Acetaminophen .................................................... II-14
Acidosis ............................................................... IV-2
Activated charcoal ................................................ I-34
Activated Charcoal .............................................. II-11
Acute coronary syndrome .................................... IV-2
Adenosine ..................................................... I-6, II-11
AED ........................................................... IV-3, X-27
AED, pediatric ..................................................... IV-3
AED, Public Access ........................................... X-13
Airway
Nasopharyngeal ............................................. IX-13
Oral ................................................................ IX-12
Airway assessment, Guideline for practical skill VIII1
Airway obstruction ..................................... III-1, III-6
Magill forceps ................................................ IX-10
Airways
Oral/nasal ........................................................... II-1
Albuterol ..................................... I-7, III-3, III-4, III-5
Alcohol ............................................................... V-14
Alcohol, isopropyl ................................................. II-3
Allergen ................................................................ V-2
Allergic reaction ................................................... V-2
Altered level of consciousness .............................. V-3
Altered Level of Consciousness (EMSC) ALS ....... 33
Altered level of consciousness (EMSC) BLS .......... 13
Amidate ............................................ I-37, II-12, II-15
Amiodarone .................................................. I-8, II-11
Ammonia Inhalants............................................... I-23
Amputation, traumatic ................................ VI-6, VI-8
Analgesia ............................................................. II-13
Anaphylaxis ................................................. III-3, V-5
Anaphylaxis, allergy (EMSC) ALS ......................... 34
Anaphylaxis, allergy (EMSC) BLS ......................... 14
Aneurysm ............................................................ IV-5
Aneurysm, ruptured abdominal aortic ................. VI-8
Apgar ................................................................ XIII-4
Apgar score ....................................................... XIII-5
Arrest, respiratory ................................................ III-6
Aspirin ................................................. I-9, II-11, IV-6
Assault ................................................................. VI-1
Assessment BLS (EMSC) ....................................... 12
Assessment parameters .......................................... II-1
Cardiovascular system ....................................... II-2
History and physical examination...................... II-8
Musculoskeletal system ..................................... II-3
Nervous system.................................................. II-3
Reproductive system.......................................... II-3
B
Back blows .......................................................... III-1
Bag-Valve device .................................................. II-1
Bag-Valve-Mask ventilation ................................ IX-8
Bandaging, Guideline for practical skill ............. XII-1
Behavioral/psychiatric problems .......................... V-4
Benadryl ............................ I-13, I-33, II-12, V-2, V-5
Bites and stings ..................................................... V-5
Bleach .................................................................... II-3
Bleeding, rectal ..................................................... V-1
Bleeding, vaginal ................................................ VII-1
Blood glucose level, monitoring ........................... V-3
Blood glucose measurement .. V-14, V-15, V-16, XI-1
Blood pressure ....................................................... II-2
Blood pressure measurement
Auscultation .................................................. VIII-4
Palpation ....................................................... VIII-4
Blood sample, obtaining ....................................... X-1
Blood sugar ........................................................... V-7
Blood, exposure to ................................................. II-3
Board splint, Guideline for practical skill ......... XII-13
Bolus medication ................................................. XI-5
Bracelet, DNR ..................................................... IV-8
Bradycardia (EMSC) ALS ....................................... 35
Bradycardia, symptomatic ......................... IV-1, X-21
Bradycardic (EMSC) BLS ....................................... 15
Breath sounds ........................................................ II-8
Breech delivery ................................................. XIII-2
Bronchial asthma ................................................. III-3
Bulb syringe ..................................... IX-3, IX-4, XIII-4
Burn (EMSC) ALS .................................................. 36
Burns ................................................................... VI-2
Burns (EMSC) BLS ................................................. 16
Butorphanol ...................................... I-35, II-11, II-14
Bypass ................................................................. II-16
C
Calcium................................................................ II-11
Calcium chloride................................................... I-26
