Bexar County SMOP`s

Transcription

Bexar County SMOP`s

Bexar County
First Responder
Organization
Standard Medical
Operating Procedures
(SMOPS)
For
_________________________
Effective January 1, 2011 – January 1, 2013
Every EMS System is a complex arrangement between science and the appropriate delivery of
that science to a patient in a professional and compassionate manner.
Our “EMS System” is comprised of multiple agencies, with multiple individuals with varying roles,
experience, operational responsibilities and provider levels. This includes a diverse group of
healthcare professionals including Communications, First Responders, Firefighters, Basic EMT’s,
Paramedics, Emergency Department personnel, and physicians involved in the management of
acute healthcare issues. By design, we are integrated into the delivery of emergent health care.
The Bexar County First Responder Organization plays a major role in this regional system of care.
Together, this “System” provides the basis for seamless delivery of care to acutely ill or injured
patients in our community. Remember, acutely ill or injured patients really don’t care which agency
comes to their aid. What they do care about is whoever provides their care knows what they are
doing and takes care of them in a timely and compassionate manner.
This document provides guidelines for providers of the Bexar County First Responder Organization
(BCFRO) operating under the medical oversight of the Office of the Medical Director (OMD),
Emergency Health Sciences Department, University of Texas Health Science Center, San Antonio.
Every effort has been made to include guidance for treatment during the majority of emergencies,
however due to the nature and scope of prehospital care, it cannot be comprehensive. Providers
should keep in mind these are guidelines, and at times improvisation with or deviation from these
guidelines may be necessary. In such cases the provider must use excellent clinical judgment in
order to optimize treatment for the patient. Whenever possible, it should be done in conjunction
with the BCFRO department’s medical officer, and/or OMD. If this is not practical, it should be
reported to the BCFRO department’s medical supervisor and OMD as soon as possible. This will
usually be considered to be immediately following the event and patient care has been transferred.
Whenever such emergency life-saving patient care is rendered, the provider must document the
treatment rendered, the reason for deviation from these SMOPS, and the reason on-line medical
consultation could not be obtained on the Patient Care Report (PCR).
All EMS medical practice within BCFRO is performed at the discretion of the Medical Director or his
or her designee. All providers must be in good standing with the Office of the Medical Director in
order to utilize these guidelines at their designated level of certification.
These guidelines are specifically written to allow a stepwise, assessment-based approach to
patient management which addresses the vast majority of complaints you will encounter. They are
also written to provide you the latitude to exercise your clinical judgment when appropriate. These
protocols are a form of “standing orders” for emergency patient care intervention in a patient who
has a potentially life-threatening illness or injury. It remains the responsibility of the ECA, EMT-B,
EMT-I, EMT-P, or LP to obtain online medical consultation when appropriate
These guidelines are a dynamic document, rather than a static one. Providers’ input is welcomed
at all times as we implement and use these guidelines. Some protocols may be confusing or
misleading initially and need to be reformatted or reworded. Frequent updates should be
expected. These will keep our guidelines current, user-friendly, and in compliance with national
guidelines and research. Prehospital care is ever-changing and maturing.
Future versions of these guidelines will provide additional medication references, equipment and
procedural updates as these items are funded and training is completed. Please provide any
constructive criticism or feedback on these guidelines to Dr Kidd and myself.
Bexar County First Responder Organization
Standard Medical Operating Procedures
(SMOPS)
TABLE OF CONTENTS
Title
I.
Page(s)
Overview
Purpose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Geographical Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
EMS Personnel Certifications, Capabilities, and Scope of Practice . . . . . . . . . . . . . . . . . . . .
Mandatory Reporting Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
I.1
I.1
I.1
I.1-2
I.2-3
II.
General Patient Care Guidelines
EMS Personnel Responsibilities and Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . II.1
Medical Direction / Office of the Medical Director (OMD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . II.1-2
Mandatory Medical Director Contact Situations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . II.2
Required Equipment on EMS Runs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . II.2-3
Confidentiality of Patient Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . II.3
Infection Control and Exposure Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . II.3-4
Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . II.4-5
Definition of a Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . II.5
Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . II.5-7
Medical Authority on Scene . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . II.7
BCFRO Partners . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . II.7
Patient Restraints . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . II.7-8
Out-of-Hospital DNR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . II.8-9
Dead on Scene . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . II.9
Notification of death to family members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . II.9-11
Patient-initiated Refusals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . II.11-12
Cancellation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . II.12
Special Patient Populations - Minors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . II.12
Special Patient Populations – Mentally Ill . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . II.13
III.
Policies
Controlled Substance Tracking and Compliance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . III.1
Physician on scene / Physician Interveners . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . III.1-2
BCFRO Personnel Riding with Transport Provider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . III.2
Medical Errors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . III.2
Helicopter Utilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . III.2-3
Suspected Abuse and/or Neglect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . III.3
Sexual Assaults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . III.4
IV.
Patient Assessment and EMS Provider Skills
General Patient Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IV.1-2
Skills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IV.3-4
Airway Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IV.4-5
Analgesia and Pain Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IV.5-7
EKG Interpretation and “Pearls” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IV.7-8
Intravenous and Intraosseous Cannulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IV.8
Cardioversion and Transcutaneous Pacing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IV.8
Cardiopulmonary Resuscitation and Cardiac Arrest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IV.9
Spinal Immobilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IV.9-10
Hemorrhage Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IV.10
Tourniquet Application . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IV.10-11
Continuous Positive Airway Pressure (CPAP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IV.11-12
V.
Adult Medical Protocols
General Medical Protocol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . V.1
Adult Resuscitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . V.2
Adult Cardiac Arrest – Initial Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . V.3
Adult Cardiac Arrest – V-fib / V-tach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . V.4
Adult Cardiac Arrest – PEA / Asystole . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . V.5
Adult Cardiac Arrest - Possible Causes and Additional Treatments . . . . . . . . . . . . . . . . . . . . . V.6
Abdominal Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . V.7
Airway Obstruction / Foreign Body / Choking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . V.8
Allergic Reaction / Anaphylaxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . V.9
Altered Mental Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . V.10
Behavioral Emergency / Intoxication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . V.11
Bites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . V.12
Bradycardia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . V.13
Carbon Monoxide (CO) Poisoning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . V.14
Chest Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . V.15
Cyanide (CN) Poisoning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . V.16
Diabetic Emergency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . V.17
Difficulty Breathing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . V.18
Drowning / Near Drowning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . V.19
Electrocution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . V.20
GI Bleeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . V.21
Headache . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . V.22
“Heart Alert” – ST Segment Elevation MI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . V.23
Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . V.24
Hyperthermia (Environmental)/ Heat Stroke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . V.25
Hypothermia (Environmental) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . V.26
Nausea / Vomiting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . V.27
Seizure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . V.28
Shock (Medical) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . V.29
Stings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . V.30
“Stoke Alert” (Cerebrovascular Accident) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . V.31
Syncope / Near Syncope / Weak & Dizzy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . V.32
Tachycardia (Narrow Complex with Pulses) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . V.33
Tachycardia (Wide Complex with Pulses) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . V.34
Toxic Ingestion / Overdose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . V.35
VI.
Adult Trauma Protocols
General Trauma Protocol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . VI.1
Traumatic Arrest / Resuscitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . VI.2
Abdominal / Chest / Pelvic Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . VI.3
Burns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . VI.4
Extremity Trauma / Orthopedic Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . VI.5
Eye Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . VI.6
Head Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . VI.7
Neck Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . VI.8
Sexual Assault . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . VI.9
Taser Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . VI.10
VII.
Pediatric Protocols
Pediatric Resuscitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . VII.1
Pediatric Cardiac Arrest – Initial Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . VII.2
Pediatric Cardiac Arrest – V-fib / V-tach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . VII.3
Pediatric Cardiac Arrest – PEA / Asystole . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . VII.4
Pediatric Cardiac Arrest – Possible Causes and Additional Treatments . . . . . . . . . . . . . . . . . VII.5
Pediatric Airway Obstruction / Foreign Body . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . VII.6
Pediatric Allergic Reaction / Anaphylaxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . VII.7
Pediatric Altered Mental Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . VII.8
Pediatric Bradycardia (with pulses) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . VII.9
Pediatric - Child Abuse / Neglect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . VII.10
Pediatric Diabetic Emergency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . VII.11
Pediatric Difficulty Breathing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . VII.12
Pediatric Drowning / Near Drowning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . VII.13
Pediatric Seizure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . VII.14
Pediatric Tachycardia (with pulses) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . VII.15
Pediatric Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . VII.16
VIII.
Obstetric Protocols
Labor / Emergency Childbirth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . VIII.1
Newborn care / Resuscitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . VIII.2
Pre-eclampsia / Eclampsia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . VIII.3
Trauma in Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . VIII.4
Vaginal bleeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . VIII.5
IX.
Special Situations
PENDING
X.
Medications
Albuterol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X.1
Amiodarone (Cordarone) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X.2
Aspirin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X.3
Atropine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X.4 -5
Calcium chloride . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X.6
Dextrose (D50, D25, D10) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X.7
Diazepam (Valium) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X.8
Duo-Dote . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X.9
Epinephrine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X.10
Furosemide (Lasix) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X.11
Glucagon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X.12
Glucose (Oral) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X.13
Hydroxocobalamin (CyanoKit) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X.14 - 15
Morphine sulfate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X.16
Naloxone (Narcan) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X.17
Nitroglycerin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X.18
Sodium bicarbonate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X.19
XI.
Appendices
A. Medical Director / Medical Control Contact Information . . . . . . . . . . . . . . . . . . . . . . . . . . . XI.1
B. Acceptable Abbreviations for Patient Care Documentation . . . . . . . . . . . . . . . . . . . . . . . . XI.2 - 8
C. STRAC Red / Blue Trauma Criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . XI.9-10
D. Rule of Nines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . XI.11-13
E. Glasgow Coma Scale – Adult and Pediatric . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . XI.14
F. APGAR Score . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . XI.15
G. Normal Pediatric Vital Signs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . XI.16
H. Out of Hospital DNR forms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . XI.17-18
I. STRAC Infectious Disease Exposure Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . XI.19-20
Bexar County First Responder
Organization
Standard Medical Operating
Procedures (SMOPS)
SECTION I
OVERVIEW
(SMOPS)
OVERVIEW
Purpose
To provide personnel of the Bexar County First Responder Organization (BCFRO) with guidelines
for effective patient medical care and transportation.
Objectives
1) Provide guidelines for delivery of efficient and effective emergency medical care to the
citizens and visitors of Bexar County, Texas.
2) Ensure delivery of consistent emergency medical care among all members of the
BCFRO.
3) Provide guidelines for scope of practice while operating as an emergency medical
provider with the BCFRO.
4) Identify expectations of personnel while operating as an emergency medical provider
with the BCFRO, and under the medical licenses of the Medical Directors for the
BCFRO.
5) Provide reference materials for patient care, medications, skills, documentation, and
other essential information needed for quality patient care.
6) Utilize medical direction/medical control for on-line and on-scene guidance.
7) Provide direction for dealing with special patient situations and unusual scenes.
8) Provide guidelines for the proper disposition of other refusals of evaluation, treatment,
and/or transport.
9) Review information regarding policies from the Office of the Medical Director on
credentialing,
recertification,
deauthorization,
reauthorization,
and
Quality
Assurance/Quality Improvement.
Geographical Area
These SMOPS shall be utilized by the members of the Bexar County First Responder Organization
while on-duty for their respective Bexar County First Responder Organization department and
during the following conditions:
1) While operating within the limits of Bexar County, Texas, or adjoining counties as
specified by specific Departments’ charters.
2) While working for a department of the BCFRO within the region or the State of Texas
during a disaster situation, mutual aid response, or other special circumstances with
specific Medical Director approval.
EMS Personnel Certifications, Capabilities, and Scope of Practice
All members of the Bexar County First Responder Organization will operate at their level of
certification or licensure as per the Texas State Department of Health Services (DSHS). Those
members who do not possess certification or licensure as an ECA, EMT-B, EMT-I, EMT-P, or LP,
shall operate in the capacity as first responder firefighters in as far as they have been trained to do
so under their own Department’s liability.
I.1
Emergency Care Attendant (ECA) shall perform patient care skills in accordance with their
training and as dictated by DSHS. ECA’s may perform those skills noted in blue (“BLS
skills”) in these SMOPS up to the level for which they have been trained and approved to
perform by the Medical Director for the BCFRO. ECA certified providers are encouraged by
the OMD to pursue additional education to meet EMT-B certification.
EMT-Basics (EMT-B) shall perform patient care skills in accordance with their training and
as dictated by DSHS. In addition, EMT-Basics may perform those skills noted in blue (“BLS
skills”) in these SMOPS up to the level for which they have been trained and approved to
perform by the Medical Director for the BCFRO. EMT-B certified providers are encouraged
by the OMD to pursue additional education to meet EMT-I certification.
EMT-Intermediates (EMT-I) shall perform patient care skills in accordance with their training
and as dictated by DSHS. In addition to their certification-allowed skills of starting IV’s and
advanced airway management, EMT-Intermediates may perform skills noted as blue (“BLS
skills”) in these SMOPS as well as any other EMT-I allowed skills specifically noted in these
SMOPS. EMT-I certified providers are encouraged by the OMD to pursue additional
education to meet EMT-P certification
EMT- Paramedics (EMT-P) or Licensed Paramedics (LP) shall perform patient care skills in
accordance with their training and as dictated by DSHS. In addition, paramedics may
perform those skills noted in red (“ALS skills”) in these SMOPS. There are some “advanced
skills” that will be allowed and designated by the Medical Director of the BCFRO only after a
paramedic has attended additional training as dictated by the Medical Director of the
BCFRO and demonstrated proficiency in these advanced skills to the Medical Director of
the BCFRO. These “advanced skills” will be specifically noted in the SMOPS.
All BCFRO personnel are ultimately responsible for maintaining their own EMT certification and
required continuing education, and for completing the requirements thereof.
Mandatory Reporting Requirements
It is important for individual members of the BCFRO to always focus on providing clinical care that
is appropriate for the patients we serve. Members will always be accountable for their actions and
the Office of the Medical Director for the Bexar County First Responder Organization will focus on
a non-disciplinary approach to support, re-educate, and re-train members of the department when
necessary.
