These standing orders were developed and approved by Monroe County Ambulance Service, Medical Director to provide standardization of basic life support interventions delivered to patients by EMR (Emergency Medical Responder) within Monroe County. These standing orders are subject to revision and additions as determined necessary by the EMS Medical Director. No set of standing orders can cover every possible situation. EMRs are expected to use common sense and provide care that is in the best interest of the patient. Progression through the Standing Order should be to the point of resolution of the medical or traumatic condition and then cease further standing order treatments. Unusual situations or any perceived need to deviate from these standing orders should be discussed with a Medical Control Physician. Any deviation from the established standard should be thoroughly documented on the patient care report. The standing orders contained within are those basic life support measures that may be instituted prior to voice contact with a Medical Control Physician. Initiation of these orders should be on the basis of patient need an indication. If at any time the EMR has a question or is uncomfortable with instituting any standing order, he/she should consult with a Medical Control Physician.
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Table of Contest Universal Care Patient Standing Orders-.....3 Initial Assessment-...3 Trauma Assessment-..4 Medical Assessment- .5 Ongoing Assessment-....6 Patient Hand off Report-.6 Calling for Medical Direction-.6 CPR and AED-..7 Combi-Tube.43 Choking-....8 Shock-9 Abdominal Pain-.18 Abdominal (open) Injury-...30 Altered Mental Status (unknown)-14 Anaphylactic Shock-..10 Behavioral Emergencies-..26 Burns-...32 BSA Chart-..44 Chest Pain-..12 Flail Chest-..33 Sucking Chest Wound-.29 Childbirth-34 Complicated-...35 Cutting the Umbilical Cord-...36 Caring for the Newborn-....36 External Bleeding-..27 Extremity Injuries-...28 Heat Related Emergencies-..23 Hyperglycemia-...16 Hypoglycemia-17 Hypothermia-...24 Localized Cold Injuries-.25 Impaled Objects-.31 Poisons-.. Absorbed-21 Inhaled-20 Ingested-..19 Injected-22 Respiratory Emergencies-.13 Seizures-..15 Stroke-.........11
Pharmacology Index-.37 Monroe County Ambulance Service Emergency Medical Responder Protocols 2011
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Universal Care Patient Standing Orders Personal Protective Equipment: Gloves, Eye Protection, Mask, Gown Scene Size Up: Scene Safety MOI/ Nature of Illness Number of Patients Request Additional Resources if Necessary (using dispatch) Extra Man Power, Extra EMS Units, Utilities, Hazmat Consider Stabilization of CSpine Initial Assessment: Determine LOC (Level of Consciousness) AVPU (Alert, Verbal, Painful, Unresponsiveness)
Circulation: Assess/Control major bleeding Assess pulse Assess skin (color, temperature and condition) Trauma Assessment ..page 4 Medical Assessment . page 5 Monroe County Ambulance Service Emergency Medical Responder Protocols 2011
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Trauma Rapid Trauma Assessment Head to Toe Exam Noting DCAPBTLS (Deformities, Contusions, Abrasions, Punctures, Burses, Tenderness, Lacerations, Swelling) Controlling life threats Baseline Vital Signs Pulse, Respirations, BP, SPO2
Obtain S.A.M.P.L.E. History Signs/Symptoms Allergies Medications Pertinent History Last Oral Intake Events leading up to Incident
Detailed Physical Exam Performing a Head to Toe Exam with more Detail
Manage Secondary Injuries/Wounds
Perform On Going Assessment & Pt Hand Off: Page: 6
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Medical Focused History, Physical Exam and Rapid Assessment
Rapid Head to Toe Assessment Note any DCAPBTLS (Deformities, Contusions, Abrasions, Punctures/Penetrations, Burns, Tenderness, Lacerations, Swelling) Controlling life threats
Obtain S.A.M.P.L.E. Signs and Symptoms OPQRST Onset- Ex: What time did it start? Provokes- Ex: Is there anything that makes the pain worse or better? Quality- Ex: Describe to me what it feels like. Radiates- Ex: Does the pain move around any where? Severity-Ex: On a scale of 1-10, 10 being the worse pain you ever had what number would you give this pain? Time- Ex: What time/day did this start? Interventions- Ex: Have you done anything for (complaint) and has this helped or made it worse? Allergies Medications Past Pertinent History Last Oral Intake Event leading to resent illness (rule out trauma)
Focused Physical Exam Assess affected body part/system or if indicated follow rapid trauma assessment on page 3.