Cannula, nasal...................................................... IX-1
Capillary Refill Time (CRT) ................................. II-2
Capped IV line ...................................................... X-4
Carbon monoxide poisoning ................................ III-5
Cardiac arrest .............................................. IV-2, IV-4
Cardiac Arrest (EMSC) ALS ................................... 44
55
State of Wisconsin – Standards & Procedures of Practical Skills
Cardiac arrest (EMSC) BLS .................................... 23
Cardiac arrest, trauma induced ............................ IV-3
Cardiac arrest, traumatic ...................................... IV-3
Cardiac disease, ischemic .................................... IV-5
Cardiac dysrhythmia ............................................ IV-1
Cardiac tamponade .............................................. IV-2
Cardiopulmonary arrest .............................. IV-2, IV-4
Cardiovascular system, assessment ....................... II-2
Cardioversion, synchronized .............................. X-15
Cardizem..................................................... I-36, II-11
care under fire ...................................................... II-19
CCR ..................................................................... IV-4
Central line access .............................................. X-23
Cerebral vascular accident (CVA) ...................... V-15
Cervical Immobilizer ........................................ XII-11
Cervical spine stabilization exclusions ............... XII-9
Charcoal, activated ..................................... I-34, II-11
Charting abbreviations ........................................... II-4
Chest injuries, penetrating ................................ XII-23
Chest pain .................................................... II-1, IV-5
Chest thrusts ........................................................ III-1
Chief complaint (HPI) ........................................... II-8
Child abuse .......................................................... VI-1
Child Abuse (EMSC) ALS ...................................... 37
Child Abuse (EMSC) BLS ...................................... 17
Chronic obstructive pulmonary disease ............... III-4
Chronic obstructive pulmonary disease (COPD) ... II-1
Chronic Obstructive Pulmonary Disease (COPD)III-3
Cincinnati Prehospital Stroke Scale .................... V-15
Circulation, peripheral ........................................... II-3
Cleaning/disinfection ............................................. II-3
Clothing, protective ............................................... II-3
Cluster headaches .................................................. V-8
Combi-tube airway ............................................ IX-14
Complaints, generalized ........................................ II-8
Congestive heart failure ....................................... IV-7
Congestive Heart Failure (CHF) .......................... III-3
Continuous Positive Airway Pressure (CPAP) .. IX-36
COPD .................................................................. III-4
Coral snakes.......................................................... V-5
CPAP ................................................................... IV-7
CPR Device
Auto-pulse ...................................................... X-30
Cricothyroidotomy............................................. IX-34
Cricothyroidotomy, Guideline for practical skillIX-34
CVA.................................................................... V-15
Cyanokit ............................................................... I-58
Diabetes mellitus .................................................. V-7
Dialysis catheters ................................................ X-23
Diazepam ................................ I-12, II-14, II-15, V-14
Dilaudid ............................................ I-39, II-12, II-14
Diltiazem .................................................... I-36, II-11
Diphenhydramine .............. I-13, I-33, II-12, V-2, V-5
Diprivan ............................................ I-54, II-14, II-15
Disaster ................................................................ II-19
Disinfection ........................................................... II-3
Distress, respiratory ............................................. III-7
Diversion ............................................................. II-17
Do Not Resuscitate .............................................. IV-8
Documentation ...................................................... II-4
Deviations from Guidelines ............................... II-4
Domestic violence ............................................... VI-1
Do-Not-Resuscitate Pediatric .............................. IV-9
Dopamine .......................................... I-29, II-12, VI-5
Drowning ............................................................. VI-3
Drowning (EMSC) ALS
Drowning (ALS) .................................................. 38
Drowning (EMSC) BLS .......................................... 18
Drugs, illicit ........................................................ V-14
DuoDote ............................................................... I-48
Dyspnea
Moderate ............................................................ II-1
Severe ................................................................ II-1
Dysrhythmia, cardiac ........................................... IV-1
E
ECG Monitoring ................................................. X-19
Edema .................................................................... II-2
Elder abuse .......................................................... VI-1