On occasion, circumstances will arise that may lead to a change in a member’s status and/or ability
to perform duties under the auspices of the Medical Director. As in any practice of medicine, there
are actions deemed unacceptable for any provider involved in medical care of patients which may
lead to immediate deauthorization from providing medical care under the license of the Medical
Director for the Bexar County First Responder Organization. These actions include, but are not
limited to:
Falsification of a patient care document
Intentionally withholding care from a patient
Intentionally harming a patient
Providing direct patient care while impaired by alcohol or drugs
Failure to remediate or participate in required education, continuing education, or reeducation and/or review as deemed necessary by the Office of the Medical Director.
I.2
Individual providers and their respective Departments are responsible for reporting any arrests of
the provider involving alcohol, drug use, or felonies directly to the Office of the Medical Director on
or before the first business day after the arrest is made. Failure to do so may result in immediate
deauthorization from providing medical care under the license of the Medical Director for the Bexar
County First Responder Organization.
Individual providers and their respective Departments are responsible for reporting any action
taken (administrative review, suspension, revocation, etc.) by the Texas Department of State
Health Services (DSHS) to the Office of the Medical Director on or before the first business day
after the provider was made aware of the DSHS action. Failure to do so may result in immediate
deauthorization from providing medical care under the license of the Medical Director for the Bexar
County First Responder Organization.
I.3
Organization
Procedures (SMOPS)
SECTION II
GENERAL PATIENT CARE
GUIDELINES
(SMOPS)
GENERAL PATIENT CARE GUIDELINES
Bexar County First Responder Organization Responsibilities and Expectations
All Bexar County First Responder Organization (BCFRO) personnel shall understand that they
provide medical care under the medical licenses of the Medical Directors for the BCFRO, and
therefore they are acting as physician extenders of the Medical Directors. As such, BCFRO
personnel will follow these SMOPS as direct medical orders, and will follow all verbal medical
orders from the Medical Directors, as well as the EMS Fellow (if applicable).
In addition, all BCFRO personnel will:
1) Act in accordance with operational expectations and the policies and guidelines of their
respective departments.
2) Treat each patient and family member with respect and concern for potential medical
emergencies.
3) Maintain patient confidentiality as per Texas Law and the U.S. Department of Health and
Human Service’s Health Insurance Portability and Accountability Act (HIPAA), and as
directed in these SMOPS.
4) Provide honest, accurate, complete, and appropriate documentation of medical care
rendered for every patient encounter, and will provide additional information when
requested by the Office of the Medical Director (OMD).
5) Maintain their EMS certification through the Texas Department of State Health Services
(DSHS) at all times, and will complete the required Continuing Medical Education to
maintain their individual certification.
6) Self-report medical errors immediately to the Medical Director.
7) Immediately report to the OMD any correspondence with the Texas Department of State
Health Services regarding patient care or certification issues.
8) Be responsible for knowing and implementing new information and patient care policies
issued by the OMD.
9) Behave in a respectful and professional manner when dealing with transporting EMS
personnel, hospital personnel, other first responders, and the general public.
Medical Direction / Office of the Medical Director (OMD)
The Medical Director (MD-1) and the Assistant Medical Director (MD-2) for the Bexar County First
Responder Organization are faculty members at the University of Texas Health Science Center at
San Antonio (UTHSC-SA). Their services are contracted by the University Health Systems and the
BCFRO to provide medical direction for the BCFRO. They provide the medical license(s) under
which members of the Bexar County First Responder Organization provide medical care, and thus
have ultimate authority over medical care delivered by BCFRO personnel. The Medical Director
also has ultimate authority over which BCFRO personnel will be allowed to operate under his/her
medical license and makes all final decisions regarding provider credentialing and deauthorization.
As previously stated, it is expected and required that all BCFRO personnel follow these SMOPS as
direct medical orders. In addition, any verbal orders for medical care given by the Medical Directors
while on-line or on-scene will be followed immediately.
II.1
On-line medical direction will be available to BCFRO personnel through the Office of the Medical
Director. In most instances, the medical direction will be provided primarily by MD-1 or MD-2,
depending on which physician is on-call or available. See Appendix A for all Medical Director
contact information.
During some time periods, there may be an additional physician working as an EMS Fellow with
the University of Texas Health Science Center at San Antonio, the San Antonio Fire Department,
and the BCFRO. He or she will be a board-certified or board-eligible emergency physician who is in
training to become an EMS Medical Director. During the fellow’s training, he or she will be working
with the BCFRO EMS Medical Directors to provide medical direction for BCFRO providers, and will
share call as the on-line medical director. The EMS Fellow will have the designation of MD-4. He or
she is to be treated with the same courtesy and respect as the EMS Medical Directors, and his or
her medical direction is to be followed in the same manner as MD-1 and MD-2.
Mandatory Medical Director Contact Situations
The on-call or on-scene Medical Director will be contacted immediately in the following situations:
1) All cardiac arrest situations in which the paramedic is considering a field termination of
resuscitation without an EMS Provider on-scene.
2) All cardiac arrest situations in which the paramedic is requesting further orders or guidance
outside of established guidelines.
3) Any requests for administration of narcotic or benzodiazepine administration in addition to,
or outside of, standing orders.
4) Problematic situations directly involving other physicians.
5) Any Mass Casualty Incident, Haz-Mat, Rescue, or other large-scale incidents in which there
are 6 or more victims.
6) Any situation in which a BCFRO firefighter or dignitary (city, county, state, federal) is
requiring treatment by BCFRO personnel.
7) Any situation noted in these SMOPS that requires a Medical Director’s order.
8) Any errors in medical treatment or medication administration made by a BCFRO member.
9) Any adverse reaction by a patient to a medication given by BCFRO personnel.
10) Any complication or error in patient care which resulted from equipment failure or lack of
proper equipment.
11) Any incident which could possibly result in future action by a Medical Director.
12) Any case which has resulted, or could result in legal action.
13) Any other unusual occurrence or situation in which the BCFRO personnel feel that
physician intervention or guidance may be needed.
Required Equipment on EMS Runs
Upon arriving at the scene of a medical emergency (adult or pediatric medical call-type), all
personnel shall carry with them into the scene the following at all times:
1)
2)
3)
4)
5)
Jump kit, fully stocked with all medications and equipment utilized by that department
Airway kit and suction device
Portable oxygen
3 or 12-lead cardiac monitor (if available)
Personal protective equipment
Emergencies involving minor trauma may not require all of the above equipment. Personnel are
expected to use their best judgment and carry equipment to the scene that is appropriate for the
patient’s injury and according to these SMOPS.
II.2
BCFRO members shall take into consideration other circumstances in which taking additional
equipment with them would be in the best interest of their patient (Stretcher for patients who should
not walk, spinal immobilization equipment for MVC’s or rescues, etc.)
Confidentiality of Patient Information
It is the responsibility of all BCFRO personnel to safeguard every patient’s Protected Health
Information (PHI). Texas law and the U.S. Department of Health and Human Service’s Health
Insurance Portability and Accountability Act (HIPAA) prohibit the disclosure of a patient’s PHI to
unauthorized persons.
Protected Health Information (PHI) is defined as information that can be used to identify a specific
person, such as name, date of birth, SSN, case/run #, etc. and relating to any details about a
person’s health status, past and current medical problems and treatments, and insurance/billing
information.
“Unauthorized Persons” includes any person not described in the following list:
1) Any medical person directly involved in the care of the patient
2) Medical or law enforcement personnel if the emergency medical services personnel, the
physician providing medical supervision, or the emergency medical services provider
determines that there is a probability of imminent physical danger to any person or if there
is a probability of immediate mental or emotional injury to the patient
3) Governmental agencies, if the disclosure is required or authorized by law
4) Qualified persons who require the information for financial audits, management audits,
program evaluation, system improvements, or research. This information shall only be
given to the extent needed for these reasons, and written reports cannot identify patients.
5) Any person bearing written consent of the patient or person authorized to act on the patient’s
behalf
6) Texas Department of State Health Services for the purpose of data collection or
investigations
7) Individuals, corporations, or governmental agencies involved in the payment or collection of
fees for emergency medical services rendered by emergency medical services personnel
8) Individuals whom the patient has given consent for medical information to be shared with
9) Parents of a minor child, as long as the child is not emancipated, and the information is not
protected information under Texas State Law
Infection Control and Exposure Guidelines
Universal barrier precautions (including gloves and protective eyewear) shall be observed
with all patients. In addition, gowns and masks should be worn by BCFRO personnel during all
patient interactions likely to produce spray, splash, or large amounts of blood or bodily secretions
(such as childbirth or trauma). All patients with a cough should have their mouth and nose covered
with a surgical mask or non-rebreather with high flow oxygen. All BCFRO personnel shall wear
masks when encountering any patient with significant coughing or influenza-like illness (fever,
cough, sore throat) or signs/symptoms of meningitis. During transport of patients with coughing or
influenza-like illness (ILI), the exhaust fan of the transporting ambulance should be on.
Each on-coming crew shall assure that an adequate stock of Personal Protective Equipment
(PPE) is available on the responding rescue vehicle. After each patient contact, personnel shall
wash and disinfect themselves, used equipment, and the apparatus appropriately.
II.3
Gloves should be removed as soon as patient contact is finished and hands should be
completely washed with warm soapy water or surgical scrub (if available and tolerated).
Stretcher or similar patient transfer equipment and all other contaminated surfaces shall be
grossly decontaminated if necessary, and always thoroughly wiped down with approved
germicidal solution.
All tubing and single-use (disposable) equipment used during patient care shall be disposed
of in an appropriate container as per departmental policy.
All contaminated reusable equipment shall be cleaned, soaked in appropriate germicidal
solution as per directions, and then thoroughly rinsed. (For laryngoscopes, remove bulb
before soaking blade, do not soak handles – wipe down with germicidal solution).
Non-disposable Ambu-bags shall be sterilized between patient uses.
Sharps should NEVER be recapped, and should be disposed of in appropriate “sharps
containers” immediately after use. When full, sharps containers should be sealed and
disposed of properly in accordance with policy and procedure.
All cleaning solutions shall be labeled, mixed, and maintained according to the manufacturer’s
instructions and checked every shift. Solutions that are used up, out-dated, or appear dirty shall be
appropriately discarded and replaced.
The following communicable disease prevention guidelines should be followed:
Yearly TB testing is recommended. This should be more frequent if exposure is suspected.
All personnel should be vaccinated for Hepatitis A and Hepatitis B, or execute
documentation acknowledging that they are assuming personal risk of this preventable and
potentially fatal illness.
All personnel should receive 0.5 ml Tdap IM (adult toxoid) every 6-10 years for diphtheria
and tetanus prophylaxis.
All personnel should receive yearly influenza vaccination(s) as recommended by the
Texas Department of State Health Services and the CDC.
Any BCFRO member with a potentially contagious infectious disease should not report to
work until he or she is not considered contagious any longer by his or her personal
physician.
If any BCFRO member has a known or possible exposure to an infectious or communicable
disease while on duty, he/she shall:
Immediately notify Department EMS Officer and follow their department’s Standard
Operating Guidelines.
If a known or suspected high-risk exposure occurs and immediate emergency medical care
is necessary, the BCFRO member should be transported to the appropriate hospital via
BCFRO or transport agency EMS vehicle. Use of personal vehicle is highly discouraged.
Personnel shall fill out the STRAC Infectious Disease Exposure Form. (See Appendix I)
Communication
The BCFRO Medical Directors shall be contacted by cell phone whenever a BCFRO member is
faced with a Mandatory Medical Director Contact situation. See Appendix A for current contact
information for BCFRO Medical Directors.
BCFRO members shall contact their departmental officer when faced with a conflict with a patient,
bystanders or family members, other responding agencies (law enforcement, private EMS
agencies, etc.), or among EMS crewmembers.
II.4
In addition to contacting the on-call Medical Director, a BCFRO crew shall contact their
departmental officer in the following situations AND FILL OUT AN INCIDENT REVIEW FORM:
1) Any errors in medical treatment or medication administration made by a member.
2) Any adverse reaction by a patient to a medication given by BCFRO personnel.
3) Any complication or error in patient care which resulted from equipment failure or lack of
proper equipment.
4) Any encounter with an acutely suicidal, homicidal, psychotic, or intoxicated patient in which
the crew feels they may be in danger.
5) Any situation in which a BCFRO firefighter or dignitary (city, county, state, federal) is
requiring treatment by BCFRO personnel.
6) Any incident which could possibly result in future action by a Medical Director.
7) Any case which has resulted, or could result in legal action.
8) Any incident in which law enforcement is required on the scene.
9) Any other unusual occurrence.
If a BCFRO member or crew is unable to make contact with a Medical Director or Department EMS
Officer in one of the above mandatory contact situations, the member(s) shall contact dispatch for
assistance in contacting the needed person.
Definition of a Patient
A “patient” is defined by the Bexar County First Responder Organization Office of the Medical
Director as:
1) Anyone who calls 911 or a non-emergency number to request medical assistance or
evaluation.
2) Anyone who self-presents to a BCFRO fire station or to BCFRO personnel requesting
medical assistance or evaluation.
3) Any person who has had another person (“third-party caller”) request assistance on his/her
behalf AND agrees with the need for medical assistance or evaluation, or is not able to
make a competent decision to refuse medical care. This includes persons in the custody of
law enforcement for whom medical assistance has been requested AND the person in
custody agrees to medical assistance.
4) Any minor child who has medical assistance requested by his/her parent or guardian, or
meets the criteria for “implied consent”.
5) Any person who is identified by on-scene BCFRO personnel as possibly needing medical
attention (obvious traumatic injury or displaying signs/symptoms of an acute medical
emergency).
If an emergency situation potentially involves risk to a person’s life or limb, and that person is
unable or incompetent to give informed consent to treatment and/or transport, treatment and
transport shall be given in accordance with these SMOPS under “implied consent.”
Documentation
The Patient Care Report is used by the Bexar County First Responder Organization, the Office of
the Medical Director, receiving hospitals, treating physicians and nurses, insurance companies, the
Texas Department of State Health Services, federal entities (Medicare/Medicaid/Worker’s Comp,
etc), and many others as a medical record and a legal document. It is imperative and expected
that a complete and accurate Patient Care Report be written for every patient (see above
“Definition of a Patient”) encountered by BCFRO personnel, regardless of whether or not the
patient was given treatment or transport.
II.5
The Patient Care Report (PCR) shall be completed AFTER complete medical care has been
rendered to the patient – BCFRO members shall not sacrifice patient care to fill out the PCR
during the time the patient still requires medical intervention.