Interventions Follow standing order for signs & symptoms. Obtain medical direction (if needed)
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Ongoing Assessment
Continuing Vital Signs and Treatment Every: 5 mins-Unstable 10 mins-Stable
Patient Hand Off Report
Only to be given to someone with the same level of care or higher. Information to be given: Patients Mental Status Age and Sex Chief Complaint ABC Status Physical Findings SAMPLE History Interventions Applied and Patients Response
Calling For Medical Direction
Medical Direction can be the unit responding (contacting them by radio) or Sweetwater ER. (423)337-6172 (865)213-8524
When calling for Medical Direction information needed: Who You Are/ Who You Are With Patients info Age, Chief Complaint, Vital Signs (what you have on hand), and interventions that have been done Why you are calling
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CPR and Automated External Defibrillator (AED) Chain of Survival Early Access Early CPR Early Defibrillation Early Advanced Life Support When to Begin CPR Perform Initial Assessment (pg 3) Note: When assessing and opening Airway Non-trauma: Head tilt method Trauma: Jaw Thrust, as appropriate (document) When assessing Breathing Look and Listen (no more than 10 seconds) Not Breathing- Check Circulation Breathing- Take necessary precautions and follow Difficulty Breathing protocol. When assessing Circulation Take no longer then 10 seconds to assess for a pulse OR any other signs of circulation AND breathing. Adult/Child (1 yr & older)- Check the Carotid pulse Infant (1mo- 1 yr)- Check the Brachial pulse Neonate (birth- 1mo)- Check the Apical pulse Newborn (just delivered)- Check Umbilical cord YOU MAY CHECK BREATHING AND CIRCULATION AT THE SAME TIME REMEMBER: DO NOT CHECK ANY LONGER THAN 10 SECONDS WHEN CHECKING BOTH BREATHING AND CIRCULATION TOGETHER!!!!! Negative findings on ABCs 1. Notify Dispatch of findings. 2. Place patient on firm hard surface in the supine position. 3. Follow American Heart Association (AHA) instruction on CPR for appropriate per age group. 4. Retrieve AED Note: Adult Place AED as soon as possible. Child If witnessed (by rescuer) give five cycles/2 mins of CPR before placing AED. Not witnessed- Place AED as soon as possible. Use the pads ADULT Pads for ADULT Patients!!! Use Pediatric pads for infant/pediatric patients when available otherwise Adult pads maybe used 5. Continue CPR until- EMS arrives to relieve rescuer, if patient recovers or if all rescuers are too exhausted to continue. 6. Combi-Tube may need to be placed (pg 43) Follow patient Hand Off Report: Page 6 Monroe County Ambulance Service Emergency Medical Responder Protocols 2011
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Choking Patient
Signs/Symptoms: (but not limited to) Mild Airway Obstruction : Good air exchange Responsive and can cough forcefully May wheeze in between coughs Severe Airway Obstruction : Poor or no air exchange Clutching the neck making the universal choking sign Weak, ineffective or no cough at all High pitch noise while inhaling or no noise at all Increased respiratory difficulty Possible cyanosis Unable to speak Unable to move air
Perform Initial Assessment: pg 3
Mild Airway Obstruction: - Encourage the patient to cough until obstruction relieved, complete airway obstruction occurs or EMS arrives on scene.
-COMPLETE AIRWAY OBSTRUCTION OCCURS- Follow Severe Airway Obstruction Protocol
Severe Airway Obstruction: -Adult Patients- Provide abdominal thrust until object is relieved, patient becomes unresponsive or EMS arrives on scene. (If patient is to large and/or pregnant provide chest thrust) -Pediatric Patients- Provide Five (5) chest thrusts and Five (5) Back blows until object is relieved, patient becomes unresponsive or EMS arrives on scene.
-Obstruction Relieved continue to Pg 4 Trauma Pg 5 Medical
-PATIENT IS UNRESPONSIVE- Follow CPR and AED protocol (pg 7) assessing airway before every ventilation.
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Shock Signs/Symptoms: (but not limited to) Altered Mental Status Restlessness/combative, Unresponsive, Anxiety Breathing Rapid and Shallow Skin Pale, cool, clammy, diaphoretic Pulse Rapid and Weak Profuse Bleeding Nausea and/or Vomiting Shaking and/or Trembling Dizziness Fear
Perform Initial Assessment: pg 3
Treat Life Threats: Provide Oxygen: 15 LPM of Oxygen by Non re-breather
Control External Bleeding: Control Life Threatening bleeding as soon as possible
Keep Patient at Rest: Place patient in position of comfort (as long as trauma is not suspected)
Keep Patient Warm: Maintain Patients body heat
Place Patient in Trendelenberg: Unless Airway is compromised
GIVE PATIENT NOTHING BY MOUTH
Follow On Going Assessment and Patient Hand Off Report Pg 6 Monroe County Ambulance Service Emergency Medical Responder Protocols 2011
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Anaphylactic Shock Signs/Symptoms: (but not limited to) Altered Mental Status Restlessness/combative, Unresponsive, Anxiety Breathing Wheezing, Rapid and Shallow Skin Pale, cool, clammy, diaphoretic Pulse Rapid, Weak, or Not Detected Swelling to Face, Tongue and Airway
Perform Initial Assessment: pg 3
Treat Life Threats: Provide Oxygen: 15 LPM of Oxygen by Non re-breather
Epinephrine Auto-injector (Epi-Pen) pg 42 Patient is having a known Anaphylactic Reaction Must be prescribed to patient
Check for the 5 Rs Right patient, Right medication, Right dose, Right route, and Right time
. Call for medical direction for further orders: pg 6
Steps for Assisting Patient After Orders Have Been Obtained
-Remove cap from autoinjector -Place tip of injector against patients lateral thigh, midway between hip and knee -Push the injector firmly against thigh until injector activates -Hold injector in place for 10 seconds/until medication is administered -Record time -Dispose injector in proper container
Keep Patient at Rest: Place patient in position of comfort, reassure patient and treat patient for shock (Treating for shock- pg 9)
Obtain Base line Vitals: Pulse, Respirations, BP, SPO2
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Follow On Going Assessment and Patient Hand Off Report Pg6 Stroke
Signs/Symptoms: (but not limited to) Altered Mental Status Headache Syncope (fainting) Numbness/Paralysis Difficulty with speech Difficulty with vision Dizziness Seizures Altered Breathing Patterns Hypertension (High Blood Pressure)
Perform Initial Assessment: pg 3
Provide Oxygen: 15 LPM of Oxygen by Non re-breather
Keep Patient at Rest: Place patient in position of comfort, reassure patient and treat patient for shock (Treating for shock- pg 9)
Obtain Base line Vitals: Pulse, Respirations, BP, SPO2
Perform the Cincinnati Pre-hospital Stroke Scale (CPSS)
Facial Droop: Have the patient smile or show their teeth. Observe for facial droop or non- symmetrical movement.
Arm Drift: Have the patient hold their arms out in front of them and close their eyes. Observe for arm drift or if patient cannot bring both arms up together.