Electrocardiogram ......................................... II-2, II-8
Electrocution........................................................ VI-4
Electrolyte imbalance .......................................... IV-2
Emboli, pulmonary .............................................. IV-5
Embolism, pulmonary ......................................... IV-2
EMSC
Altered Level of Consciousness (ALS) ............... 33
Altered Level of Consciousness (BLS)................ 13
Anaphylaxis, Allergy (ALS) ................................ 34
Anaphylaxis, Allergy (BLS) ................................ 14
Bradycardia (ALS) .............................................. 35
Bradycardia (BLS) ............................................... 15
Burn (ALS) .......................................................... 36
Burns (BLS) ......................................................... 16
Cardiac Arrest (ALS) ........................................... 44
Cardiac arrest (BLS) ............................................ 23
Child Abuse (ALS) .............................................. 37
Child Abuse (BLS) .............................................. 17
Drowning (BLS) .................................................. 18
Hyperthermia (ALS) ............................................ 39
Hyperthermia (BLS) ............................................ 19
Hypothermia (ALS) ............................................. 40
Hypothermia (BLS) ............................................. 20
Initial Assessment (ALS) ..................................... 32
Initial assessment BLS ......................................... 12
Neonatal Resuscitation (ALS) ............................. 41
Neonatal Resuscitation (BLS) ............................. 21
Poison (BLS) ....................................................... 24
D
Death, obvious ..................................................... IV-8
Decontamination .................................................... II-3
Defibrillation ......................... IV-2, IV-3, X-12, X-27
Defibrillation, guideline for practical skill ......... X-12
Defibrillation, hypothermia in ............................ V-11
Defibrillation, manual .......................................... IV-3
DeLee mucous trap ........................... IX-3, IX-4, XIII-4
Demerol ............................................ I-42, II-13, II-14
Dependent lividity ............................................... IV-8
Deviation from Guideline for Care ........................ II-4
Dextrose .......................... I-11, II-11, V-3, V-12, V-14
56
State of Wisconsin – Standards & Procedures of Practical Skills
Poisoning (ALS) .................................................. 43
Respiratory Arrest (ALS) .................................... 45
Respiratory arrest (BLS) ...................................... 25
Respiratory Distress (ALS) .................................. 46
Respiratory Distress (BLS) .................................. 26
Save haven for infants (BLS) .............................. 27
Save Haven for Newborns (ALS) ........................ 47
Seizure (ALS) ...................................................... 48
Seizure (BLS) ...................................................... 28
Shock (ALS) ........................................................ 49
Shock (BLS) ........................................................ 29
Tachycardia, stable (ALS) ................................... 50
Tachycardia, unstable (ALS) ............................... 51
Tracheostomy care (ALS) .................................... 42
Tracheostomy care (BLS) .................................... 22
Trauma (ALS)...................................................... 52
Trauma (BLS) ...................................................... 30
Enalapril ..................................................... I-57, II-14
Endotracheal administration of medication ....... XI-12
Endotracheal intubation, Guideline for practical skill
............................................................ IX-18, IX-42
Endotracheal tube, suctioning of ......................... IX-3
Envenomation ....................................................... V-5
Epinephrine ........... I-14, II-12, III-3, IV-2, V-5, XI-13
Esophageal reflux ................................................ IV-5
Etomidate .......................................... I-37, II-12, II-15
Excited delirium .................................................... II-6
Exhalation diverter cap ...................................... IX-23
External jugular intravenous line .......................... X-6
Extracatheter ......................................... X-3, X-4, X-6
Extrication device, seated patient ....................... XII-5
Extubation, Guideline for practical skill ............ IX-25
Eye irrigation, chemical substance ..................... XII-3
Eye, foreign body removal from ......................... XII-3
EZ-IO placement ................................................ X-25
Oxygen administration....................................... II-1
Routine medical care ......................................... II-2
Universal precautions ........................................ II-3
Guideline for practical skill
Airway assessment ....................................... VIII-1
Bag-valve-mask ventilation ............................. IX-8
Bandaging ....................................................... XII-1
Blood glucose measurement ............................ XI-1
Blood pressure measurement ........................ VIII-4
Blood sample .................................................... X-1
Board splint .................................................. XII-13
Central line access .......................................... X-23