ALL Patient Care Reports shall include ALL of the following:
1) Names, badge numbers, and EMS certification level of ALL EMS crew members direct
patient care involvement (Denote “FF” for any firefighters involved in patient care.)
2) Response address, Destination address / disposition
3) ACCURATE response times
4) Patient’s name, social security number, gender, date of birth, home and mailing
addresses.
5) Next of kin information if available
6) Complete patient history, including allergies, chief complaint, medications, and past
medical history
7) A full and complete patient assessment
8) The BCFRO member’s impression of the patient’s medical problem
9) Vital Signs
- At least TWO complete sets of vital signs should be recorded on EVERY patient – these
are to include blood pressure, heart rate, and respiratory rate.
o All Priority I patients shall have a set of vital signs documented at least every 5
minutes during treatment.
o All Priority II patients shall have a set of vital signs documented at least every 15
minutes during treatment.
- All medical patients (adult and pediatric) and all patients with major trauma shall have at
least one pulse oximetry reading recorded.
- All patients with respiratory complaints should have at least one end-tidal CO2 recorded
(if available on inventory).
- All patients with the following should have at least one blood glucose level recorded:
diabetes, syncope, altered mental status, headache, stroke symptoms, chest pain,
respiratory difficulty, behavioral issue, seizure, vomiting, cardiac or respiratory arrest,
patients for whom this is noted in the patient care flowcharts in these SMOPS, and
other patients as the BCFRO member feels appropriate.
- All trauma patients should have at least two GCS recorded.
10) Complete Treatment Summary with accurate times, correct information on BCFRO
member performing treatment(s), indications, accurate dosage, response to treatment(s),
and other information as appropriate
11) A FULL and COMPLETE narrative to include: history of the event, subjective and
objective findings - including complete primary and secondary survey findings, summary
of treatments and response to treatments by patient, changes to patient condition during
treatment and transport, and disposition of the patient.
12) Signatures of the patient or person signing on patient’s behalf and relationship, and all
crew members with patient contact.
If there was a deviation from these SMOPS made during the course of care of a patient, the
documentation is to include a complete explanation of the reason for the deviation (example: no IV
was started because patient had decision-making capacity and refused IV).
Likewise,
documentation shall also include a complete explanation for any prolonged on-scene time.
BCFRO personnel will occasionally encounter persons on a scene who refuse evaluation or
assessment by BCFRO personnel. These persons may be involved in a motor vehicle collision, the
subject of a third-party call, or otherwise involved in a traumatic or medical event. Because it is still
important to have documentation of these persons refusing assessment, treatment, and transport,
BCFRO personnel shall disposition the run as “cancelled at scene” and obtain the following
documentation from every person refusing assessment at a scene:
II.6
1) Each person’s name and date of birth
2) Each person’s signature that he or she is refusing assessment, treatment, and transport (for
minors, a parent or guardian over the age of 18 should sign the refusal for each minor.)
Of course, any patients at the same scene receiving assessment, treatment, and/or transport shall
be documented in the PCR as a separate patient report and documented appropriately. Any
questions about specific scenes or scenarios should be directed toward a departmental officer or
Medical Director.
Medical Authority On Scene
It is understood that although the highest ranking Fire Officer will serve as the Incident Commander
on scene, the BCFRO member with the highest EMT certification level will be in charge of patient
care at all medical scenes until patient care is turned over to the transporting EMS agency.
Personnel with EMT-P certification and Licensed Paramedics will be considered of the same EMT
rank for patient care decisions.
The order of authority for medical care on scene shall fall in the following order:
1) Medical Director
2) EMS Officer – Paramedic
3) EMT-P or Licensed Paramedic
4) EMT-I
5) EMT-B
6) ECA
The caveat to this is if there is disagreement on a scene about whether a patient requires
resuscitation or treatment/transport, and an on-scene fire officer (regardless of EMT certification)
feels the patient requires resuscitation or treatment/transport, resuscitation or treatment/transport
shall be given. Specifically:
In a cardiac arrest situation, if there is disagreement among personnel about whether a
patient meets DOA criteria, but even one on-scene paramedic believes resuscitation efforts
should be started, resuscitation efforts should be started immediately, the appropriate
protocol should be followed, and the on-call Medical Director shall be notified.
Unresolved patient care decisions shall be resolved immediately by a Department EMS officer or a
Medical Director.
BCFRO Partners
The highest certified BCFRO Department personnel and his/her partner are both responsible for
patient care on a scene.
Patient Restraints
BCFRO personnel will occasionally encounter patients who require physical restraint for the safety
of the BCFRO personnel and other responders or for the patient him/herself. Restraints might be
necessary for certain patients who are agitated, confused, intoxicated, acutely psychotic, suicidal,
post-ictal, combative, or violent. Physical restraint should only be used as a last resort after all
attempts to get the patient to cooperate have been exhausted, or when BCFRO personnel feel that
they or the patient are in imminent danger unless the patient is immediately restrained.
II.7
Chemical restraint utilizing authorized medications (if available) is the preferred method to control
these patients and every attempt should be made to use these medications before physically
restraining a patient. If it is determined that a patient needs to be physically restrained, BCFRO
personnel shall remove themselves to a safe area and law enforcement personnel should be
contacted if not already on scene to restrain the patient. If this is not possible, or a patient requires
immediate restraint for his/her safety or the safety of responders, the patient’s wrists and ankles
should be restrained with Kerlix or Coban or other similar soft material and tied to a backboard or
the stretcher. The minimal amount of restraint needed should be used. The patient’s pulses and
neurologic function shall be checked every 2 minutes to assure good neurovascular status of the
restrained extremities, and the restraints should be loosened if capillary refill is > 2 seconds, pulses
distal to the restraints are absent, or the patient has diminished motor or sensory function to the
restrained extremity.
A patient shall never be placed in a prone (face-down) position, and should never be “hogtied” by both hands and feet, or “sandwiched” between backboards. All of these methods of
restraint can lead to respiratory arrest and death of the patient.
At all times, BCFRO personnel shall assure their own safety first. If a patient is restrained, a law
enforcement officer should be with the patient.
Out-of-Hospital DNR
BCFRO members will honor all Texas and out-of-state Do Not Resuscitate (DNR) forms as long as
ALL of the following apply:
1. BCFRO personnel can establish the identity of the patient as the person for whom the order
was executed.
2. The form is an original form or a legible photocopy or facsimile of the original form.
3. The form has all required information filled out, and has signatures by the patient or person
acting on the patient’s behalf, the patient’s physician, and either two witnesses or a notary
public.
4. The form has a date in the place designated on the form that the order was executed.
5. BCFRO personnel have no question of the authenticity of the DNR form.
6. There is no suspicion of homicide, suicide, or other unnatural cause of death (trauma).
7. The patient is NOT pregnant.
A valid, intact, unaltered Texas DNR identification device on a person (such as a plastic or metal
bracelet or necklace) will be considered sufficient evidence of the DNR order, and the DNR will be
honored as long as conditions 5-7 above still apply. (See Appendix H for examples of Out-ofHospital DNR forms and devices.)
BCFRO personnel shall attempt to obtain a copy of the DNR order for the transport provider if at all
possible.
BCFRO personnel may occasionally encounter a legal guardian, Medical Power of Attorney,
Managing Conservator, or the physician who executed the order who wish to revoke the DNR. If
any of these persons, or a spouse, adult child, or next-of-kin of the patient wishes for resuscitation
to proceed despite a DNR being in place, BCFRO personnel shall start basic CPR and airway
support and contact the on-call Medical Director immediately.
If BCFRO personnel are faced with a patient in cardiac or respiratory arrest, and the patient’s
physician is on-scene and orders that resuscitation efforts be ceased, that order shall be honored.
II.8
If the physician is not on-scene, personnel shall continue resuscitation efforts and contact the oncall Medical Director immediately for resolution of the situation.
In the instance of BCFRO personnel being presented with Living Wills, Advanced Directives,
Hospice orders, or Medical Power of Attorney, the on-call Medical Director should be contacted for
further guidance. In addition, the on-call Medical Director should be contacted for any other
conflicts, questions, or unusual situations regarding Do-Not-Resuscitate orders.
Dead on Scene
There are very specific criteria for making the determination of “Dead on Scene” (DOS) or “Dead
on Arrival” (DOA). With the exception of patients with DNR orders as above, only patients who are
apneic AND pulseless AND with one or more of the following criteria should be considered
“DOA” and resuscitation should be withheld:
Rigor mortis of the extremities and/or trunk
Dependent Lividity
Decapitation
Visual Massive Trauma / Injuries incompatible with life
Incineration
Decomposition
If bystanders or first responders have begun resuscitative efforts and the patient meets the above
criteria, BCFRO personnel should tactfully and courteously point out the DOA criteria observed and
suggest cessation of efforts. If there is a conflict at the scene regarding cessation of resuscitation
with obvious DOA criteria, BCFRO members should contact the on-call Medical Director
immediately.
The absence of vital signs shall be confirmed by hands-on palpation by TWO EMS- certified
department personnel. If there is any question about absence of pulse, the patient shall be
connected to an AED or a three-lead monitor (if available) to confirm asystole by an EMT-P. If
there is any question about absence of pulse, respirations, or blood pressure, resuscitation shall be
started immediately.
Documentation of patients meeting DOA criteria shall include a TIMED absence of all vital signs,
with the names and badge numbers of the confirming personnel, as well as what DOA criteria the
patient meets.
If any question or conflict exists about the DOA status of a patient, BCFRO members shall start
basic CPR and contact the on-call Medical Director immediately.
Notification of Death to Family Members
If possible, the First Responder and EMS team should inform the family of the progress of a
resuscitation during the event. Simple words such as, “Your wife’s heart has stopped and she is
not breathing” should be used. Do not make statements such as “She will be okay” or “Everything
will be alright”. Invite family members to observe resuscitation efforts if they wish. Explain what is
being done and assure them that everything is being done that can be done. Prepare the family
for what they will be seeing – CPR, IV, ETT, blood, secretions, etc. Giving bad news to the family
incrementally will allow them to mentally prepare for a negative outcome should the patient not be
revived.
II.9
In the event the patient is DOA or is pronounced dead in the field by EMS:
Identify family members and attempt to give them some privacy from others on the scene.
Have everyone sit down, including yourself.
Be sensitive. Ask yourself how you would want this message delivered, because people are
going to remember this for the rest of their lives.
Introduce yourself; be empathetic, caring, and direct. Use plain language and simple terms
to explain your care and the patient’s response. Say that the patient, using the patient’s
name, “has died.” Then wait in silence for the family to hear and accept those words. Never
use words such as “expired”, “passed away”, “gone to a better place”, “with their maker”,
etc. This could allow for confusion with some family members or could be offensive to
some people.
Reaction to the news can vary from calm acceptance to screaming to syncopal episodes –
there is no way to predict. Different cultures will react differently and there is no
“appropriate response”.
Tell the person(s) with heartfelt sincerity that you are sorry for their loss. Do not offer advice
or give the person reassurance that everything will be alright.
Answer questions in a compassionate, honest, thorough, and professional manner, to the
best of your ability. Do not hold back any information that you are able to provide. Do not
speculate on cause of death or be judgmental.
Listen to the grieving person as they speak about their loss. Give them your undivided
attention; make eye contact, lean forward, hold their hand, give them a hug – do what you
can within your comfort level (and theirs). If you and the family feel comfortable with a
prayer, it is acceptable for you to offer one.
Assure them that it’s okay to be sad, angry, or to cry as much as they need to.
Make sure that the Police have been notified. Attempt to answer questions the family may
have about what will happen next.
o PD will contact the Medical Examiner’s Office and give them details of the death.
o If the patient is under the care of Hospice, the doctor may sign the death certificate,
and the body can be released to the mortuary.
o If a mortuary has not been chosen, the patient is not under Hospice care, the doctor
will not sign the death certificate, the death does not appear natural, etc. – the body
will be transported to the ME’s Office.
Allow the family to spend time with the deceased. Do not leave the family alone with the
body.
Treat the body and the family with respect.
Ask the family if there is anyone they would like you to notify to be with them.
Pediatric death notification should be handled using the same principles, but a child’s death is
viewed as particularly tragic. Unlike an adult’s death, a child’s death is often felt to be unnatural or
unfair. Survivors require emotional support and all actions should be avoided that could possibly
make the situation worse.
Use the child’s name when speaking with survivors.
If expressions of anger are directed at you, try to accept them without becoming angry.
BCFRO personnel are never expected to remain in a hostile or dangerous environment,
however.
Never speculate on reasons for the death of a child. Never label a death “SIDS”.
Remain with survivors long enough for them to start absorbing the facts of death
emotionally.
Do not speak philosophically or attempt to find a “silver lining” in discussing the death.
Expect to have strong feelings yourself – the fear of losing your own children may become
strong and many will identify strongly with the parents.
II.10
In all instances, never leave the family alone with the body. If a patient death is suspected of being
due to foul play or unnatural causes (homicide, suicide, etc.) make every attempt to preserve the
crime scene while dealing with family members or bystanders.
Patient Initiated Refusals
1. Adults with Decision-Making Capacity
Adults are entitled to make informed decisions about their own health care, including EMS
treatment and transport. If BCFRO personnel are confronted with a patient who is refusing
any or all medical care, or transport to a hospital, it is incumbent on the BCFRO members
to assure that:
The patient possesses decision-making capacity. This means that the patient is
awake, alert and oriented to person, place, time, and event.
The patient is able to understand, and recite back to BCFRO personnel an
understanding of possible medical problems that may be occurring and risks to
the patient if his/her medical problems are not evaluated and treated.
Another adult, even a spouse or family member, may not refuse treatment or transport for a
patient if that patient meets the above criteria.
If BCFRO personnel feel that the patient has a potentially life threatening illness or injury
and the patient is refusing treatment and/or transport, everything possible should be done
to convince the patient to accept treatment and transport. The help of family, friends,
coworkers, law enforcement personnel, and the patient’s personal physician should be
enlisted. If the patient is still refusing, BCFRO members should contact the on-call Medical
Director if necessary.
If a patient continues to refuse treatment/transport after all possible avenues have been
exhausted:
Document that the patient possesses decision-making capacity and was able to
understand and repeat back possible risks/medical problems that may occur as a
result of the refusal, up to and including death.
Obtain a signature of refusal from the patient in the appropriate area on the PCR. If
the patient refuses to sign, fully document this on the PCR as well.
Obtain a signature of witness of the refusal from a bystander (preferably a law
enforcement officer if available).