Abnormal Speech: Observe for slurred speech, inappropriate words or unable to respond verbally
Follow On Going Assessment and Patient Hand Off Report Pg 6 Monroe County Ambulance Service Emergency Medical Responder Protocols 2011
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Chest Pain Signs/Symptoms: (but not limited to) Chest / Upper Abdominal Pain Chest/Upper Abdominal Pressure Chest/Upper Abdominal Burning Pain behind the Sternum Pain radiating to either arm, shoulder, jaw, upper back, upper and middle abdomen. Shortness of Breath Nausea Sweating Weakness Increased/ Irregular pulse
Perform Initial Assessment: pg 3
Provide Oxygen: 15 LPM of Oxygen by Non re-breather
Keep Patient at Rest: Place patient in position of comfort, reassure patient and treat patient for shock (Treating for shock- pg 9)
Obtain Base line Vitals: Pulse, Respirations, BP, SPO2
Nitroglycerin: pg 41 If patient is prescribed nitroglycerin, blood pressure is over 100 systolic and has not taking more than 3 tabs for this initial chest pain, assist patient in taking 1nitroglycerin tab sublingual. Reassess patient after 3-5 mins.
Check for the 5 Rs Right patient, Right medication, Right dose, Right route, and Right time
. Call for medical direction for further orders: pg 6
Contraindications- Systolic pressure less 100, Head injury Patient has already taken max dose prescribed IF IN DOUBT CALL FOR MEDICAL DIRECTION Pg6
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Follow On Going Assessment and Patient Hand Off Report Pg 6 Respiratory Emergencies
Signs and symptoms: (but not limited to) Absent or shallow rise and fall of the chest No air heard or felt at the nose and mouth Noisy breathing or gasping sounds Irregular, rapid, slow, and /or labored breathing Use of accessory muscles and/or nasal flare Skin pale or cyanotic Patient in tripod position
Perform Initial Assessment: pg 3
Provide Oxygen: 15 LPM of Oxygen by Non re-breather
Keep Patient at Rest: Place patient in position of comfort, (preferably sitting up) reassure patient and treat patient for shock. (Treating for shock on pg 9)
Obtain Base line Vitals: Pulse, Respirations, BP, SPO2
Metered- Dose Inhaler: pg 40 If patient is prescribed a metered-dose inhaler
Call for medical direction: pg 6
Check for the 5 Rs Right patient, Right medication, Right dose, Right route, and Right time
Contraindications- Altered Mental Status (Ex: patient unable to use device properly) Permission was not given Patient has already taken maximum prescribed dose Not patients prescription
IF IN DOUBT CALL FOR MEDICAL DIRECTION Pg6
Follow On Going Assessment and Patient Hand Off Report Page 6
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Unknown Altered Mental Status
Signs and symptoms: (but not limited to) Decrease in Patients Alertness Decrease in Patients Responsiveness Decrease in Patients Responsiveness to Surrounds
Perform Initial Assessment: pg 3
MAINTAIN C SPINE UNTIL PROVEN NONE IS NEEDED
Provide Oxygen: 15 LPM of Oxygen by Non re-breather
Treat Patient for Shock: Pg: 9
Obtain Base line Vitals: Pulse, Respirations, BP, SPO2
IF IN DOUBT CALL FOR MEDICAL DIRECTION Pg6
Follow On Going Assessment and Patient Hand Off Report Page 6
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Seizure
Signs and symptoms: (but not limited to) Sudden Loss of Responsiveness Convulsions Loss of Bladder and/or Bowel Control Labored Breathing/ Frothing at the Mouth After Seizure Patient body is relaxed/ combative May have headache (before/after)
Perform Initial Assessment: pg 3
Protect Patient from Injury: Do not Restrain patient Do not place anything in Patients Mouth Loosen Restrictive Clothing Watch for Vomiting (suction maybe needed)
MAINTAIN C SPINE UNTIL PROVEN NONE IS NEEDED
Provide Oxygen: 15 LPM of Oxygen by Non re-breather
Keep Patient at Rest: Place patient in position of comfort, (preferably recovery position) reassure patient and treat patient for shock. (Treating for shock on pg 9)
Obtain Base line Vitals: Pulse, Respirations, BP, SPO2
Look for Underlining Cause of Seizure: A seizure is not a disease, but a sign of an underlying condition.
IF IN DOUBT CALL FOR MEDICAL DIRECTION Pg6
Follow On Going Assessment and Patient Hand Off Report Page 6
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Hyperglycemia
Signs and symptoms (but not limited to) Gradual onset Over hours/days Altered Mental Status Unresponsive, Restlessness and/or Stupor Breathing Difficulty, Abnormal, Deep and Rapid Pulse Rapid, Weak Skin Warm, Dry, may have a Red appearance Extreme Thirst Abdominal Pain Ketone Breath Sweet fruit smell Dry Mouth
Perform Initial Assessment: pg 3
Provide Oxygen: 15 LPM of Oxygen by Non re-breather
Treat Patient for Shock: Place patient in position of comfort, (preferably recovery position) reassure patient and treat patient for shock. (Treating for shock on pg 9)
Obtain Base line Vitals: Pulse, Respirations, BP, SPO2
IF IN DOUBT CALL FOR MEDICAL DIRECTION Pg6
Follow On Going Assessment and Patient Hand Off Report Page 6
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Hypoglycemia Signs and symptoms (but not limited to) Rapid Onset Minutes Altered Mental Status Abnormal, Hostile/Aggressive Behavior (May appear Intoxicated) Convulsions, Fainting, occasionally coma Pulse Full Rapid, or Weak Rapid Skin Pale, Cool, Clammy, Diaphoretic Dizziness Headache Intensely Hungry; Drooling
Perform Initial Assessment: pg 3
Provide Oxygen: 15 LPM of Oxygen by Non re-breather
Treat Patient for Shock: Place patient in position of comfort, (preferably recovery position) reassure patient and treat patient for shock. (Treating for shock on pg 9)
Obtain Base line Vitals: Pulse, Respirations, BP, SPO2
KNOWN HISTORY OF DIABETES, PATIENT IS ALERT AND ABLE TO SWALLOW
Oral Glucose: pg 39 Administer one (1) tube of Oral Glucose Place Glucose into mouth (preferable between cheek and gum).