Cervical immobilizer .................................... XII-11
Cricothyroidotomy......................................... IX-34
Defibrillation .................................................. X-12
Endotracheal administration of medication ... XI-12
Endotracheal intubation ...................... IX-18, IX-42
Extubation...................................................... IX-25
EZ Intraosseous placement ............................. X-25
Foreign body removal from eye...................... XII-3
Helmet removal ............................................ XII-25
Intramuscular injection .................................. XI-14
Intraosseous line placement .............................. X-8
IV bolus medication administration ................. XI-5
IV drip medication administration ................... XI-7
Joint splint ....................................... XII-15, XII-17
Magill forceps, removal of airway obstruction .. IX10
MAST ............................................................. XII-7
Nasotracheal intubation ................................. IX-21
Nebulized medication ...................................... XI-9
Obstetrical delivery....................................... XIII-1
Oral airway insertion ..................................... IX-12
Oral medication .................................. XI-20, XI-24
Pericardiocentesis ........................................... X-10
Pneumatic anti-shock garment (PASG) .......... XII-7
Pocket mask ventilation ............ IX-6, X-32, XII-29
Preparation of medication for administration .. XI-2
Rectal administration of medication .............. XI-18
Seated patient extrication device .................... XII-5
Sling and swathe ........................................... XII-19
Spinal immobilization ........................ XII-9, XII-12
Sublingual medication ........................ XI-20, XI-24
SubQ injection ............................................... XI-16
Synchronized cardioversion ............................ X-15
Thoracentesis ................................................. IX-32
Tracheostomy care ......................................... IX-29
Traction splint ............................................... XII-21
Ventilation, bag-valve-mask ............................ IX-8
Ventilation, pocket mask ....................... IX-6, X-32
Gynecological complaints .................................. VII-1
F
Face masks, oxygen ............................................. IX-1
Fentanyl ...................................................... I-38, II-14
Fentanyl Citrate ................................................... II-12
Fever ................................................................... V-10
Fibrillation, ventricular ........................................ IV-2
Flail chest.......................................................... XII-23
Flumazenil .................................................. I-30, II-14
Foreign body aspiration ....................................... III-3
Foreign body, airway ........................................... III-1
Furosemide ........................................I-15, II-12, IV-7
G
Geodon ............................................... I-53, II-14, II-6
Germicidal agent.................................................... II-3
Glasgow Coma Scale ................................ VI-6, VI-13
Glass ampule, medication preparation ................. XI-2
Gloves .................................................................... II-3
Glucagon................................... I-16, II-12, V-3, V-14
Glutose ................................................................... I-11
Guideline for Care
Assessment parameters ...................................... II-1
History and Physical examination ..................... II-8
Medication administration ............................... II-10
H
Heart failure, congestive ...................................... IV-7
Helmet removal ................................................ XII-25
Hematemesis......................................................... V-1
Hemorrhage ......................................................... VI-5
Hemostatic Dressing ......................................... XII-29
Hiatal hernia ........................................................ IV-5
Hickman catheter ................................................ X-23
57
State of Wisconsin – Standards & Procedures of Practical Skills
High efficiency particulate air (HEPA) respirator . II-4
History and physical .............................................. II-8
History of the present illness
Guideline for practical skill .......................... VIII-2
History of the present illness (HPI) ....................... II-8
Hospital Destination ............................................ II-16
Hospital Diversion ............................................... II-17
Hpothermia (EMSC) ALS ....................................... 40
Huber needle ....................................................... X-23
Hy[erthermia (EMSC) ALS ..................................... 39
Hydration ............................................................... II-2
Hydromorphone ................................ I-39, II-12, II-14
Hydroxocobalamin ............................................... I-58
Hymenoptera (bees) .............................................. V-5
Hyperbaric chamber ............................................ III-5
Hypertension......................................................... V-9
Hyperthermia ...................................................... V-10
Hyperthermia (EMSC) BLS .................................... 19
Hypoglycemia........................................... V-14, V-15