2. Adults without Decision-Making Capacity
An adult who does not possess decision-making capacity to make informed decisions about
his or her health care may not refuse medical evaluation, treatment, or transport. If BCFRO
personnel encounter a patient who appears to be without decision-making capacity and is
refusing medical care, the BCFRO members shall first try to gently verbally convince the
patient to consent to treatment/transport. Whenever possible, BCFRO members should
enlist the help of the patient’s spouse, adult children, next of kin, friends, coworkers, and
personal physician in helping to convince the patient to accept treatment and transport. If
the patient continues to refuse medical care, BCFRO personnel shall contact their
departmental EMS Officer, law enforcement, and Medical Director on-call for assistance. It
is very likely that in this scenario, BCSO or other law enforcement will be enlisted to invoke
an Emergency Detention (ED) order to force the patient to get medical evaluation and care.
II.11
3. Minors and Emancipated Minors
See the section on “Special Patient Populations” below.
Cancellation
If BCFRO personnel are called to a scene for a medical emergency, but do not make patient
contact due to any of the following, and no patient contact, assessment, or care is given, the
BCFRO members shall create a run report as “Cancellation” as per BCFRO guidelines.
Person gone on arrival to scene
Another responding agency (ex. law enforcement) advises that there is no patient on the
scene or no need for medical care.
If BCFRO personnel arrive on a scene with persons involved in a motor vehicle accident or other
potential trauma or medical emergency, and the person(s) on scene refuse evaluation by EMS,
follow the guidance set forth in these SMOPS in the Documentation section (pages II.5-7).
Special Patient Populations – Minors
A minor is defined as a person who is under 18 years of age. Minors who have a life- or limbthreatening condition shall be treated and transported appropriately, regardless of parental
availability for consent. In these cases, consent is implied. A parent or legal guardian CANNOT
refuse consent for treatment/transport of a minor in a life-threatening situation.
A minor’s parent or legal guardian should be contacted for consent prior to treatment or transport
for a non-life-threatening condition. Parents/legal guardians do have the right to refuse treatment
and/or transport for a minor in a non-life-threatening situation. If BCFRO personnel feel a parent’s
refusal for treatment/transport of a minor is inappropriate and the minor may be in danger if
medical treatment is not sought, the BCFRO personnel should contact the on-call Medical Director,
a department Medical Officer, and the appropriate law enforcement agency.
If a parent or legal guardian is unavailable, and unable to be contacted, the following persons may
give consent, as long as they do not have notice from a parent or legal guardian forbidding
consent:
1) Grandparents, adult siblings, adult aunts or uncles
2) School officials, baby sitters, or day care personnel with written authorization from a
parent or legal guardian
3) Court orders issuing authority for consent
Minors can consent or refuse treatment or transport if one or more of the following conditions
exists:
1) He/she is or has been married
2) He/she is on active military duty
3) She is pregnant and requires treatment for a pregnancy related problem
4) He/she requires or is requesting treatment for drug use or a sexually transmitted
disease
5) He/she is 16 or 17 years old and lives apart from parents and independently
manages his/her own financial affairs
II.12
Special Patient Populations – Mentally Ill
Mentally ill patients require a medical evaluation by a physician whenever there appears to be an
exacerbation of mental illness or chemical dependence. When BCFRO personnel are faced with a
mentally ill patient, the BCFRO members shall perform a full medical evaluation on these patients
and render any necessary medical care as with any other patient. Mentally ill patients who are
refusing care and do not appear to have decision-making capacity for their medical care shall be
treated as any other patient without decision-making capacity (see Patient Initiated Refusals
section).
If BCFRO members are encountered with a violent or potentially violent patient, the first concern
should be for the safety of the BCFRO personnel. Law enforcement should be called for if not
already on scene, and BCFRO members shall stay a safe distance from the patient until police
assistance is available. If a patient is threatening harm to himself or others and is not found to have
an acutely life- or limb-threatening by BCFRO and the transporting agency, the patient may be
taken into custody by law enforcement officers and transported to the nearest appropriate facility.
II.13
Organization
Procedures (SMOPS)
SECTION III
POLICIES
(SMOPS)
POLICIES
Controlled Substance Tracking and Compliance
Narcotic and benzodiazepine usage is an important part of the medical and pain management of
our patients. Narcotics and benzodiazepines, however, also have the potential to be abused and
can be highly addictive if not used properly. For this reason, the United States Drug Enforcement
Administration, the Texas Department of State Health Services, and the Office of the Medical
Director for the Bexar County First Responder Organization maintain strict rules regarding the
tracking of narcotic and benzodiazepine usage and wasting that must be adhered to (for those
Departments that utilize these medications).
Agencies authorized to maintain and use controlled substances must have policy and procedure
for controlled substance tracking and compliance in place and approved by the BCFRO Medical
Director. In addition, this information on each department’s policy and procedure must be on file
with the Medical Director’s office. Deviations, changes without prior approval, and non-compliance
with the approved policy and procedure for controlled substance tracking and compliance may
result in immediate cessation of controlled substance storage and administration. All BCFRO
personnel who are authorized to use narcotics and benzodiazepines are responsible for following
their respective department’s policies regarding controlled substance tracking and accountability.
Physician on scene / Physicians Interveners
If BCFRO personnel are faced with a patient in cardiac or respiratory arrest, and the patient’s
physician is on-scene and orders that resuscitation efforts be ceased, that order shall be honored.
The on-call Medical Director shall be notified as soon as possible.
If BCFRO personnel respond to a scene where the patient’s personal physician is on-scene (for
example, in a clinic) and the physician is requesting that BCFRO provide patient care that is
outside the medics’ scope of practice, or deviates from these patient care protocols, the following
shall occur:
1) BCFRO members shall politely and respectfully inform the physician of
BCFRO’s protocols and advise the physician that these protocols cannot
be deviated from without direct orders from the BCFRO Medical Director or
Assistant Medical Director.
2) The BCFRO Medical Director on-call shall be contacted for further
guidance.
If BCFRO members encounter a physician on scene who is not the patient’s personal physician,
and that physician attempts to give medical orders to the BCFRO personnel, the following should
occur:
1) BCFRO members shall politely and respectfully inform the physician of
BCFRO’s protocols and advise the physician that these protocols cannot
be deviated from without direct orders from the BCFRO Medical Director or
Assistant Medical Director.
2) The BCFRO Medical Director on-call shall be contacted for further
guidance.
III.1
There may be situations where a physician on scene wishes to accept responsibility for the care of
the patient until that patient arrives at the hospital. In these situations, the physician shall provide
proof of Texas medical licensure to the paramedics, the physician shall ride in the back of the
transporting agency’s ambulance with the patient, and approval shall be given by the BCFRO
Medical Director on-call.
BCFRO Personnel riding with the Transport Provider
BCFRO personnel requested to assist and/or accompany the EMS provider for patient care and
transport to the hospital will be mutually agreed upon between the BCFRO/IC ranking officer and
EMS provider on scene. If a BCFRO provider accompanies the EMS transport provider to assist
with patient care, that EMS transport provider will assume liability and medical direction of
accompanying BCFRO personnel. BCFRO personnel are never to provide care or utilize
equipment/medications past their scope of practice or credentialing level authorized by the BCFRO
Medical Director.
Medical Errors
The Medical Director(s) for the Bexar County First Responder Organization expect BCFRO
personnel to report any self-discovered medical errors immediately to the on-call Medical Director
and to the BCFRO member’s direct supervisor. If it is discovered that a BCFRO member failed to
self-report a medical error as soon as it was discovered, that BCFRO member may be subject to
immediate de-authorization by the Medical Director.
Helicopter Utilization
Air Medical providers perform a significant role in the care of critically ill or injured patients in our
community. Potential advantages include a more rapid transport to a hospital and critical care skills
that can be provided by the crew. The decision-making process for utilization of air medical
transport is complex. These are valuable resources and must be used appropriately. Safety is the
primary concern when requesting air medical services. We must utilize this resource only if there is
an advantage to our patients that outweighs the risk to the patient, on-scene personnel, and airmedical personnel. Additionally, there are significant costs associated with air medical transport.
Consider the following timing issues when requesting air medical transport:
Activation time of 7-8 minutes is required for services to check availability, weather, and
launch preparation
Flight time to the location
Time for air crew patient assessment and stabilization measures
Also consider these factors when deciding to call air medical transport:
Patient Illness / Injury
o Life Threatening Trauma
o Heart Alert
o Stroke Alert meeting TPA administration time limit
o Others conditions as required
Weather
Multiple Casualty Incidents/ Number of patients
Availability of receiving hospitals (may alter transport times)
III.2
Critical care skills provided by air medical provider
Traffic conditions
Remote access
Extrication required
Location of incident
If the decision is made to utilize air medical transport for a patient, BCFRO personnel shall
continue to care for that patient and manage the scene until ground transport EMS units arrive and
assume patient care, or until the air medical transport unit arrives and assumes patient care. Use
the method of transportation that offers the least delay in delivering the patient to an appropriate
hospital.
*Not all patients meeting Level I Trauma Center criteria need helicopter transport.
*Not all patients in need of helicopter transport meet Level I Trauma Center criteria.
Consider utilization of a helicopter when the patient’s condition warrants transport to a trauma or
specialty referral center and the use of a helicopter would result in a clinically significant
reduction in time compared with driving to a trauma/specialty center.
Utilization of a high value resource such as air medical transport requires ongoing assessment and
process improvement. Anticipate feedback and review from the Office of the Medical Director
regarding patient outcome, medical appropriateness, etc.
Suspected Abuse and/or Neglect
If BCFRO members are confronted with a patient whom they suspect is a victim of any form of
abuse or neglect, the BCFRO members shall remove the abused/neglected person from the scene
as quickly as possible, and law enforcement shall be contacted immediately. If abuse or neglect is
suspected in a patient, no other person will be allowed to refuse care or transport for the patient.
This shall include parents/guardians for minors and caregivers/Power of Attorney for adults. If a
person is attempting to prevent treatment/transport of a suspected abuse/neglect victim, BCFRO
personnel shall immediately contact law enforcement, a Medical Officer, and the Medical Director
on-call.
If the suspected abuse/neglect patient is refusing treatment and/or transport for him/herself,
BCFRO members shall make every attempt to convince the patient to accept treatment and
transport. If the patient continues to refuse, BCFRO personnel shall immediately contact law
enforcement, a departmental medical officer, and the Medical Director on-call.
State Law mandates that health care professionals report all suspected abuse and neglect.
Suspected abuse and/or neglect must be reported to law enforcement, the staff at the receiving
hospital, and either Adult Protective Services or Child Protective Services. A report to APS/CPS
should be made immediately by the treating BCFRO medic, even though a report is made to the
transporting agency and the hospital.
Adult Protective Services
24-hour hotline for police and EMS personnel – 1-800-877-5300
Online: https://www.txabusehotline.org
Child Protective Services
24-hour hotline for police and EMS personnel – 1-800-877-5300
Online: https://www.txabusehotline.org
III.3
Sexual Assaults
All potential victims of sexual assault shall be treated with respect and dignity. Attention should be
given to life threatening emergencies and treated accordingly. Unless necessary for life-saving
procedures, the patient’s clothing, particularly any undergarments, as well as any other potential
evidence should be left in place.
All sexual assault victims meeting the STRAC criteria for Level I Trauma Center shall be
transported Priority I to the nearest Trauma Center
Adult sexual assault victims not meeting Level I Trauma Center criteria should be transported to
Methodist Specialty and Transplant Hospital for Sexual Assault Nurse Examiner (SANE) services.
Pediatric sexual assault victims not meeting Level I Trauma Center Criteria should be transported
to Santa Rosa Children’s Hospital for Pediatric Sexual Assault Nurse Examiner services.
If law enforcement has not been notified of a possible sexual assault, BCFRO personnel shall
notify the appropriate law enforcement agency. See the Sexual Assault patient care flowchart
(page VI.9) for further guidance on caring for these patients.
III.4
Organization
Procedures (SMOPS)
SECTION IV
PATIENT ASSESSMENT AND
EMS PROVIDER SKILLS
(SMOPS)
PATIENT ASSESSMENT AND EMS PROVIDER SKILLS
General Patient Assessment
The chart on the following page denotes how initial patient assessment shall flow. Upon arrival to a
scene, BCFRO personnel shall assess the safety of a scene and potential threats. If personnel feel
a scene may not be safe to enter, personnel shall immediately withdraw from the scene and call
appropriate back-up personnel (fire suppression crews for fire danger, law enforcement for
potentially violent patients or suspected weapons on scene, CPS for electrical dangers, etc.)
After a scene has been made safe, BCFRO personnel shall enter and do a rapid primary
assessment of the patient. The rapid primary assessment shall include:
1. Brief history of present illness (what happened, circumstances that prompted 911 call,
recent illness or injury)
2. Assess patient’s chief complaint
3. Assessment of airway, breathing, circulation, and potential spinal injuries
4. Assessment of potentially life- or limb-threatening illness/injury
5. Complete set of vital signs
a. Blood pressure, heart rate, respiratory rate, pulse oximetry on every patient
b. Blood glucose, EtCO2, GCS, and temperature as indicated
During and after the primary assessment, initial life-saving interventions shall be begun per the
appropriate protocol(s). At this time, BCFRO crews should also determine if the patient is a Medical
patient or Trauma patient. It is acknowledged that in some cases, a patient may have a
combination of medical and trauma issues, or it may be difficult to determine whether a
precipitating event was medical or traumatic. In these cases, BCFRO personnel are expected to
use their best medical judgment and the information they have at the time to make the
determination to the best of their ability.
If a patient is felt to be a Trauma patient, BCFRO personnel shall continue life-saving interventions
per these protocols while performing a secondary assessment and provide appropriate patient care
while awaiting the arrival of ground or air transport units.
With the exception of patients who meet DOA criteria and patients in traumatic cardiac arrest who
do not meet resuscitation criteria, BCFRO personnel shall stay on the scene of a patient in cardiac
arrest and provide appropriate care until the patient has a return of spontaneous circulation
(ROSC) OR until the EMS transport provider has transported the patient or terminated resuscitative
efforts.
All other patients shall be treated as per the appropriate protocol(s). Because most patients may
have a combination of problems, it is expected that BCFRO personnel will often need to operate
under more than one protocol at a time.