IF IN DOUBT CALL FOR MEDICAL DIRECTION Pg6
Follow On Going Assessment and Patient Hand Off Report Page 6
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Abdominal Pain Signs and symptoms (but not limited to) Altered Mental Status Signs of Shock Abdominal Pain Back Pain Nausea/Vomiting Breathing Rapid and Shallow Pulse Rapid Bleeding Rectal, urine and vaginal Fever Pulsating Mass Rigidity Distension Tenderness
Perform Initial Assessment: pg 3
Provide Oxygen: 15 LPM of Oxygen by Non re-breather
Keep Patient at Rest: Place patient in position of comfort, reassure patient and treat patient for shock. (Treating for shock on pg 9)
Obtain Base line Vitals: Pulse, Respirations, BP, SPO2
GIVE PATIENT NOTHING BY MOUTH Collect any vomitus/body fluids in bio-hazard bag. To be transported with patient to hospital.
Follow On Going Assessment and Patient Hand Off Report Page 6
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Ingested Poison
Signs and symptoms (but not limited to) Altered Mental Status/ Unresponsive Dilated/Constricted Pupils Burns/Stains around/in patients mouth/throat Excessive saliva Breathing Abnormal Pulse Abnormal rate and rhythm Skin Diaphoretic Unusual Breath odor, Body odor Abdominal Pain Nausea/Vomiting Convulsions
Perform Initial Assessment: pg 3
Provide Oxygen: 15 LPM of Oxygen by Non re-breather
Keep Patient at Rest: Place patient in position of comfort, reassure patient and treat patient for shock. (Treating for shock on pg 9)
Obtain Base line Vitals: Pulse, Respirations, BP, SPO2
GIVE PATIENT NOTHING BY MOUTH (unless Medical Direction Orders) Activated Charcoal (pg38) Collect any vomitus/body fluids in bio-hazard bag. To be transported with patient to hospital.
Contact Medical Direction/Poison Control for Further Instruction Pg 6 (800)-2221222
Follow On Going Assessment and Patient Hand Off Report Page 6
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Inhaled Poison
Signs and symptoms (but not limited to) Altered Mental Status Breathing Shortness of Breath, coughing Pulse Rapid/Slow Eyes will appear irrigated
1 ST PRIORITY IS EMR
Remove Patient from Source Patient May Need to be Decontaminated Hazmat May Need to be Contacted
Perform Initial Assessment: pg 3
Provide Oxygen: 15 LPM of Oxygen by Non re-breather
Keep Patient at Rest: Place patient in position of comfort, reassure patient and treat patient for shock. (Treating for shock on pg 9)
Obtain Base line Vitals: Pulse, Respirations, BP, SPO2
Contact Medical Direction/Poison Control for Further Instruction Pg 6 (800)-2221222
Follow On Going Assessment and Patient Hand Off Report Page 6
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Absorbed Poison
Signs and symptoms (but not limited to) Altered Mental Status Anaphylactic Shock (pg 10) Skin Mild Irritation/Severe Burns, Itching, Increase Tempature Eye Irritation
1 ST PRIORITY IS EMR
Remove Patient from Source Patient May Need to be Decontaminated Hazmat May Need to be Contacted
Perform Initial Assessment: pg 3
Provide Oxygen: 15 LPM of Oxygen by Non re-breather
Keep Patient at Rest: Place patient in position of comfort, reassure patient and treat patient for shock. (Treating for shock on pg 9)
Obtain Base line Vitals: Pulse, Respirations, BP, SPO2
Contact Medical Direction/Poison Control for Further Instruction Pg 6 (800)-2221222
Follow On Going Assessment and Patient Hand Off Report Page 6
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Injected Poison Signs and symptoms (but not limited to) Altered Mental Status Weakness, Dizziness, Syncope Anaphylactic Shock (pg 10 ) Breathing Abnormal/Difficult Pulse Abnormal Skin Itching, Pain around Wound Site, Puncture Marks, Swelling, Discoloration Nausea/Vomit Vision Problems
Perform Initial Assessment: pg 3
Provide Oxygen: 15 LPM of Oxygen by Non re-breather
Keep Patient at Rest: Place patient in position of comfort, reassure patient and treat patient for shock. (Treating for shock on pg 9)
Obtain Base line Vitals: Pulse, Respirations, BP, SPO2
DO NOT FORGET TO REMOVE ANY CONSTRICTING ITEMS
For Snake Bites Clean Site with Soap and Water Immobilize Bitten Extremities Keep Bitten Extremity level with or below heart level
Contact Medical Direction/Poison Control for Further Instruction Pg 6 (800)-2221222
Follow On Going Assessment and Patient Hand Off Report Page 6
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Heat-Related Emergency
Signs and symptoms (but not limited to) Altered Mental Status Breathing Rapid, Shallow, Abnormal Pulse Rapid, Weak/Strong Skin Normal, Pale, Hot, Heavy/None Perspiration Muscles Cramps, Twitching Seizure
Perform Initial Assessment: pg 3
Remove Patient from Environment Cool Patient but Do Not Allow Patient to Become Chilled
Provide Oxygen: 15 LPM of Oxygen by Non re-breather
Keep Patient at Rest: Place patient in position of comfort, reassure patient and treat patient for shock. (Treating for shock on pg 9)
Obtain Base line Vitals: Pulse, Respirations, BP, SPO2
If Patient is Alert and Able to Maintain own Airway Sips of Water Maybe Given
Follow On Going Assessment and Patient Hand Off Report Page 6
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Hypothermia
Signs and symptoms (but not limited to) Altered Mental Status Decreased, Lack of Coordination, Impaired Judgment Pulse Initially rapid then slow Skin Shivering, Cool/Cold, Muscle rigidity/stiffness, Joint Stiffness
Perform Initial Assessment: pg 3