Hypotension ......................................................... VI-5
Hypotension, orthostatic ..................................... V-16
Hypotensive trauma victims ................................ VI-5
Hypothermia .............................................. V-11, VI-3
Hypothermia (EMSC) BLS ..................................... 20
Hypothermia, cardiac arrest in ............................. IV-3
Hypovolemia ....................................................... IV-2
Hypoxia ..................................................... IV-2, V-14
IV line, capped...................................................... X-4
IV line, discontinue............................................... X-5
J
Jamshidi intraosseous needle ................................ X-8
Joint splint ........................................................ XII-15
Jugular vein distention (JVD) ................................ II-2
Jugular, extermal
Intravenous line placement ............................... X-6
K
KED .................................................................... XII-5
Kendrick Extrication Device .............................. XII-5
Ketalar .................................................................. I-56
Ketamine..................................................... I-56, II-12
Ketanest ................................................................ I-56
Ketaset .................................................................. I-56
Ketorolac .......................................... I-40, II-12, II-14
L
Labor .................................................................. VII-1
Laryngeal Mask Airway .................................... IX-42
Laryngoscopy ...................................................... III-1
Lasix .................................................. I-15, II-12, IV-7
Levalbuterol ................................................ I-52, II-12
Level of consciousness .......................................... II-3
Level of consciousness, altered ............................ V-3
Lidocaine ...................... I-17, II-12, X-8, X-25, XI-13
Lights and Siren Transport .................................. II-21
LMA .................................................................. IX-42
Log roll ................................................ XII-10, XII-11
Lopressor .............................................................. I-55
Lorazepam .............................. I-41, II-13, II-15, V-14
I
Ibuprofen ............................................................. II-14
Ice ......................................................................... V-2
Impedance Threshold Device ............................ IX-40
Implanted IV ports .............................................. X-24
Ingestions ............................................................ V-13
Inhalation injury .................................................. III-5
Intoxication ......................................................... V-12
Intramuscular injection, Guideline for practical skill
....................................................................... XI-14
Intranasal ........................................................... XI-24
Intraosseous line placement, Guideline for practical
skill ................................................................... X-8
Intraosseous placement, EZ-IO .......................... X-25
Intravenous bolus medication, Guideline for practical
skill .................................................................. XI-5
Intravenous drip medication administration ........ XI-7
Intravenous line placement
Peripheral .......................................................... X-3
Umbilical vein .................................................. X-4
Intravenous line, capped ....................................... X-4
Intubation
Endotracheal ....................................... IX-18, IX-42
Nasotracheal .................................................. IX-21
Through a stoma ............................................ IX-30
Intubation, rapid sequence ................................. IX-38
IO ...................................................... See Intraosseous
Ipratropium .............................. II-11, III-3, III-4, III-7
Iprotropium ........................................................... I-24
Ischemic cardiac disease ...................................... IV-5
Isopropyl alcohol ................................................... II-3
IV ................................................ See Intravenous line
M
Magill forceps ............................... III-1, IX-18, IX-27
Magill forceps, removal of obstruction .............. IX-10
Magnesium sulfate ...................................... I-31, II-13
Magnesium Sulfate ............................................. V-14
Mark 1 autoinjector skill .................................... XI-22
Masks..................................................................... II-3
MAST .................................................................. VI-8
MAST suit ........................................................... VI-5
MAST suit, guideline for practical skill ............. XII-7
Meconium aspirator ............................................. IX-4
Med ports ............................................................ X-24
Medical Control ................................................... II-10
Medical Examiner.................................................VI-7
Medication administration ................................... II-10
Medication preparation
Glass vial ......................................................... XI-2
Intravenous drip ............................................... XI-4