IV.1
IV.2
Skills
Adequate space and information cannot be communicated in a SMOPS format to train BCFRO
personnel in the application of emergency or life saving skills. This section is provided to highlight
specific areas of concern and provide a philosophy of care. By virtue of initial education and
completion of continuing education, BCFRO personnel have been credentialed to perform
procedures authorized by these SMOPS. Exclusions include procedures identified as requiring
additional credentialing and or training. This training can be demonstrated and approved by the
Medical Director or designee on an individual basis. BCFRO personnel shall not perform any
procedure for which they have not been trained.
Skills Verification and Maintenance
Additional Recognized Certifications:
1. ACLS
2. PALS PEPP
3. PHTLS or ITLS
Skills/Interventions Authorized by Credential Level and Qualification
Each Credentialing level builds on all previous Credentialing levels (i.e., EMT-Intermediate
is responsible for all ECA, EMT-Basic & EMT-Intermediate skills). Credentialing Level
authorizes the following skills/interventions: (If available in the department inventory)
Emergency Care Attendant (ECA):
1.
2.
3.
4.
5.
6.
7.
Bandaging and Splinting
Mechanical Aids to Breathing
Spinal Immobilization
Traction Splinting
Physical Assessment of Patient
CPR
Epi-Pen Auto-injectors assist vs admin.
Emergency Medical Technician- Basic (EMT-B):
1. Epinephrine Auto Injector
2. Bronchodilator Administration / Small volume nebulizer (as credentialed by
Medical Director)
3. Cardiac Arrest Management/AED
4. Assist patient with prescribed medications:
a. SL Nitroglycerin
b. Albuterol Metered- Dose Inhaler
5. Supraglottic Airway – King LTD, LMA, or Combi-tubes (as credentialed by
Medical Director)
6. 3 & 12-Lead ECG acquisition (excluding interpretation)
7. Blood Glucose Assessment
8. Capnography application
9. Aspirin 324 po assist or administer (as credentialed by Medical Director)
10. Nitrostat/spray assist or administer (as credentialed by Medical Director)
Maintenance requirements for ECA and EMT-B:
1. Current PEPP or PALS
2. PHTLS or ITLS certification is recommended
IV.3
Emergency Medical Technician- Intermediate (EMT-I):
1.
2.
3.
4.
Peripheral Venipuncture
Adult Endotracheal Intubation
Infant Endotracheal Intubation
Medication Administration: Glucagon IM, Narcan, D50
Maintenance requirements for EMT-I:
1. PHTLS or ITLS certification mandatory
2. Current PEPP or PALS & ACLS is recommended
Emergency Medical Technician- Paramedic (EMT-P) / Licensed Paramedic (LP):
1.
2.
3.
4.
5.
Drug Administration
Defibrillation/Cardioversion
3- and 12-lead EKG Interpertation
External jugular vein cannulation
Pronouncement of death in field (as per these SMOPS)
Maintenance requirements for EMT-P / LP:
1. ACLS/PALS certification mandatory
Specialty Skills
Qualifications are added competencies in specialty areas such as Training, Transport, Air
Medical, Hazardous Materials Medicine, Tactical Medicine, etc. The Qualifications available
may change based on the needs of the FRO. A Qualification may be operational in nature
making the specific requirements and/or skill set beyond the scope of this document. The
requirements for all patient-care-related Qualifications are in addition to the credentialing
requirements outlined in these SMOPS. Every Provider that delivers medical care within the
FRO must be initially credentialed (for example when they are new to the FRO or just receive
a new state certification or licensure) and must maintain their credentialing in order to
continue providing care at their designated level. For ILS and ALS credentialing, the
provider’s agency or organization must be designated as a "Public Safety Organization” by
the Office of the Medical Director.
By the State of Texas Department of State Health Services and the Texas Medical
Practice Act, all emergency medical care is performed under the auspices of the
Medical Director (System Certification to Practice). All privileges and rights are granted
with the requirement of maintaining all State, National, and System standards,
certifications, and licenses, as appropriate. The Medical Director has the authority at
any time to limit, suspend, or revoke System Certification to practice.
Airway Management
It is expected BCFRO personnel will rapidly and aggressively provide airway management to
patients based on the patient’s need and the member’s skills. Adequate oxygenation and
ventilation is paramount to the management of a patient’s airway. Our goal is to provide adequate
oxygenation and ventilation, NOT necessarily to perform a procedure or place a device. Providing
basic airway management such as clearing the airway, performing a jaw thrust, and/or placing oral
and nasopharyngeal airways will resolve the majority of airway issues. Supplemental oxygen
should be administered as needed and as directed in these SMOPS. Performance of bag-valveIV.4
mask ventilation is the most important skill BCFRO personnel can provide, whether EMT-B, EMT-I,
or paramedic. Non-invasive ventilation such as CPAP may assist in our goal of improving
oxygenation and ventilation. Endotracheal intubation is still a performance standard and a BCFRO
certified provider’s expertise in this skill is mandatory. Additionally, nasotracheal intubation is
authorized for those who have been trained and demonstrated competency to the Medical Director.
The utilization of alternative or rescue devices is encouraged. Currently, BCFRO fields the King LT
Airway for this purpose. An Eschmann stylet or gum elastic bougie is authorized for individuals who
have been trained and demonstrated their competency.
In addition to adults, BCFRO personnel must be expert in the management of pediatric airways.
Knowledge of anatomic differences between the child and adult is imperative and will improve
success in the management of pediatric airways. Additionally, there are a number of additional
airway issues BCFRO personnel are expected to be familiar with, including the management of
tracheostomies and individuals with post operative changes.
Many controversies are present in the medical literature regarding the prehospital intubation of
patients. It is each BCFRO member’s professional responsibility to be familiar with these areas of
conflict.
The success of each BCFRO medical provider is dependent on the provider’s knowledge of and
experience of basic airway management skills. Any BCFRO member who has questions or
concerns, or feels that he or she needs additional review or training in airway management should
contact a Medical Officer or the CE Coordinator with the BCFRO Office of the Medical Director.
Analgesia / Pain Control
Analgesia administration has beneficial therapeutic properties for our patients. It has historically
been under-utilized in the prehospital environment. Pain may be present in many different patient
conditions EMS providers will encounter. One of the primary goals in EMS is to relieve pain and
suffering. The administration of narcotic medication for pain management in the field can alleviate
patient suffering and improve patients’ conditions, make transport easier and less stressful for the
patient and the EMS provider, and allow emergency department personnel to initiate specific
treatment sooner.
Use of certain drugs for analgesia (reduction of pain) may also interfere with diagnostic procedures
in the emergency department, and their use in such circumstances must be judicious, with medical
control consulted when necessary.
Non-Verbal Cues to Pain:
Tachycardia
Tachypnea
Sweating
Increase in blood pressure
Decreased SaO2
Nausea / Vomiting
Flushing or Pallor
Shivering
Increased muscle tension, restlessness, frequent positional changes, or immobility
Contraindications for narcotic administration by EMS:
Head injury
Hypotension
IV.5
Sensitivity to the medication
Know drug allergy to the medication
Non-Pharmacological Methods to Manage Pain (applicable to all BCFRO Providers):
Provide a calm and controlled environment. When the environment
surrounding the patient is controlled it helps to relieve anxiety and provides
initial pain relief. Examples include: dimming lights, quiet room, and soft
spoken voice.
Explanation of procedures and calm re-assurance.
Providing relaxation techniques and distractions.
Splint and stabilize fractures/dislocations. By limiting the spinal reflex, tissue
and muscle metabolism is slowed preventing spasms that increase pain
reception and transmission.
Minimizing tissue damage – prevention and protection from the environment
to reduce further injury, thereby reducing the perception of pain by receptors.
Use of cold and heat packs.
Pad backboards including padding the natural voids created by the curvature
of the spine.
Allow patients to remain in the position most comfortable (when medically
safe to do so), thus minimizing anxiety and reducing pain transmission.
Examples of patients who may benefit from pain management:
Acute myocardial infarction
Burns
Isolated injuries requiring pain relief
Acute sickle cell pain crisis
Acute abdominal pain
DNR / Palliative Care
Guidelines for pharmacological pain management (applicable to BCFRO Departments who
utilize narcotics):
Vascular access should be initiated prior to administration when safely able to do
so.
Naloxone should be available anytime an opiate is administered for rapid reversal.
The intramuscular (IM) route is indicated only when vascular access is
unobtainable.
A baseline blood pressure or radial pulse (age appropriate) should be assessed
prior to analgesia and should be reassessed every 5 minutes, or as appropriate.
ETCO2 monitoring is essential when administering narcotic analgesics. It is not only
a great tool to assess effectiveness, but also provides an early warning of potential
complications. Analgesics should be titrated to the patient’s perception of pain and
the ETCO2 readings/waveform.
Indications that adequate sedation/pain relief has been achieved:
Deeper and slower respiratory rate (evident by elongated waveform)
Slowly rising carbon dioxide level due to the respiratory rate and depth
Patient reports decrease in pain
Sleepiness or alteration in awareness
*Constant monitoring of patient condition utilizing all available tools including ETCO2, SaO2, and
vital signs is critical.
IV.6
Procedure for pharmacological pain management:
1) Ask adults to rate their pain on a scale from 0 (no pain) to 10 (worst pain
imaginable).
2) On the PCR, document the level of pain prior to medication administration and the
patient’s response to the medication administration (pain scale before and after
medication).
3) Allow patient to remain in position of comfort unless contraindicated.
4) Monitor airway and vital signs every 5 minutes for unstable patients.
5) Administer analgesic medications in accordance with the specific medication
guidelines.
6) Remember pediatric patients also benefit from analgesia medications. Monitor them
appropriately.
EKG Interpretation and “Pearls”
• STEMI
•
•
•
•
(ST elevation in two or more contiguous leads)
- look for reciprocal changes in other leads for further confirmation.
Septal – V1 V2
Anterior – V3 V4
Lateral – I, avL V5, V6 (II,III,avF reciprocal)
Inferior – II, III, avF (I,avL,V5,V6 reciprocal)
.STRAC HEART ALERT Criteria
1. Patients with signs & symptoms of an Acute Coronary Syndrome (ACS)*
-------------------------AND---------------------------2. ST segment Elevation of 1mm or more in 2 or more contiguous leads
I
Lateral
avR
V1
Septal
V4
Anterior
II
Inferior
avL
Lateral
V2
Septal
V5
Lateral
III
Inferior
avF
Inferior
V3
Anterior
V6
Lateral
To increase your accuracy in indentifying a STEMI, ask the following questions:
Is there ST elevation greater than 1mm in height in two or more contiguous leads?
Does the ST elevation follow the morphology of a STEMI vs. J point elevation?
Is there ST depression in the reciprocal leads? (If you have an MI you will very likely have
reciprocal changes)
IV.7
Does the ECG say >>>>>>>>ACUTE MI<<<<<<<<<<< (*** Caution – while this may be a
part of the “big picture” in identifying a STEMI, paramedics should NOT rely solely on the
EKG Machine interpretation to rule in OR rule out a STEMI!)
*** The following 12 lead ECG findings are considered “abnormal”:
Any tachycardic rhythm with a rate over 120
Any bradycardic rhythm with a rate under 50
Atrial fibrillation or atrial flutter with any rate if the patient does not have a known history of afib or a-flutter
Junctional rhythm
Second or third degree heart block
ST elevation in two or more contiguous leads
ST Depression in two or more contiguous leads
T-wave inversions in any lead except aVR and V1
Peaked T-waves
Left bundle-branch block
Prolonged QT
Intravenous and Intraosseous Cannulation
IV and IO access are skills required of BCFRO paramedics and EMT-I’s on a daily basis. BCFRO
personnel must be able to perform this skill in common and unique conditions. Additionally,
paramedics and EMT-I’s should be able to perform this skill in the back of a moving ambulance.
BCFRO personnel must use personal protective equipment as outlined in these SMOPS at all
times. Peripheral IV access is preferred. An external jugular vein is considered a peripheral access
site. IO sites commonly used include the proximal tibia and proximal humerus. Additional sites are
available for use, but these non-standard areas should be utilized only in unusual circumstances,
and with Medical Director approval.
A fluid bolus will be interpreted as the rapid administration of 500 cc of Normal Saline solution. The
use of pressure bags to improve flow rates is encouraged and is expected in hemodynamically
unstable patients. Documentation of the patient’s response to fluid therapy is required.
Cardioversion and Transcutaneous Pacing
Cardioversion and transcutaneous pacing are standard paramedic skills. Their use is standard-ofcare in certain life-threatening cardiac conditions and it is therefore expected BCFRO paramedics
are comfortable and knowledgeable in their indications and use.
Cardioversion shall be utilized for patients with tachyarrhythmias who are hypotensive.
Transcutaneous pacing shall be utilized for patients who are bradycardic with hemodynamic
instability and who have failed pharmacologic interventions (Atropine). These treatments should
never be withheld due to close proximity to the hospital or because a paramedic is
uncomfortable performing them. Any BCFRO member who has questions or concerns, or feels
he or she needs additional review or training in cardioversion and/or transcutaneous pacing should
contact their Medical Officer or CE Coordinator with the BCFRO Office of the Medical Director.
IV.8
Cardiopulmonary Resuscitation and Cardiac Arrest
Cardiopulmonary resuscitation (CPR) is a mandatory basic skill BCFRO personnel should be
familiar with and comfortable performing.
While performing CPR, personnel should press “hard and fast” at a rate of 100 compressions per
minute (120 compressions/minute for neonates), ensure full chest recoil between compressions,
and should switch CPR providers every 2-3 minutes to prevent fatigue and ineffective
compressions.
Compressions should be started immediately upon determination of
pulselessness, and interruptions in chest compressions should be minimized. Before an advanced
airway is placed, compression:ventilation ratio should be 30:2 for adults, 15:2 for children, and 3:1
for neonates. Once an advanced airway has been established, compressions and ventilations
should occur simultaneously with a ventilation rate of 8-10 breaths/minute for adults and children,
and 20 breaths/minute for neonates.
During a cardiac arrest, all personnel should have a specific task, and perform that task
continuously during the code. A lead paramedic should be established as soon as possible. The
lead paramedic’s task is to “run the code”, or manage all aspects of the resuscitation. The lead
paramedic should not be performing specific skills once airway and IO access have been
established. The lead paramedic should ensure continuous CPR, proper techniques of
compressions and ventilations, proper timing of rhythm checks and medication administration, and
is responsible overall for the resuscitation. Other on-scene paramedics should assume the tasks of
airway management, IO/IV access, and drug administration. Other on-scene personnel should be
utilized for CPR (rotating every 2-3minutes), setting up IV sets, hemorrhage control (if applicable),
c-spine control (if applicable), and retrieving equipment.