On Unresponsive Patients Check for a pulse for at least 30-40 seconds IF NONE IS FELT INITIALLY
Remove Patient from Environment Handle Patient Very Carefully
MAINTAIN C SPINE UNTIL PROVEN NONE IS NEEDED
Provide Oxygen: 15 LPM of Oxygen by Non re-breather
Keep Patient at Rest: Place patient in position of comfort, reassure patient and treat patient for shock. (Treating for shock on pg 9)
Obtain Base line Vitals: Pulse, Respirations, BP, SPO2
REMEMBER DO NOT GIVE PATIENT ANYTHING BY MOUTH
IF IN DOUBT CALL FOR MEDICAL DIRECTION Pg6
Follow On Going Assessment and Patient Hand Off Report Page 6
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Localized Cold Injury Signs and symptoms (but not limited to)
Early Blanching of the skin Feeling cold, pain, or loss of feeling/sensation to injured area Skin remains soft If thawed, tingling sensation is present Late White, waxy skin Firm to frozen feeling on palpation Swelling Blisters If thawed, may appear flushed with areas of purple/blanching
Perform Initial Assessment: pg 3
Remove Patient from Environment Handle Patient Very Carefully
Provide Oxygen: 15 LPM of Oxygen by Non re-breather
Keep Patient at Rest: Place patient in position of comfort, reassure patient and treat patient for shock. (Treating for shock on pg 9)
Obtain Base line Vitals: Pulse, Respirations, BP, SPO2
Early: Manually stabilize the extremity; Cover the extremity, DO NOT rub/massage injury, and DO NOT re-expose injury to cold. Late: Remove restrictive items, Cover injury with sterile dressings, DO NOT break blisters, DO NOT rub/massage injury, DO NOT apply heat, DO NOT rewarm and DO NOT allow patient to use effected site.
IF IN DOUBT CALL FOR MEDICAL DIRECTION Pg6
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Behavioral Emergencies
Signs and symptoms (but not limited to) Altered Mental Status Abnormal behavior that is unacceptable or intolerable to the patient, family or community. Experiencing Extreme emotions Psychological/ Mental Condition Under the influence
Perform Initial Assessment: pg 3
Provide O2 if needed: 15 LPM of Oxygen by Non re-breather / BVM
Keep Patient at Rest: Place patient in position of comfort, reassure patient and treat patient for shock. (Treating for shock on pg 9)
Obtain Base line Vitals: Pulse, Respirations, BP, SPO2
IN SURE SCENE SAFETY AT ALL TIME!
IF IN DOUBT CALL FOR MEDICAL DIRECTION Pg6
Follow On Going Assessment and Patient Hand Off Report Page 6
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External Bleeding Signs and symptoms (but not limited to) Arterial Bleeding: Blood spurting with each heart beat. (Bright Red) Venous Bleeding: Blood flows steadily from injury. (Dark Red) Capillary Bleeding: Blood oozes from injury. (Bright/Neutral Red)
DO NOT FORGET PPE!
Perform Initial Assessment: pg 3
Provide O2 if needed: 15 LPM of Oxygen by Non re-breather / BVM
MAINTAIN C SPINE UNTIL PROVEN NONE IS NEEDED
Control Bleeding: 1) Direct pressure (if bleeding continues) 2) Elevation with Direct pressure (if bleeding continues) 3) Pressure Points are Applied (if bleeding continues) 4) Use Tourniquet! Use tourniquet as last resort! DO NOT remove once placed! Remember to write on patient time tourniquet was placed!
Remember: that impaled objects must be stabilized and are not removed unless; it is in the cheek or effecting chest compressions.
Keep Patient at Rest: Place patient in position of comfort, reassure patient and treat patient for shock. (Treating for shock on pg 9)
Obtain Base line Vitals: Pulse, Respirations, BP, SPO2
Amputated Injuries: Cover Amputated injury (that has been removed from body) in sterile dressing place in a baggy that can be sealed in placed baggy in ice water. NEVER place amputated injury directly on ice. Transport with Patient.
IF IN DOUBT CALL FOR MEDICAL DIRECTION Pg 6
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Extremity Injuries
Signs and symptoms (but not limited to) Bruising/Contusing Deformity Pain Swelling Discoloration Inability to move joint/limb Numbness/Tingling Sensation Slow Capillary Refill Sound of Breaking at time of Injury Exposed Bone or Punctured Skin
Perform Initial Assessment: pg 3
Provide O2 if needed: 15 LPM of Oxygen by Non re-breather / BVM
MAINTAIN C SPINE UNTIL PROVEN NONE IS NEEDED
Keep Patient at Rest: Place patient in position of comfort, reassure patient and treat patient for shock. (Treating for shock on pg 9)
Obtain Base line Vitals: Pulse, Respirations, BP, SPO2
Expose Injury If you cant see it you cant treat it! Remove jewelry from injured extremity
Immobilize Injury ONLY if Pulse is present (if not notify EMS of findings) Use proper splint for suspected injury site Splint one (1) joint above and below injury site Recheck distal PMS
Apply Cold Pack Do Not Place Ice Pack Directly on Exposed Skin
IF IN DOUBT CALL FOR MEDICAL DIRECTION Pg 6
Follow On Going Assessment and Patient Hand Off Report Page 6
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Sucking Chest Wounds
Signs and symptoms (but not limited to) Open Chest wound Torn/Punctured Sucking Sound Bubbling at Injury Site Coughing of Red Bright, Frothy Blood
Perform Initial Assessment: pg 3
Provide O2 if needed: 15 LPM of Oxygen by Non re-breather / BVM
MAINTAIN C SPINE UNTIL PROVEN NONE IS NEEDED
Keep Patient at Rest: Place patient in position of comfort, reassure patient and treat patient for shock. (Treating for shock on pg 9)
Obtain Base line Vitals: Pulse, Respirations, BP, SPO2
Expose Injury If you cant see it you cant treat it!