Multidose vial .................................................. XI-2
Preloaded syringe ............................................ XI-3
Medication preparation, Guideline for practical skill
......................................................................... XI-2
Medication, reconstitution of ............................... XI-3
Melena .................................................................. V-1
Mental status .......................................................... II-8
Meperidine ........................................ I-42, II-13, II-14
58
State of Wisconsin – Standards & Procedures of Practical Skills
Methylprednisolone .................................... I-32, II-13
Metoclopramide .......................................... I-33, II-13
Metoprolol ............................................................ I-55
Midazolam .............................. I-28, II-14, II-15, V-14
Migraine headaches ............................................... V-8
Morphine ............... I-18, II-13, II-14, IV-6, IV-7, V-5
Movement, peripheral ............................................ II-3
Multidose vial, medication preparation ............... XI-2
Musculoskeletal system assessment ...................... II-3
Oxygen equipment ............................................... IX-1
Oxygen therapy ..................................................... II-1
P
Pacemakers .......................................................... IV-2
Pacing, transcutaneous........................................ X-21
Pain protocol ........................................................ II-13
PASG ................................................................... VI-5
Past medical history
Guideline for practical skill .......................... VIII-2
Past medical history (PMH)................................... II-8
Pediatric DNR ..................................................... IV-9
PEEP ............................................... III-5, VI-3, IX-23
Penetrating chest injuries .................................. XII-23
Pericardial tamponade ........................................ X-10
Pericardiocentesis, Guideline for practical skill . X-10
Peripheral circulation ............................................. II-3
Personal protective equipment ............................... II-3
Phenergan ................................................... I-45, II-14
Phenolic compound ............................................... II-3
Physical assessment ...................... II-8, VIII-1, VIII-2
Physical Restraint .................................................. II-5
Physician On-Scene ............................................. II-10
PICC lines ........................................................... X-23
Piggyback administration technique .................... XI-7
Pit vipers ............................................................... V-5
Pleurisy ................................................................ IV-5
Pneumatic anti-shock garment ............................. VI-5
Pneumatic Anti-shock Garment .......................... XII-7
Pneumonia ........................................................... IV-5
Pneumothorax, spontaneous ................................ IV-5
Pneumothorax, tension ........................................ IV-2
Pocket mask ventilation, Guideline for practical skill
.................................................. IX-6, X-32, XII-29
Poison (EMSC) BLS ............................................... 24
Poisoning (EMSC) ALS .......................................... 43
Positive End Expiratory Pressure ... III-5, VI-3, IX-23
Pralidoxime ........................................................... I-48
Pralidoxime chloride.......................................... XI-22
Pregnancy ................................................... V-1, VII-1
Pregnancy categories of drugs ............................. II-14
Preloaded syringe, medication preparation .......... XI-3
Pro splint........................................................... XII-17
Procainamide .............................................. I-21, II-13
Prolapsed cord .................................................. XIII-2
Promethazine .............................................. I-45, II-14
Pronestyl .............................................................. II-13
Propofol ............................................ I-54, II-14, II-15
Protocol, medical
Trauma, multiple ............................................. VI-7
Psychiatric problems............................................. V-4
Public Access AED ............................................ X-13
Pulmonary emboli................................................ IV-5
Pulmonary embolism ........................................... IV-2
Pulse ...................................................................... II-2
Pulseless Electrical Activity (PEA) ........... IV-2, X-21
Pulseless ventricular tachycardia ......................... IV-2
Pupils ............................................................. II-3, II-8
N
Nalbuphine ....................................... I-43, II-13, II-14
Naloxone................................. I-19, II-13, V-3, XI-13
Narcan .......................... I-19, II-13, V-3, V-13, XI-13
Nasal cannula......................................................... II-1
Nasogastric tube ................................................ IX-27
Nasogastric tube, Guideline for practical skill ... IX-27
Nasopharyngeal airway ....................................... IX-8
Nasotracheal intubation, Guideline for practical skill
....................................................................... IX-21
Nebulized medication
via endotracheal tube ..................................... XI-10