A time-keeper should be established as soon as resuscitation is started, and is responsible for
recording the following times:
1) Beginning of the resuscitation
2) Times that all interventions were achieved (intubation, IO access, placement
of monitor, etc.)
3) Times of rhythm checks and what rhythm was noted at each rhythm check
4) Medications given and time they were administered
5) Times of defibrillations administered
6) Times of return of spontaneous circulation (ROSC)
7) Time of contact of Medical Control or Medical Director (if applicable)
8) Time of movement of patient to the ambulance and transport to hospital
The timekeeper should also remind the lead paramedic when it is time for a rhythm check (2
minutes after defibrillation or medication administration) or if it has been over 3 minutes since the
last drug was given. The on-scene fire officer is an ideal person to be the time-keeper, or should
delegate this to a firefighter if he/she is a paramedic and is performing paramedic-level skills on the
patient.
Spinal Immobilization
Spinal immobilization is a standard-of-care for many trauma patients. It is expected every BCFRO
member be familiar with and well-practiced at identifying patients who require spinal immobilization
and at applying appropriate immobilization procedures. Spinal immobilization includes placing the
patient in a cervical collar, head blocks, and on a backboard.
It is expected all patients will be FULLY immobilized who have had a potentially serious injury,
have multi-trauma injury, or otherwise meet the criteria stated in the patient-care flowcharts in
IV.9
these SMOPS. All patients who are involved in motor vehicle crashes, auto-pedestrian incidents,
industrial accidents, or falls from standing height in elderly patients or greater than standing-height
in younger patients shall be fully immobilized. It is NEVER acceptable to walk any patient who
requires immobilization to the ambulance or stretcher before the patient is immobilized.
Patients should be immobilized immediately from the place and position they are found by SAFD
personnel, unless immediate movement to another area is required due to imminent danger to the
patient or BCFRO personnel.
If a patient requires intubation and meets any criteria for spinal immobilization, a BCFRO firefighter
or paramedic shall be enlisted to hold the head in position of cervical spine immobilization
throughout the intubation procedure and until the cervical collar can be re-applied to the patient.
If a patient who requires spinal immobilization refuses any or all parts of immobilization, it must be
determined the patient has decision-making capacity to refuse such care and understands the risks
of refusing immobilization. The patient’s refusal and documentation of decision-making capacity
and understanding of risks must be included in the PCR for any patient who refuses immobilization
or any part thereof.
Hemorrhage Control
Hemorrhage control is part of the primary assessment (ABC’s) and is a potentially life-saving
technique. Every BCFRO member should be comfortable and skillful at controlling bleeding. Small
injuries with minimal bleeding should be bandaged as soon as possible for infection control
reasons and to prevent further contamination of the wound. Larger wounds with continuous
bleeding should be covered and direct pressure applied to the bleeding site continuously until the
bleeding has stopped. Very large wounds with significant bleeding or large arterial bleeds may
need to be controlled with a tourniquet. See Tourniquet Application below for further guidance.
Tourniquet Application
Tourniquet use can cause ischemia and major damage to tissue, and should not routinely be used
as a first line method of hemorrhage control. However, it is recognized there will be certain
instances when conventional hemorrhage control methods fail, and a tourniquet may be necessary
to control life- or limb-threatening bleeding.
There are also some situations in which it might be best to consider the use of a tourniquet first.
These situations include:
1) A complete or partial amputation of an extremity proximal to the ankle or wrist.
2) A wound with major arterial or venous bleeding that, upon visualization, is obvious
conventional methods will likely not work to control bleeding.
3) Multiple major injuries to the same extremity with either venous or arterial bleeding.
When it is apparent that application of a tourniquet is necessary, these steps should be followed
when using the SOF tourniquet:
1)
Place the tourniquet as high up on the extremity as is necessary to control
bleeding. Ensure it is not over a joint.
2)
Pull the running strap to tighten the tourniquet and secure it in place.
3)
Tighten the screw found on the clamp.
4)
Turn the windlass until the bleeding stops. Secure the windlass in one or both
triangular clips.
5)
Note the time of application on your run report.
IV.10
6)
7)
If applied during a MCI. Mark the time on the victim’s forehead and also mark the
forehead with a “T”.
Do not loosen tourniquets unless directed to do so by the Medical Director oncall.
In the event BCFRO personnel do not have access to the SOF tourniquet, a blood pressure cuff
can be placed on the extremity, inflated until bleeding stops, and then kept inflated to maintain
hemorrhage control.
Continuous Positive Airway Pressure (CPAP)
Continuous Positive Airway Pressure, (CPAP), is a non-invasive treatment designed to assist a
patient in respiratory distress. CPAP provides positive pressure ventilation that improves the
patient’s tidal volume, opens collapsed alveoli, and decreases the work of breathing.
Situations where CPAP would be beneficial may include:
1) CHF with severe pulmonary edema
2) Severe asthma attack or COPD exacerbation not responding to conventional treatments
(with Medical Director approval).
3) CO exposures
4) Exposures to Phosgene or Chlorine gas (Choking agents)
CPAP is not a definitive airway, nor does it ventilate the patient. A patient who is a candidate for
CPAP must be conscious with a GCS of at least 12, be able to maintain his/her own airway and
breathe on his/her own, and be able to tolerate the mask. The patient must also have a good blood
pressure (SBP > 80), have a good fit to the mask, and must not be exhibiting any signs or
symptoms of a pneumothorax or tension pneumothorax.
The CPAP mask and tubing should be already assembled and should be checked during unit
inspection each morning. To use the CPAP device:
1)
2)
3)
4)
5)
6)
7)
8)
9)
Take the CPAP mask and tubing out and apply 2 PEEPs. This will give you a
PEEP (Positive End Expiratory Pressure) of 10 cm H2O.
Attach the generator to the oxygen source.
Attach the CPAP mask and tubing to the generator.
If the generator is attached to a direct outlet, oxygen will begin to flow
immediately. If it is attached to a regulator, turn the oxygen flow rate up as high
as it will go (15 to 25 LPM).
Once CPAP is operating, slowly place the mask over the patient’s face. The
patient may be hypoxic and anxious, and you may meet some resistance from
them if they have not used CPAP before. Be patient and coach the patient to
relax and breathe with the mask.
Once the patient has accepted the mask, ensure you have a good fit. If you have
a tight seal air will flow out of the PEEP values.
Place the mask harness and straps over the patient’s head. Tighten these straps
while maintaining a good seal of the mask.
Monitor the patient’s vital signs, respiratory status, and tolerance closely.
If needed, the patient can receive a nebulized breathing treatment while also
receiving CPAP. To do this, cut the tubing and insert the “T” adapter into the tube
space. Connect the nebulizer to another O2 source and turn it on to about 4 LPM.
IV.11
For BCFRO Departments with CPAP availability:
CPAP should be started immediately in patients who meet criteria and when CPAP is indicated.
CPAP should NEVER be withheld or postponed due to paramedic discomfort with the
device, or close proximity to the hospital (even 2 minutes of CPAP may prevent a patient from
being intubated upon arrival to the ER). It is expected all BCFRO paramedics be familiar with
indications and usage of this device. Any BCFRO member who has questions or concerns, or feels
he or she needs additional review or training in CPAP should contact their Medical Officer or CE
Coordinator for BCFRO Office of the Medical Director.
IV.12
Organization
Procedures (SMOPS)
SECTION V
ADULT MEDICAL PROTOCOLS
V.1
V.2
V.3
V.4
V.5
V.6
V.7
V.8
V.9
V.10
V.11
V.12
V.13
V.14
V.15
V.16
V.17
V.18
V.19
V.20
V.21
V.22
V.23
V.24
V.25
V.26
V.27
V.28
V.29
V.30
V.31
V.32
V.33
V.34
V.35
Organization
Procedures (SMOPS)
SECTION VI
ADULT TRAUMA PROTOCOLS
VI.1
VI.2
VI.3
VI.4
VI.5
VI.6
VI.7
VI.8
VI.9
VI.10
Organization
Procedures (SMOPS)
SECTION VII
PEDIATRIC PROTOCOLS
VII.1
VII.2
VII.3
VII.4
VII.5
VII.6
VII.7
VII.8
VII.9
VII.10
VII.11
VII.12
VII.13
VII.14
VII.15
VII.16
Organization
Procedures (SMOPS)
SECTION VIII
OBSTETRIC PROTOCOLS
VIII.1
VIII.2
VIII.3
VIII.4
VIII.5
Organization
Procedures (SMOPS)
SECTION IX
SPECIAL SITUATIONS
THIS PAGE INTENTIONALLY LEFT BLANK
SPECIAL SITUATIONS PROTOCOLS FORTHCOMING
Organization
Procedures (SMOPS)
SECTION X
MEDICATIONS
Albuterol
(Proventil, Ventolin)
I.
Classification
Bronchodilator
II.
Action(s)
Selective B2-agonist – relaxes bronchial smooth muscle, causing bronchodilation
III.
Indications
Bronchial asthma
Bronchospasm associated with chronic bronchitis and emphysema (COPD)
Moderate to severe allergic reaction and anaphylaxis
Suspected hyperkalemia
IV.
Contraindications
Known hypersensitivity / allergy
V.
Precautions
The patient’s vital signs should be monitored for tachycardia and hypertension
Caution in elderly patients and those with cardiovascular disease or Hypertension –
monitor closely for tachydysrhythmias.
Lung sounds should be auscultated before and after treatment to determine
efficacy of treatment.
VI.
Drug interactions
Beta-blockers may antagonize effect
Ipratropium bromide increases duration of bronchodilation
Caution if patient takes MAOIs, tricyclic antidepressants, sympathomimetics
VII.
Adult Dosing and Administration
mg in 3 ml NS nebulized
Repeat as needed and per protocols
VIII.
Pediatric Dosing and Administration
– 2.5 mg in 3 ml NS nebulized
Repeat as needed and per protocols
IX.
Onset
5-15 minutes, Peak effects 1-1.5 hours
X.
Duration
5 hours
XI.
Possible adverse effects
Hypersensitivity / allergy
Paradoxical bronchospasm
Tachycardia / hypertension / palpitations / arrhythmias / myocardial infarction
Cough
Nausea / vomiting
Dizziness / nervousness / tremulousness
X.1
Amiodarone
(Cordarone, Pacerone)
I.
Classification
Antidysrhythmic
II.
Action(s)
Increases action potential duration and refractory period duration
Noncompetitive alpha and beta adrenergic inhibition
III.
Indication(s)
Ventricular tachycardia and ventricular fibrillation
Atrial dysrhythmia refractory to other treatments
IV.
Contraindications
Hypersensitivity to Amiodarone
Sinus Bradycardia, 2nd or 3rd degree Heart Block
Cardiogenic Shock
Severe CHF
V.
Precautions
Do Not Mix with any other drugs.
Precipitates with sodium bicarbonate
VI.
Drug interactions
Quinolone antibiotics (cipro, levaquin, etc)
VII.
Wide-complex tachycardia with pulse, Atrial Fibrillation / Atrial Flutter with
RVR, Multifocal Atrial Tachycardia - 150 mg IV/IO over 10 minutes
Ventricular fibrillation or pulseless V-tach - 300 mg IV/IO push
if rhythm continues may administer a second bolus of 150 mg IV/IO
VIII.
Pediatric Dosing and Administration (Weight less than 50 Kg)
Ventricular fibrillation or pulseless V-tach 5 mg/kg IV/IO push
Wide-complex tachycardia with pulse – 5 mg/kg IV/IO over 20 minutes
Max dose is 15 mg/kg
IX.
Onset
2-5 minutes
X.
Duration
Very long half-life – several days
XI.
Possible Adverse Effects
Dizziness, headache,
Hypotension
Bradycardia
AV Blocks
Ventricular dysrhythmias
Nausea/Vomiting, anorexia
Dyspnea, Pulmonary toxicity, CHF
X.2
Aspirin
(Bayer / Ecotrin / Bufferin / Anacin / Excedrin)
I.
Classification
Salicylate , non-steroidal anti-inflammatory
II.
Action(s)
Inhibits platelet aggregation
Inhibits prostaglandin synthesis and effects hypothalamus, which produces anti-pyretic,
non-opioid and non-steroidal anti-inflammatory and analgesic effects
III.
Indication(s)
Acute Myocardial Infarction
Cardiac related chest pain, angina pectoris
(Non-EMS uses: prevention of recurring MI and ischemic stroke after TIA; soft tissue,
arthritic, and musculoskeletal pain; fever reduction)
IV.
V.
Contraindication(s)
Hypersensitivity / allergy to aspirin
Bleeding gastric or duodenal ulcers
Hemophilia
Thrombocytopenia (low platelet count)
Children
Precautions
NSAIDs may cause increase in gastric irritation
May enhance the activity of anti-coagulant therapy
VI.
Drug Interactions
No drug interactions that should prevent administration when indicated
VII.
Acute coronary syndrome – 324 mg PO x 1 dose, chew before swallowing
VIII.
Not given in pediatric EMS patients
IX.
X.
XI.
Onset
1 – 2 hours
Duration
Half life is approximately 6 hours
Allergic reaction
Bleeding
Heartburn, Nausea/vomiting
Drop in blood sugar levels (in diabetics)
Kidney / liver toxicity
X.3
Atropine sulfate
(Atropine)
I.
Classification
Parasympathetic blocking agent
II.
Action(s)
Inhibits parasympathetic actions of acetylcholine at postganglionic cholinergic
neuroreceptor sites
Decreases vagal tone, allows bronchial dilation, decreases secretions in respiratory tract
and GI tract
III.
Indication(s)
Symptomatic bradycardia
Asystole / PEA with rate < 60 (in adults)
Organophosphate and nerve agent poisoning
(Non-EMS uses: decrease respiratory secretions during anesthesia, treatment of
Parkinson’s Disease, treatment of severe diarrhea and other GI disorders)
IV.
Contraindications
Known hypersensitivity
Tachycardia
No absolute contraindications in use for organophosphate / nerve agent poisoning
V.
Precautions
Can cause paradoxical bradycardia if pushed slowly or if less than therapeutic dose
given (less than 0.5 mg in adults, less than 0.1 mg in children)
VI.