Treatment: 1. Seal the patients wound with the palm of your gloved hand as the patient exhales. (DO NOT unseal wound to prepare dressing). 2. Place occlusive under your hand while patient exhales. -Tape three (3) sides 3. Monitor patient!
IF IN DOUBT CALL FOR MEDICAL DIRECTION Pg 6
Follow On Going Assessment and Patient Hand Off Report Page 6
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Open Abdominal Injury
Signs and symptoms (but not limited to) Deep Cut/Puncture Wound Exposure of Organs
DO NOT FORGET PPE!
Perform Initial Assessment: pg 3
Provide O2 if needed: 15 LPM of Oxygen by Non re-breather / BVM
MAINTAIN C SPINE UNTIL PROVEN NONE IS NEEDED
Keep Patient at Rest: Place patient in position of comfort, reassure patient and treat patient for shock. (Treating for shock on pg 9)
Obtain Base line Vitals: Pulse, Respirations, BP, SPO2
Expose Injury If you cant see it you cant treat it!
Treatment: 1. Have patient lie on back -Flex the patients legs and support them with a pillow/blanket. - If signs if pelvic, lower limb, or back injury DO NOT flex legs. 2. Be alert for VOMITING. 3. Do NOT touch exposed internal organs 4. Cover them with occlusive Dressing - Tape four (4) sides 5. Maintain Warmth -Place bulky dressing/towel over occlusive dressing.
IF IN DOUBT CALL FOR MEDICAL DIRECTION Pg 6
Follow On Going Assessment and Patient Hand Off Report Page 6
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Impaled Objects
Signs and symptoms (but not limited to) Object Protruding From Patient
Perform Initial Assessment: pg 3
Provide O2 if needed: 15 LPM of Oxygen by Non re-breather / BVM
MAINTAIN C SPINE UNTIL PROVEN NONE IS NEEDED
Keep Patient at Rest: Place patient in position of comfort, reassure patient and treat patient for shock. (Treating for shock on pg 9)
Obtain Base line Vitals: Pulse, Respirations, BP, SPO2
Expose Injury If you cant see it you cant treat it!
Treatment: 1. DO NOT Remove object -Object must be stabilized UNLESS affecting airway/chest compressions. 2. Stabilize object with bulky dressing/pads -Place material on opposite sides of object (long axel) - Second 2 nd layer opposite direction to the first (1 st ) - Use tape or triangle dressing to secure dressing/pads in place Abdominal injury leave patient in position found to minimize injury. Cheek injury make sure suction is available. Eye DO NOT forget to cover both eyes.
IF IN DOUBT CALL FOR MEDICAL DIRECTION Pg 6
Follow On Going Assessment and Patient Hand Off Report Page 6
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Burns Signs and symptoms (but not limited to) Superficial (1 st Degree) Top layer of skin (epidermis) Reddening of Skin Pain at Site Partial-Thickness (2 nd Degree) Top two (2) layers of skin (epidermis & dermis) Intense Pain Skin-Moist, Mottled, White/Red, Blisters Full-Thickness (3 rd Degree) All layers of skin May involve subcutaneous layers, muscle and/or bone Skin-Dry, Leathery, White, Dark Brown/ Charred Little to No Pain at initial Site (Remember that around site will be partial, superficial burns which are painful)
Perform Initial Assessment: pg 3
Treatment: 1. Stop Burning Process Extinguish Flames, (Caution in Hazmat Situations, Pt may need decontaminated before treatment can start) (Chemical- Wash away chemical, flush for at least 20 mins) 2. Flush Burn Only if burn is less than 9% of total BSA (body surface area) Pg 44 Flush with cool water for several minutes DO NOT allow patient to becomes chilled 3. Remove Clothing and Jewelry (DO NOT remove clothing that has melted to skin) 4. Cover Burned area with sterile dry dressing and bandage. Eyes- Moisten sterile dressing cover both eyes.
Provide O2 if needed: 15 LPM of Oxygen by Non re-breather / BVM
MAINTAIN C SPINE UNTIL PROVEN NONE IS NEEDED
Keep Patient at Rest: Place patient in position of comfort, reassure patient and treat patient for shock. (Treating for shock on pg 9)
Obtain Base line Vitals: Pulse, Respirations, BP, SPO2
IF IN DOUBT CALL FOR MEDICAL DIRECTION Pg 6
Follow On Going Assessment and Patient Hand Off Report Page 6
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Flail Chest Signs and symptoms (but not limited to) Pain and Tenderness At site, moving, breathing Deformity May swell or have obvious rib deformity Guarding Patient may splint affected side for stabilization Movement When the patient is breathing a section of chest wall moves in the opposite direction to the rest of the chest wall.