via non-rebreather mask .................................. XI-9
Nebulized medication, Guideline for practical skill
......................................................................... XI-9
Nebulizer ............................................................. IX-1
Needle cricothyroidotomy ................................. IX-34
Needle recapping ................................................... II-4
Neonatal Resuscitation (EMSC) ALS ..................... 41
Neonatal Resuscitation (EMSC) BLS...................... 21
Nervous system assessment ................................... II-3
Newborn assessment ......................................... XIII-4
Nitroglycerin............................................... I-20, II-13
Nitroglycerin drip .................... I-50, II-13, IV-6, IV-7
Nitroglycerine ............................................. IV-5, IV-7
Nitrous oxide .................................... I-44, II-13, II-14
Non-rebreather mask ............................................. II-1
Nubain .............................................. I-43, II-13, II-14
O
Obstetrical delivery
Arm or leg presentation ................................ XIII-2
Prolapsed cord .............................................. XIII-2
Vertex ........................................................... XIII-1
Obstetrical Delivery
Breech ........................................................... XIII-2
Multiple births .............................................. XIII-3
Prolapsed amniotic sac ................................. XIII-3
Prolapsed cord .............................................. XIII-2
Obstetrical emergencies ...................................... VII-1
Obstruction, airway .................................... III-1, III-6
Ondansetron ................................................ I-49, II-13
On-Scene Physicians ........................................... II-10
Oral airway ............................................... IX-8, IX-19
Oral medication ...................................... XI-20, XI-24
Orogastric tube .................................................. IX-27
Orthostatic hypotension ...................................... V-16
Orthostatic vital signs ......................................... V-16
Overdose .............................................................. IV-2
Oxygen administration, Guideline for care ............ II-1
59
State of Wisconsin – Standards & Procedures of Practical Skills
Q
Spinal Immobilization, Guideline for practical skill
........................................................... XII-9, XII-12
Spinal injury assessment ..................................... XII-9
Stadol ................................................ I-35, II-11, II-14
Stoma, intubation of .......................................... IX-30
Stridor .................................................................. III-2
Stroke.................................................................. V-15
Subcutaneous medication administration .......... XI-16
Sublingual medication ............................ XI-20, XI-24
Substance abuse .................................................. V-12
Succinylcholine ............................... I-46, II-14, IX-38
Suicide ........................................................ V-4, V-13
Synchronized cardioversion................................ X-15
Syncope .............................................................. V-16
Quaternary ammonium compound ........................ II-3
R
Range of motion .................................................... II-3
Rapid sequence intubation ................................. IX-38
Recapping needles ................................................. II-4
Reconstitution of medication ............................... XI-3
Rectal administration of medication, Guideline for
practical skill.................................................. XI-18
Rectal bleeding ..................................................... V-1
Refusal of Care ...................................................... II-7
Reglan ......................................................... I-33, II-13
Reproductive system assessment ........................... II-3
Respiratory arrest ................................................. III-6
Respiratory Arrest (EMSC) ALS ............................. 45
Respiratory arrest (EMSC) BLS .............................. 25
Respiratory assessment .......................................... II-1
Respiratory distress.............................................. III-7
Respiratory Distress (EMSC) ALS .......................... 46
Respiratory Distress (EMSC) BLS .......................... 26
Respiratory distress, moderate ............................... II-1
Respiratory distress, severe ................................... II-1
ResQPOD .......................................................... IX-40
Restraint ................................................................. II-5
Restraints .............................................................. V-4
Resuscitation, termination of ............................... IV-3
Revocation, DNR order ....................................... IV-8
rhabdomyolysis ................................................. XII-27
Rigor mortis ......................................................... IV-8
Romazicon ........................................ I-30, II-14, V-13
Routine medical care ............................................. II-2
Rule of 9’s ........................................................... VI-2
T
Tachycardia, narrow complex ............................. IV-1
Tachycardia, stable (EMSC) ALS ........................... 50