Drug interactions
Other anticholinergics – additive anticholinergic effects, vagal blockade
Digitalis, cholinergics, neostigmine – potential adverse reaction
Antihistamines, procainiamide, quinidine, antipsychotics, antidepressants, benzos
enhance effects
VII.
For bradycardia – 0.5 mg – 1 mg IV/IO (max dose 3 mg)
For PEA / Asystole – 1 mg IV/IO every 3-5 minutes (max dose 3 mg)
Nerve agent / organophosphate – 2 mg IV/IM, repeat as necessary until patient is
asymptomatic (no max dose)
VIII.
IX.
For vagally-mediated bradycardia ONLY – 0.02 mg/kg IV/IO
- Minimum dose 0.1 mg
- Max single dose 0.5 mg, Max total dose – 3 mg
Nerve agent / organophosphate – 0.05 mg/kg IV/IM, repeat as necessary
o max single dose – 2mg, no max total dose for poisoning
Onset
2-5 minutes
X.4
X.
Duration
Half life is approximately 3 hours
XI.
Tachycardia, cardiac dysrhythmia
Seizures
Dry mouth, difficulty swallowing
Flushed skin
Dilated pupils / blurred vision
Acute glaucoma
XII.
Other Notes
 Not recommended in ASYMPTOMATIC bradycardia
X.5
Calcium chloride
I.
Classification
Electrolyte
II.
Action(s)
An essential component for proper function of nervous and muscular systems, normal
cardiac contractility, and coagulation of blood
III.
Indication(s)
Hyperkalemia
Calcium channel or beta blocker toxicity
(Non-EMS uses: Hypocalcemia, hypermagnesemia, Black Widow bites)
IV.
Contraindications
V-fib during cardiac resuscitation
Digitalis toxicity
Hypercalcemia
V.
Precautions
Flush IV line between administration of calcium chloride and sodium bicarbonate
Very irritating to soft tissues if extravasation occurs
VI.
Drug interactions
Digitalis – asystole, worsen arrhythmias
VII.
500 – 1000 mg of 10% solution, slow IV/IO
Administer no faster than 100 mg / min (1 ml/min)
VIII.
20 mg/kg of 10% solution, slow IV/IO – Max dose 1 gram
Administer no faster than 100 mg / min (1 ml / min)
IX.
Onset
5-15 minutes
X.
Duration
30 – 90 minutes
XI.
Nausea
Bradycardia (with rapid administration)
Hypotension (with rapid administration)
XII.
Other Notes
 Avoid giving in the pre-hospital environment if patient takes digoxin
X.6
Dextrose
(D50, D25, D10)
I.
Classification
Carbohydrate
II.
Action(s)
Restores blood glucose levels in hypoglycemia for cellular metabolism
III.
Indication(s)
Hypoglycemia – blood sugar < 60 mg/dl
(Non-EMS use – given with IV insulin for hyperkalemia)
IV.
Contraindications
Intracranial hemorrhage
Increased intracranial pressure
Absence of hypoglycemia
Delirium tremens if patient is dehydrated
V.
Precautions
Causes necrosis with extravasation into tissues
May sometimes precipitate severe neurologic symptoms (Wernicke’s encephalopathy) in
thiamine deficient patients
VI.
Drug interactions
No significant adverse interaction
VII.
VIII.
25 gm (50 ml) of D50 IV/IO
May be repeated once if blood glucose is < 60 after 10 minutes
Neonates – 2.5 ml/kg IV/IO of D10
< 50 kg – 2 ml/kg IV/IO of D25
> 50 kg – 25 gm (50 ml) IV/IO of D50
IX.
Onset
< 1 minute
X.
Duration
Depends on degree of hypoglycemia
XI.
Warmth, pain or burning from infusion
XII.
Other Notes
Dilute 1:1 for D25
o 12.5 gram (25 ml of D50) diluted with 25 ml normal saline
Dilute 1:4 for D10
o 5 gram (10 ml of D50) diluted with 40 ml normal saline
X.7
Diazepam
(Valium)
I.
Classification
Benzodiazepine
II.
Action(s)
Binds to benzodiazepine receptors and enhances GABA effects
Anti-convulsant, anxiolytic, sedative, and muscle-relaxant effects
III.
Indication(s)
Seizures / Status epilepticus
Excited Delirium
Cocaine / methamphetamine overdose
Alcohol withdrawal
Anxiety
Shivering in treatment of hyperthermia, certain types of muscle spasm
IV.
Contraindications
Hypersensitivity to this class of drug
Impaired respiratory function
Shock / hypotension
V.
Precautions
Sedation - Potential for Respiratory Depression
Bradycardia
Hypotension
VI.
Drug interactions
Caution with other CNS depressants – opioids, benzodiazepines
VII.
5-10 mg IV/IO (may be given IM but absorption not predictable)
Higher / additional doses by Medical Director order only
VIII.
0.1 mg/kg IV/IO
0.2 mg/kg PR
max dose 5 mg – additional doses per MD order only
IX.
Onset
1-2 minutes
X.
Duration
15 minutes to 2.5 hours
XI.
Respiratory depression, apnea
Dizziness, drowsiness, sedation
Hypotension, bradycardia
XII.
Notes
ETCO2 Should be monitored in any patient receiving sedative agents
X.8
Duo-Dote
(Pralidoxime chloride and atropine sulfate)
I.
Classification
Antidote
II.
Action(s)
Atropine counters effect of nerve agents / organophosphates by blocking the effects of
acetylcholine at the nerve receptor level
Pralidoxime reactivates acetylcholinesterase, which breaks down excess acetylcholine,
therefore restoring normal cholinergic nerve function
III.
Indication(s)
Nerve agent poisoning (sarin, soman, tabun, VX, etc.)
Organophosphate poisoning
IV.
Contraindications
None
V.
Precautions
None
VI.
Drug interactions
None significant enough to prevent use when needed
VII.
1-3 autoinjectors IM in outer quadrant of thigh
Dose dependent on severity of signs/symptoms (1 for mild symptoms, 2 for moderate
symptoms, 3 for severe symptoms)
VIII.
Same as adult
IX.
Onset
Immediate
X.
Duration
Varies by patient’s age and metabolism
XI.
Allergic reaction
Dilated pupils / dry mouth / decreased sweating / dry skin / urinary retention
Tachycardia / atrial fibrillation / PVCs / palpitations / V-fib
Tachypnea
Hypertension
XII.
Other Notes
 Inject into outer quadrant of thigh only – hold in place for 10 seconds
X.9
Epinephrine
I.
Classification
Sympathomimetic agent
II.
Action(s)
Stimulates alpha and beta receptors
Causes smooth muscle relaxation in the airways, increases cardiac output, and
contraction of the smooth muscle that lines most arterioles.
III.
Indication(s)
Cardiac Arrest
Extremis of asthma or allergic reaction
Anaphylaxis
Pediatric bradycardia
Cardiac output maintenance
IV.
Contraindications
Coronary insufficiency
V.
Precautions
Age over 50 (contact Medical Director)
Diabetes (stimulates glycogenolysis)
HTN
VI.
Drug interactions
Beta blockers will inhibit effects
Haldol may decrease or reverse effects
Tricyclic antidepressants may cause prolonged hypertension
VII.
Cardiac arrest - 1 mg IV/IO, repeat every 3 minutes
Anaphylaxis - 0.5 mg IM
Asthma unresponsive to Albuterol – 0.3 - 0.5 mg IM (requires MD order)
VIII.
Bradycardia - 0.01 mg/kg (1:10,000) IV/IO (max single dose 1 mg)
Anaphylaxis – 0.01 mg/kg (1:1000) IM (max dose 0.5 mg)
IX.
Onset
1-2 minutes
X.
Duration
5 to 15 minutes
XI.
Cardiac dysrhythmias
Hypertension
Chest Pain / Myocardial Infarction / Tachycardia
Anxiety / Headache
X.10
Furosemide
(Lasix)
I.
Classification
Loop diuretic
II.
Action(s)
Inhibits reabsorption of sodium and chloride in the ascending loop of Henle and distal
renal tubule.
Increased excretion of water, sodium, chloride, magnesium and calcium
III.
Indication(s)
Acute pulmonary edema
Hyperkalemia
IV.
Contraindications & Cautions
Hypersensitivity to drug
Electrolyte imbalances
Hypovolemia
Sepsis
V.
Precautions
Monitor closely for hypotension and arrhythmias
Use caution in elderly pts
Pregnancy (use only in life-threatening situations)
VI.
Drug interactions
Lithium – when given with lasix, lithium toxicity may occur
Antihypertensives – may cause hypotension
VII.
20-40 mg IV/IO (requires MD order)
VIII.
Dose: 0.5-2 mg/kg IV/IO – max is 6 mg/kg (requires MD order)
IX.
Onset
20-90 minutes
X.
Duration
Variable
XI.
Allergic reaction / anaphylaxis
Electrolyte disturbances – possibly severe
Urinary frequency
Dizziness
Nausea/vomiting, diarrhea, abdominal cramps
Weakness / muscle cramps
Hypokalemia, hypomagnesemia
Hypotension
X.11
Glucagon
(Glucagen)
I.
Classification
Hormone
II.
Action(s)
Converts hepatic glycogen to glucose, thus increasing blood glucose concentration
Relaxes smooth muscles of the gastrointestinal tract
III.
Indication(s)
Hypoglycemia – blood glucose reading < 60 mg/dL
Calcium channel blocker overdose, beta-blocker overdose
(Non-EMS uses: relief of esophageal food bolus)
IV.
Contraindications
Adrenal or pancreatic tumors (pheochromocytoma, insulinoma)
V.
Precautions
Patient must be advised to eat a carbohydrate-heavy meal after use
Does not work well in malnourished persons (minimal glycogen stores)
VI.
Drug interactions
Beta blockers decrease effectiveness of Glucagon
Use with anticoagulants can increase the risk of bleeding
VII.
Hypoglycemia – 1 mg IM, may repeat once
Calcium channel blocker or Beta-blocker overdose - 3-5 mg IV/IO
VIII.
0.05 mg/kg IM or IV/IO - max dose of 1 mg
IX.
Onset
5 – 20 minutes
X.
Duration
Peaks 30 minutes post injection
Designed to increase blood sugar at least 30 mg/dl in < 5 minutes
XI.
Headache and nausea
Rash / allergic reaction
Hyperglycemia
XII.
Other Notes
 Comes supplied in 2 vials – one contains white powder and one contains water – mix
thoroughly
X.12
Oral Glucose
(Glutose, Insta-Glucose)
I.
Classification
Carbohydrate
II.
Action(s)
Increases circulating blood sugar for cellular metabolism
III.
Indication(s)
Hypoglycemia (blood sugar < 60 mg/dl) in an alert patient with the ability to swallow
IV.
Contraindications
Altered level of consciousness
V.
Precautions
Patient must have ability to swallow without airway compromise
VI.
Drug interactions
None
VII.
15 – 45 gm until improved condition and blood glucose > 60 mg/dl
Must have intact gag and be able to handle own secretions
VIII.
5 – 45 gm until improved condition and blood glucose > 60 mg/dl
Must have intact gag and be able to handle own secretions
IX.
Onset
Within 10 minutes
X.
Duration
Depends on degree of hypoglycemia
XI.
Nausea / Vomiting
Aspiration
X.13
Hydroxocobalamin
(Cyanokit)
I.
Classification
Antidote
II.
Action
Binds with cyanide to form cyanocobalamin (vitamin B12), which is excreted through the
urinary tract
III.
Indication(s)
Cyanide poisoning
Smoke inhalation with suspicion of cyanide poisoning
IV.
Contraindications
Known hypersensitivity or allergy
V.
Precautions
May cause transient hypertension
May cause allergic reaction
Start a second IV line to administer as hydroxocobalamin reacts with many other IV
medications
VI.
Drug interactions
None
VII.
VIII.
5 gm IV diluted in normal saline (there are two 2.5 gram vials to be reconstituted) and
administered over total of 15 minutes
70 mg/kg IV – Max dose 5 grams (see attached chart)
Administer at 10-15 cc/min
IX.
Onset
Immediate
X.
Duration
Majority of urinary excretion occurs within 24 hours
XI.
Allergic reaction
Hypertension (transient)
Reddish discoloration of skin and urine
Dry throat
Nausea / vomiting
XII.
Other Notes
 Give only with Medical Director approval
X.14
Cyanokit Pediatric Dosing Chart
(based on Broselow Tape)
X.14-15
X.16
X.17
450 mg or 18 cc
600 mg or 24 cc
X.18
700 mg or 28 cc
900 mg or 36 cc
1200 mg or 1.2 g or 48 cc
1600mg or 1.6 g or 64 cc
2000 mg or 2 g or 80 cc
2500 or 2.5 g or 100 cc or one bottle
X.15
Morphine sulfate
(Astramorph, Duramorph, MS Contin, Oramorph SR)
I.
Classification
Opioid Analgesic
II.
Action(s)
Binds to opiate receptors in the CNS.
Alters the perception of and reponse to painful stimuli while producing generalized CNS
depression
III.
Indication(s)
Severe Pain
Pain associated with Acute Myocardial Infarction
IV.
Contraindications
Hypersensitivity
V.
Precautions
Caution if patient has head trauma
Caution / lower doses if renal, hepatic, or pulmonary disease
Caution if history of substance abuse
Use lower doses in elderly or debilitated patients
Rapid administration may lead to increased respiratory depression, hypotension and
circulatory collapse
VI.
Drug interactions
Warfarin - increases anticoagulant effect
Sedative/Hypnotics, clomipramine, barbiturates,
antihistamines - may increase CNS depression
tricyclic
VII.
2 - 10mg IV/IO (high doses require Medical Director order)
VIII.
0.1mg/kg IV/IO (max dose 4 mg – higher doses require MD order)
antidepressants
IX.
Onset
10 – 60 minutes
X.
Duration
4-5 hours
XI.
Allergic reaction
Hypotension, bradycardia, tachycardia, palpitations
Respiratory depression, apnea
Dizziness, lightheadedness, flushed feeling
Nausea / vomiting / abdominal pain
Prolonged use may lead to physical and psychological dependence and tolerance.
X.16
and
Naloxone
(Narcan)
I.
Classification
Opioid antagonist
II.
Action(s)
Competes for opioid receptor sites
III.
Indication(s)
Complete or partial reversal of narcotic depression (depressed mental status or
respiratory rate < 10) induced by narcotics
IV.
Contraindications
Hypersensitivity
V.