Perform Initial Assessment: pg 3
Provide O2 if needed: 15 LPM of Oxygen by Non re-breather / BVM
MAINTAIN C SPINE UNTIL PROVEN NONE IS NEEDED
Keep Patient at Rest: Place patient in position of comfort, reassure patient and treat patient for shock. (Treating for shock on pg 9)
Obtain Base line Vitals: Pulse, Respirations, BP, SPO2
Expose Injury If you cant see it you cant treat it!
Treatment: 1. Locate flail section by gently feeling the injury site. 2. Apply bulky dressing/pillow (small & lightweight) 3. Use large strips of tape to secure pad in place. DO NOT tape entirely around patients chest.
IF IN DOUBT CALL FOR MEDICAL DIRECTION Pg 6
Follow On Going Assessment and Patient Hand Off Report Page 6
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Childbirth Signs and symptoms (but not limited to) Having Laboring Pains Less than five (5) minutes part Watery/Bloody Discharge Feeling Strain in Pelvis/Lower Abdomen Need to Move Bowels Feel Baby at Vaginal Opening/Moving to
Perform Initial Assessment: pg 3
Provide O2 if needed: 15 LPM of Oxygen by Non re-breather
Obtain Base line Vitals: Pulse, Respirations, BP, SPO2
Prepare Mother for Delivery: 1. Extra BSI Proper gloves, mask with eye shield, gown 2. Prepare Patient for Delivery Remove clothing from waist down. Place patient on back, knees bent feet flat on floor, legs spread a part. Use clean sheets, towels to cover patient. 3. Check for Crowning Look for normal presentation, (head first) -If normal continue with delivery -NOT NORMAL go to pg 35 Normal & Crowning 1. Support Head 2. Check for cord around infants neck If cord is around neck attempt to remove UNABLE to remove cord clamp twice and cut in between clamps 3. Suction Mouth and Nose 4. Assist in the Head and Shoulders (DO NOT PULL) 5. Support Head, Trunk and Legs 6. Keep infant at level with vagina until umbilical cord is cut. (DO NOT move infant from location until cord has been cut, MUST call for Medical Direction to cut umbilical cord). If ALLOWED to cut cord go to pg 36. 7. Keep Infant Warm & Note time of Birth 8. Monitor and Record Infants (and go to pg 36) and Mothers Vital Signs 9. Prepare for Delivery of Placenta If placenta is delivered, place remains in a doubled bagged bio-hazard bag. (Should be transported with patient to receiving hospital) 10. Place sanitary pad over vaginal opening, lower and place legs together.
Keep Mother at Rest: Place mother in position of comfort, reassure patient and treat patient for shock. (Treating for shock on pg 9)
IF IN DOUBT CALL FOR MEDICAL DIRECTION Pg 6 Follow On Going Assessment and Patient Hand Off Report Page 6 Monroe County Ambulance Service Emergency Medical Responder Protocols 2011
Provide O2 if needed: 15 LPM of Oxygen by Non re-breather
Obtain Base line Vitals: Pulse, Respirations, BP, SPO2
Meconium Staining- (black/green discharge) is noted in newborns airway; suction repeatedly Call for Medical Direction pg 6 Continue Care pg 34
Breech Birth- Newborn can be delivered without complication Insure newborns airway by performing the V technique around newborns nose & mouth. Call for Medical Direction (pg 6) if complication pursue. Continue Care pg 34
Presenting Limb- Place patient in knee-chest position Notify EMS/Medical Direction (pg 6)
Prolapsed Cord- Place patient in knee-chest position Place moist dressing over cord Notify EMS/Medical Direction (pg 6) You may need to insert two (2) fingers in patients vagina to take pressure off the umbilical cord. (Push gently up on the infants head. You should feel in cord pulsating at that point). Once done DO NOT remove fingers. You will be going with patient to Hospital.
Seizures- Contact Medical Control/EMS (pg 6) Go to Page 15
Spontaneous Abortion- Contact Medical Control/EMS (pg 6) Having Patients Information before Contacting EMS is Vital!
Premature Birth- Follow AHA guidelines if Patient needs assistance with Breathing/Circulation. Contact Medical Control/ EMS (pg 6)
IF IN DOUBT CALL FOR MEDICAL DIRECTION Pg 6 Follow On Going Assessment and Patient Hand Off Report Page 6
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Cutting Umbilical Cord
Must Contact Medical Direction Prior to Doing Skill!
1. Wait for the cord to stop pulsating. (Unless Medical Direction has advised other wise). 2. Use sterile clamps- Apply 1 st clamp 10 inches from newborns belly. Apply 2 nd clamp 3 inches closer to newborn. 3. Cut between the two clamps. 4. Check for BLEEDING. If bleeding continues place another clamp as close to the original as possible.
Caring For Newborn
REMEMBER THESE THINGS SHOULD BE DONE EVEN BEFORE THE UMBILICAL CORD IS CUT!!!
Perform Initial Assessment: pg 3
Provide O2 if needed: 15 LPM of Oxygen by Non re-breather
Obtain Base line Vitals: Pulse, Respirations, BP, SPO2
-Insure ABCs
-Follow AHA guidelines if newborn needs assistance with Breathing/Circulation Heart Rate- Less than 100 but more then 60 Assist in ventilations for 30 seconds then revaluate Continue until Heart rate is above 100, EMS arrives or heart rate falls below 60. Heart Rate- Less than 60 Start CPR, Follow AHA guidelines
-Maintain newborns body temperature!