Tachycardia, unstable (EMSC) ALS ....................... 51
Tachycardia, wide complex ................................. IV-1
Tactical ................................................................ II-19
Tamponade, cardiac ............................................. IV-2
Tension headache .................................................. V-8
Tension pneumothorax ............................. IV-2, IX-32
Termination of resuscitation ................................ IV-3
Thiamine ........................................... I-27, II-14, V-12
Thoracentesis ..................................................... IX-32
Guideline for practical skill ........................... IX-32
Thoracic Decompression ................................... IX-32
Thoracic injuries ............................................... XII-23
TIA ..................................................................... V-15
Tissue decomposition .......................................... IV-8
Toradol ............................................. I-40, II-12, II-14
tourniquet .......................................................... XII-27
Toxic inhalation ................................................... VI-2
Toxin inhalation .................................................... V-8
Tracheostomy Care (EMSC) ALS ........................... 42
Tracheostomy care (EMSC) BLS
Tracheostomy care (BLS) .................................... 22
Tracheostomy care, Guideline for practical skillIX-29
Tracheostomy, permanent.................................. IX-29
Tracheostomy, temporary .................................. IX-29
Traction splint, Guideline for practical skill ..... XII-21
Transcutaneous pacing ....................................... X-21
Transfer of Care ................................................... II-11
Transient ischemia attack ................................... V-15
Transport.................................................... II-16, II-21
Trauma ................................................................. VI-6
Trauma (EMSC) ALS .............................................. 52
Trauma (EMSC) BLS .............................................. 30
Trauma incompatible with life ............................. IV-8
Trauma, multiple, protocol .................................. VI-7
Trauma-related cardiac arrest .............................. IV-3
Tuberculosis .......................................................... II-4
Twins ................................................................ XIII-3
S
Safe Haven for Newborns (EMSC) ALS ................. 47
Save Haven for Infants (EMSC) BLS...................... 27
Seated patient extrication device ........................ XII-5
Secondary assessment, Guideline for practical skill
...................................................................... VIII-1
Seizure (EMSC) ALS .............................................. 48
Seizure (EMSC) BLS .............................................. 28
Sellick’s Maneuver ............................................ IX-39
Sensation, peripheral ............................................. II-3
Sexual assault/abuse ............................................ VI-1
Shock ................................................................... VI-5
Shock (EMSC) ALS ................................................ 49
Shock (EMSC) BLS ................................................ 29
Sinus headaches ..................................................... V-8
Skin ................................................................ II-2, II-8
Sling and swathe ............................................... XII-19
Snake bites .................................................... V-2, V-5
Sodium Bicarbonate ................................... I-22, II-14
Solu-Medrol ................................................ I-32, II-13
Special Operations ............................................... II-19
Spider bites ........................................................... V-5
Spinal immobilization
Log roll ......................................................... XII-10
U
Umbilical IV line placement ................................. X-4
Universal precautions............................................ IX-4
60
State of Wisconsin – Standards & Procedures of Practical Skills
V
W
Vaginal bleeding ................................................. VII-1
Valium .............................................. I-12, II-14, V-14
Vasopressin........................................I-25, II-14, IV-2
Vasotec ....................................................... I-57, II-14
Vecuronium .....................................I-47, II-14, IX-38
Ventolin ............................................................... II-11
Ventricular fibrillation ............................... IV-2, X-12
Ventricular fibrillation, hypothermia in .............. V-11
Ventricular tachycardia ....................................... X-12
Ventricular tachycardia, pulseless ....................... IV-2
Versed ....................................... I-28, II-14, II-6, V-14
Vital signs ..........................................II-8, II-9, VIII-2
Vital signs, orthostatic ........................................ V-16
Wheezing ............................................................. III-2
WITRAC ............................................................. II-17
Working assessment .............................................. II-8
X
Xopenex ...................................................... I-52, II-12
Y
Yankauer suction tip ............................................ IX-3
Z
Ziprasidone ................................................. I-53, II-14
Zofran ............................................... I-49, II-13, II-15
61