Precautions
Duration of action of some narcotics may exceed that of Narcan
Use of Narcan can precipitate acute narcotic withdrawal
Narcan should ONLY be used if narcotic use / overdose is suspected AND the patient
has signs / symptoms of CNS and/or respiratory depression
VI.
Drug interactions
None significant
VII.
0.4 - 2 mg IV / IO / IM, can be repeated after 2-3 minutes
Max dose 6 mg – contact Medical Director for additional doses
VIII.
0.1 mg/kg IV / IO / IM (max dose 2 mg)
IX.
Onset
Within 2 minutes
X.
Duration
30 – 80 minutes
XI.
Nausea and vomiting
Tachycardia, hypertension, cardiac arrhythmias
Tremulousness
Seizures
X.17
Nitroglycerin
(Nitro-bid, Nitro-dur)
I.
Classification
Vasodilator
II.
Action(s)
Potent smooth muscle relaxer – dilates arteries and veins
Reduces cardiac workload
Dilates coronary arteries – improves perfusion of ischemic cardiac muscle
III.
Indication(s)
Chest pain associated with Acute MI or angina pectoris
Acute pulmonary edema / CHF exacerbation
IV.
Contraindications
Recent (within 24 hours) ingestion of sexual enhancement drugs
Hypotension
Increased intracranial pressure
Shock
V.
Precautions
Do not administer if SBP < 100 (SBP < 120 if right ventricular MI suspected)
Blood pressure should be monitored before and after each dose
Do not administer nitroglycerin without an IV established (unless specific order by
Medical Director)
VI.
Drug interactions
Sexual enhancement medications (Cialis, Viagra, Levitra) – can cause life-threatening
hypotension
Beta blockers and calcium channel blockers– can cause hypotension
VII.
VIII.
0.4 mg tablet or spray sublingual every 3-5 minutes
Max 3 doses for chest pain, unlimited dosing for CHF
Not routinely indicated in pediatric patients
IX.
Onset
1 to 3 minutes
X.
Duration
30 to 60 minutes
XI.
Hypotension, bradycardia
Headache / dizziness / weakness
Dry mouth
Nausea / vomiting
X.18
Sodium Bicarbonate
(Baking Soda, Citrocarbonate, Neut)
I.
Classification
Alkalinizing agent
II.
Action(s)
Acts as an alkalinizing agent by increasing bicarbonate ions, raising blood pH
Following oral administration, releases bicarbonate, which is capable of neutralizing
gastric acid
III.
Indication(s)
Prolonged cardiac arrest
Metabolic acidosis
Hyperkalemia
Tricyclic antidepressant overdose
IV.
Contraindications
Metabolic or respiratory alkalosis
V.
Precautions
CHF / severe peripheral edema
Renal insufficiency
Concurrent corticosteroid therapy
Children with DKA (may increase risk of cerebral edema)
VI.
Drug interactions
Must be cautious when pushing through IV line with several other medications (calcium
chloride, Amiodarone)
VII.
1 meq/kg IV/IO
VIII.
1 mEq/kg IV/IO
IX.
Onset
Immediate
X.
Duration
Variable depending on patient situation
XI.
Fluid Overload
Alkalosis
Hypernatremia (elevated blood sodium levels)
XII.
Other Notes

Watch IV site closely. Extravasation may cause tissue irritation or cellulitis.
X.19
Organization
Procedures (SMOPS)
SECTION XI
APPENDICES
Appendix A
Medical Director / Medical Control
Contact Information
Bluff Creek Main Office
(210) 567-7860
Rudy Salazar, BSN, LP
CE Coordinator
For CE and QA issues call:
Cell – (210) 557-4093
Work – (210) 567-7876
Email – [email protected]
MD-1 - Dr. Manifold
Cell – (210) 265 – 7891
Office – (210) 567 - 7827
MD-2 - Dr. Kidd
Cell – (210) 388 – 6121
Office – (210) 567 - 7860
MD-4 (EMS Fellow)
Variable
XI.1
Appendix B
Acceptable Abbreviations for Patient Care
Documentation
AAA
abdominal aortic aneurysm
abd
abdomen
ACLS
Advanced Cardiac Life Support
AED
automatic external defibrillator
Afib
atrial fibrillation
AICD
automatic internal cardio-defibrillator
AIDS
acquired immune deficiency syndrome
ALOC
altered level of consciousness
AMI
acute myocardial infarction
A&O
alert and oriented
A&O x 1
alert and oriented to person
A&O x 2
alert and oriented to person and place
A&O x 3
alert and oriented to person, place, and time
A&O x 4
alert and oriented to person, place, time, and event
approx
Approximately
APGAR
appearance, pulse, grimace, activity, respirations
APS
Adult Protective Services
ARDS
adult respiratory distress syndrome
ASA
aspirin
ASAP
as soon as possible
A-tach
atrial tachycardia
AV
Atrioventricular
AVPU
Alert, Verbal, Painful, Unconscious
BBB
bundle branch block
BBS
bilateral breath sounds
BBS=CTA
bilateral breath sounds equal and clear to auscultation
BCLS
basic cardiac life support
bilat
bilateral
BLS
basic life support
bm or BM
bowel movement
BP
blood pressure
bpm
beats per minute or breaths per minute
BSA
body surface area
BS
breath sounds
BSI
body substance isolation
BVM
bag valve mask
XI.2
C#
cervical vertebrae number 1-7
ca or CA
cancer
CABG
coronary artery bypass graft
CAD
coronary artery disease
CC
chief complaint
CED
conductive electrical device (taser)
CHF
congestive heart failure
cm
Centimeter
CMS
circulation, motion, sensation
CNS
central nervous system
c/o or C/O
complains of
COPD
chronic obstructive pulmonary disease
CP
cerebral palsy or chest pain
CPAP
continuous positive airway pressure
CPR
cardiopulmonary resuscitation
CPS
Child Protective Services
CSF
cerebrospinal fluid
C-spine
cervical spine
CTA
clear to auscultation
CVA
cerebrovascular accident
D50
50% dextrose
d/c
Discontinue
defib
Defibrillate
DIC
disseminated intravascular coagulation
DJD
degenerative joint disease
DKA
diabetic ketoacidosis
DM
diabetes mellitus
DNR
Do Not Resuscitate
DOA
dead on arrival
DOB
date of birth
DOE
dyspnea on exertion
DOS
dead on scene
Dr.
doctor
DTs
delirium tremens
DVT
deep vein thrombosis
Dx
diagnosis
ECG or EKG
Electrocardiogram
ED
emergency department
EDC
expected date of confinement
EEG
Electroencephalogram
EJ
external jugular
ET
Endotracheal
ETT
endotracheal tube
XI.3
ETA
estimated time of arrival
ETCO2
end tidal carbon dioxide
ETOH
ethanol or alcohol
fib
Fibrillation
ft
feet or foot
F/U
follow-up
FUO
fever unknown origin
fx or FX
fracture
G
gravida
GCS
Glasgow Coma Scale
GI
Gastrointestinal
GU
Genitourinary
GSW
gunshot wound
GYN
Gynecology
H&P
history and physical
H/A or HA
headache
Haz-Mat
hazardous material
HB
heart block
HCTZ
Hydrochlorothiazide
HEENT
head, eyes, ears, nose, throat
HIV
human immunodeficiency virus
h/o or H/O
history of
HR
heart rate
hr
hour
ht
height
HTN
Hypertension
Hx
history
ICD
implantable cardioverter-defibrillator
ICP
intracranial pressure
IDDM
insulin dependent diabetes mellitus
IM
Intramuscular
IO
Intraosseous
irreg
irregular
IV
Intravenous
IVDA
intravenous drug abuse
IVP
intravenous push
J
joule
JVD
jugular venous distention
K+
potassium
Kg
kilogram
KVO
keep vein open
L
left
L
liter
XI.4
L#
lumbar vertebrae #1-5
lac
Laceration
LAD
left anterior descending
lat
lateral
lg
large
LLE
left lower extremity
LLQ
left lower quadrant
LMP
last menstrual period
LNMP
last normal menstrual period
LOC
level of consciousness or loss of consciousness
LUE
left upper extremity
LUQ
left upper quadrant
LZ
landing zone
max
maximal or maximum
mcg
Microgram
MCI
multiple casualty incident
MDI
metered dose inhaler
mEq
Milliequivalent
mg
milligram
MI
myocardial infarction
min
minimum or minute
ml / mL
milliliter
mm
millimeter
mm/Hg
millimeters of mercury
MOI
mechanism of injury
MRI
magnetic resonance imaging
MRSA
methicillin resistant staphylococcus aureus
MS
multiple sclerosis
MSC
motor, sensory, circulation
MVC
motor vehicle crash
MVPed
motor vehicle pedestrian
Na
sodium
NAD
no acute distress
NC or N/C
nasal cannula
NKA
no known allergies
NKDA
no known drug allergies
NPO
nothing by mouth
NRB
non-rebreather mask
NS
normal saline
NSR
normal sinus rhythm
NSTEMI
non-ST elevation myocardial infarction
NT
Nasotracheal
NTG
Nitroglycerin
XI.5
N/V
nausea and vomiting
N/V/D
nausea, vomiting, and diarrhea
O2
oxygen
OB
Obstetrical
OTC
over the counter
oz
p
ounce
PAC
premature atrial contraction
palp
palpation
PCP
primary care physician
PE
pulmonary embolism
PEA
pulseless electrical activity
ped or Ped
Pedestrian
pedi
pediatric
PERRLA
pupils equal, round, react to light and accommodation
PERRL
pupils equal, round, reactive to light
PMHx
past medical history
PID
pelvic inflammatory disease
PJC
premature junctional contraction
PMS
premenstrual syndrome
pn
pain
po or PO
orally / by mouth
POS
physician on scene
post
posterior
POV
privately owned vehicle
PPE
personal protective equipment
pt
patient
PTA
prior to arrival
psych
Psychiatric
PVC
premature ventricular contraction
q or Q
every
R or rt
right
RA or R/A
room air
reg
regular
RLE
right lower extremity
RLQ
right lower quadrant
r/o or R/O
rule out
ROM
range of motion
ROSC
return of spontaneous circulation
RR
respiratory rate
RUE
right upper extremity
RUL
right upper lobe
RUQ
right upper quadrant
after
XI.6
Rx
s
prescription / therapy / treatment
SA
sinus arrhythmia
sat or Sat
Saturation
SIDS
sudden infant death syndrome
SL
Sublingual
SMOPS
standard medical operating procedures
SaO2
oxygen saturation
SOB
short of breath or shortness of breath
S/P
status post
SROM
spontaneous rupture of membranes
s/s
signs and symptoms
STD
sexually transmitted disease
STEMI
ST-elevation myocardial infarction
SC or SQ
Subcutaneous
SVT
supraventricular tachycardia
sync
Synchronized
sz or Sz
seizure
T#
thoracic vertebrae 1-12
T or temp
Temperature
TB
Tuberculosis
TBSA
total body surface area
Tbsp
Tablespoon
TI
toxic ingestion
TIA
transient ischemic attack
TKO
to keep open
trach
Tracheostomy
tsp
teaspoon
tx / Tx
traction / therapy / treatment / transfer
UE
upper extremity
unk
unknown
URI
upper respiratory infection
UTI
urinary tract infection
vag
vaginal
Vfib or VF
ventricular fibrillation
vs.
versus
VS
vital signs
VT
ventricular tachycardia
w/
with
WMD
weapons of mass destruction
W/C
Wheelchair
wk
week
wnl / WNL
within normal limits
without
XI.7
w/o or WO
without or wide open
x
times
yrs
years
y/o
years old
@
at
∆
change
↑
increase(d)
↓
decrease(d)
<
less than
>
greater than
º
hours or degree
Ø
negative
+
plus or positive
-
minus or negative
≈
Approximately
≠
not equal
=
equal
♀
female
♂
male
&
and
XI.8
Appendix C
STRAC Red / Blue Trauma Criteria
XI.9
XI.10
Appendix D
Rule of Nines
Adult
XI.11
Child
XI.12
Infant
XI.13
Appendix E
Glasgow Coma Scale
Motor Response
Patient response
Obeys commands fully
Localizes to pain
Withdraws from pain
Abnormal flexion (decorticate posturing)
Extensor response (decerebrate posturing)
No response
Score
6
5
4
3
2
1
Verbal Response
Patient Response
Alert and oriented, normal speech
Confused, speech still normal (coherent)
Inappropriate words, jumbled phrases
Incomprehensible sounds
No sounds
Score
5
4
3
2
1
Eye Opening
Patient Response
Spontaneous eye opening
Eyes open to speech
Eyes open to pain
No eye opening
Score
4
3
2
1
TOTAL
XI.14
3 - 15
Appendix F
APGAR scoring
Term newborn normal vital signs
Heart rate (awake) – 100 -180 beats/minute
Respiratory rate – 30 - 60 breaths/minute
Systolic blood pressure – 55- 90 mm/Hg
Diastolic blood pressure – 26 – 55 mm/Hg
Sign
0
1
2
Color
Blue or pale
Pink body with
blue extremities
Completely pink
Heart rate
Absent
< 100 beats/min
Reflex irritability
No response
Grimace
Muscle tone
Limp
Respiration
Absent
Some flexion
Weak cry,
Hypoventilation
> 100 beats/min
Cry
/
active
withdrawal
Active motion
Strong cry
Measure total APGAR score at 1 minutes
and 5 minutes post delivery.
XI.15
Appendix G
Normal Pediatric Vital Signs
Heart Rate
Age
Neonate
Newborn – 3 mos.
3 mos – 2 years
2 – 10 years
> 10 years
Awake Rate
100 – 180
85 - 205
100 – 190
60 – 140
60 – 100
Mean
Sleeping Rate
140
130
80
75
80-160
75 - 160
60 - 90
50 - 90
Respiratory Rate
Age
Neonate
Infant
Toddler
Preschooler
School age
Adolescent
Rate
30 – 60
30 – 60
24 – 40
22 – 34
18 – 30
12 – 66
Systolic Blood Pressure (mm Hg)
Neonate
1 – 10 years (typical SBP)
1 – 10 years (lower limit for SBP)
> 10 years (lower limit)
XI.16
55 – 90
90 + (age in years x 2)
70 + (age in years x 2)
90
Appendix H
Out of Hospital DNR Forms
XI.17
XI.18
Appendix I
STRAC Infectious Disease Exposure
Form
XI.19
XI.20

Bexar County SMOP`s

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