Follow On Going Assessment and Patient Hand Off Report Page 6
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Pharmacology
Drugs that EMR may ASSIST With
Activated Charcoal- Page 38
Oral Glucose- Page 39
Metered-Dose Inhaler- Page 40
Nitroglycerin- Page 41
Epinephrine Autoinjectors- Page 42
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-Activated Charcoal-
Indication- Poisoning by Mouth (Ingestion)
Contraindications- Altered Mental Status Ingestion of Acid/ Alkalis Unable to Swallow Dosage- 1gram activated charcoal/kg of body weight. (Adult: 25-50 grams, Pediatric: 12.5-25 grams)
Administration- 1. Contact Medical Direction 2. Shake Container Vigorously 3. Encourage patient to take recommended dose 4. Record Name, Dose, Route, and Time administered
Side Effects- Black Stools May cause nausea/vomiting
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-Oral Glucose-
Indications- Patient with altered mental status with known history of diabetes Patient has taken insulin with no food/has been physically active.
Contraindications- Unresponsiveness/unable to swallow Unable to maintain own airway Known diabetic that hasnt taken insulin for days.
Dosage- One (1) tube/15g of glucose
Administration- 1. Ensure patient is alert enough to swallow/maintain own airway 2. Assist in administration - administer into mouth (preferably under patients tongue) and have patient swallow gel until gel is gone. Administering small amounts at one time. 3. Perform on going assessment.
Side Effect- None when given properly.
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-Metered-Dose Inhaler-
Indications- Meets all of the Following Criteria: 1. Authorized by Medical Direction 2. Signs and Symptoms Respiratory Difficulty 3. Patient is Prescribed Medication
Contraindications- - Altered Mental Status (unable to assist with device properly) - No permission given - Patient has taken Maximum Dose Prior to EMR Arrival
Dose- Number of inhalations based on Medical Directions/Physician Order.
Administration- 1. Obtain order from Medical Direction. 2. Confirm patient is alert enough to use inhaler. 3. Ensure it is the patients own prescription. 4. Check expiration date. 5. Check if patient has already taken any doses. 6. Shake inhaler several times. 7. Have patient exhale deeply. 8. Have patient put lips around the opening of the inhaler. 9. Have patient depress the handheld inhaler when beginning to inhale 10. Instruct patient to hold breath for as long as possible 11. Allow patient to breathe a few time and repeat dose if ordered. 12. Provide oxygen as appropriate.
Side Effects- - Increased Pulse Rate. - Anxiety. - Nervousness.
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-Nitroglycerin-
Indications- All of the Following Must is Met: 1. Patient Complains of Chest Pain. 2. Patient has a History Cardiac Problems. 3. Patients Physician has Prescribed Nitroglycerin. 4. Systolic Blood Pressure is Greater than 100. 5. Medical Direction must Authorize 2 nd /3 rd dose.
Contraindications- - Patient has a systolic blood pressure below 100. - Patient has a head Injury. - Patient has already taken maximum prescribed dose.
Dose- - One dose is = to 0.4mg. - Repeat in 3 5 minutes as long as systolic remains above 100. - Maximum 3 doses (Spray is typically prescribed for one metered spray followed by second in 15 mins).
Administration- 1. Must meet indication. 2. Ensure Right medication, Right Patient, Right Dose, Right Route 3. Check Expiration Date 4. Ensure patient is Alert. 5. Ask Patient when last dose was taken and how it was taken. 6. Ask patient to lift tongue and place tablet or spray under tongue. 7. Recheck blood pressure in 2 3 minutes. 8. Record administration, route and time. 9. If systolic pressure is still above 100, Call For Medical Direction.
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-Epinephrine Autoinjectors-
Indications- Must Meet the Following Three Criteria: 1. Patient exhibits signs of severe allergic reaction, Including Respiratory Distress/Shock. 2. Medication is prescribed to patient 3. Authorized by Medical Direction.
Contraindications- None in lfe-threating situation!
Dosage- Adult- One adult autoinjector (0.3mg) Infant/Child- One infant/child autoinjector (0.15mg)
Administration- 1. Obtain patients prescribed autoinjector. Ensure- Its patient prescription Medication is not expired/discolored 2. Obtain order from Medical Direction 3. Remove cap from autoinjector 4. Place tip of autoinjector against patients lateral thigh Midway between hip and knee 5. Holding injector tightly, push firmly against thigh Until the injector activates 6. Hold the injector in place until the medication is injected At least 10 seconds 7. Record activity and time 8. Dispose of injector in biohazard container
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-Combi-Tube-
Indications- Must meet all of the Following Criteria: 1. Patient must be unresponsive. 2. Patient must be Pulse less and Apneic (not breathing). 3. Patient must be between 5 to 7 feet tall. 4. Patient must not have a Gag Reflex. Must have placed a oral airway prior to the use of this device! 5. Patient must not have Esophageal Varices.
Contraindications- -Patient Does Not Meet all the Indications List Above!
Administration- 1. With oral air way in place have partner hyperventilate patient. 2. Prepare and Check Equipment. -Check Comi-Tube for any defects -Check/Inflate bulbs properly Blue (1)-100 ml of air White (2)- 15 ml of air -Deflate bulbs and Lubricate(water soluble). 3. Remove oral airway and have partner prepare BVM. 4. Place Combi-tube (DO NOT FORCE DEVICE). -Insert Combi-tube until teeth are in between the two (2) black lines. 5. Place 100 ml of air in the blue (1) pilot balloon. (Remove syringe from pilot balloon). - DO NOT HOLD COMBI-TUBE AT THIS TIME 6. Place 15 ml of air in the white (2) pilot balloon. (Remove syringe from pilot balloon). 7. Ventilate through the blue (1) tube 1 st . Check for placement. -If no chest rise is noted and ventilation not heard in lungs go to white (2) tube and reassess. 8. Keep equipment together in case tube becomes displaced or is needed in the future for this patient.
If patient becomes alert deflate bulbs and remove Combi-tube be prepare for VOMITUS!
IF IN DOUBT CALL FOR MEDICAL DIRECTION Pg6
Monroe County Ambulance Service Emergency Medical Responder Protocols 2011