E.P.A.B. i

Transcription

E.P.A.B. i

i
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E.P.A.B.
Emergency Physicians Advisory Board
Medical Control for MedStar System
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EMERGENCY PHYSICIANS ADVISORY BOARD
Medical Oversight and Direction for the MedStar System
MEDICAL PROTOCOLS, PROCEDURES, AND POLICIES
AS APPROVED BY THE
EMERGENCY PHYSICIANS ADVISORY BOARD
April 13, 2013 through May 31, 2015
Last Update: April 12, 2012
(Subject to revision prior to the end of this period, as authorized by the Medical Director)
PROVED
Jeffrey K. Beeson, DO, LP
Signature Date: January 2nd, 2013
Medical Director
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Acknowledgements
The Emergency Physicians Advisory Board thanks the following people for their work on
developing, reviewing, editing, and finalizing this document.
Protocol Drafting and Editing Committee
John K. Griswell, M.D.
Jeff Beeson, D.O., R.N., LP
Raymond Fowler, M.D.
Jon Puryear, NREMT-P
Lisa Bennett, LP
Angela Weimer, EMT-P
Macara Trusty, EMT-P
Jim Nelson, EMT
Casey Davis, EMT-P
Eugene Homuth, EMT-P
Anthony “Tony” Wood, EMT-P
Protocol Editing Author
Jon Puryear, NREMT-P
Copyright 2009, Emergency Physicians Advisory Board, Fort Worth, Texas.
Printed in the United States of America.
All rights reserved. No part of this book may be reproduced or transmitted in any form or
by any means, electronic or mechanical, including photocopying, recording, or any
information storage and retrieval system, without permission from the Emergency
Physicians Advisory Board. All EPAB, MedStar/AMAA, First Responder Agency
members of the MedStar System (listed on the Jurisdiction page), may reprint this book
as needed to provide a copy to their staff.
551 E. Berry
Fort Worth, TX 76110
817-923-1500
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Jurisdiction
The Uniform EMS Ordinance establishes the relationship between the Emergency
Physicians Advisory Board; the Medical Director; and each Provider.
Unless otherwise noted, the jurisdiction of these protocols includes only the following
members of the MedStar System:
MedStar (AMAA) EMS Provider
Fort Worth Fire Department
Burleson Fire Department
Forest Hill Fire Department
Haltom City Fire Department
Haslet Fire Department
Lake Worth Fire Department
Blue Mound Fire Department
Edgecliff Village Fire Department
River Oaks Fire Department
Saginaw Fire Department
Sansom Park Fire Department
Westworth Village Fire Department
White Settlement Fire Department
NAS JRB Fire Department
*Lockheed Martin (FW) Fire Department
* EPAB does not provide direct medical oversight for these agencies
These protocols only apply during official responses within these jurisdictions and apply
to personnel who are considered to be “On-Duty” by their respective agencies. Agencies
responding to mutual aid requests are expected to continue to operate under these
protocols.
In the case of a regional disaster, the Providers who normally operate under these
protocols will continue to do so, regardless of the location of the disaster, until other
instructions can be provided.
Questions regarding the applicability of this document within any specific jurisdiction or
for a particular event should be directed to the EPAB office by calling 817-923-1500 or
in writing to the following address:
EPAB
551 East Berry
Fort Worth, Texas 76110
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Medical Oversight of the System
Oversight of medical care provided within the System is accomplished in several ways:
• EPAB Board
The EPAB Board was created pursuant to the Uniform EMS Ordinance and adopted by
each of the Member Jurisdictions. The EPAB is empowered to promulgate the clinical
standards, rules, and regulations of ambulance and first responder services within the
Service Area. The EPAB Board is composed of the System area hospital Emergency
Department Medical Directors (8) and additional licensed physicians appointed at the
pleasure of the Tarrant County Medical Society (5). The EPAB power and duties are
defined in the Uniform EMS Ordinance.
• EPAB Medical Director
The System Medical Director is appointed by the EPAB serving as administrative officer
in carrying out the duties and powers of the EPAB. The Medical Director establishes the
clinical care requirements of the System and the credentialing standards for all EMS
Providers in the System. The EPAB Board collaboratively reviews changes for medical
appropriateness and consistency with sound medical practice. All medical protocols must
be approved by the EPAB Medical Director. The EPAB Medical Director’s power and
duties are defined in the Texas Medical Board Rules in the Texas Administrative Code,
Title 22, Part 9, Chapter 197-Emergency Medical Service and a Professional Services
Contract.
• The EPAB Protocol Committee
The EPAB Protocol Committee is a representative group of the EPAB who review
existing clinical practice; any proposed changes, and approve clinical protocol
modifications. The Protocol Editing Committee is a collaborative subcommittee of the
EPAB Protocol Committee charged with authoring clinical protocols. The Protocol
Editing Committee consists of representatives from MedStar Ambulance and the System
First Responder agencies. The Office of the Medical Director will evaluate system-wide
implications, training needs, and collaborate with stakeholders to accomplish consistent
implementation of protocol-related changes.
• Medical Directives
Medical Directives are issued by the Medical Director and describe specific clinical
changes or updates in the System. Medical Directives are distributed to all affected
System stakeholders. Medical Directives are preferably distributed electronically but may
be physically distributed to Agency contact persons. Each System Agency is responsible
for disseminating Medical Directives to their stakeholders and credentialed EMS staff.
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Table of Contents
Acknowledgements ...................................................................................................................................... iii
Jurisdiction................................................................................................................................................... iv
Medical Oversight of the System ................................................................................................................. v
Table of Contents........................................................................................................................................ vii
1
EXPLANATION OF THE LEVELS OF CARE ........................................................................... 1-0
2
UNIVERSAL PATIENT CARE ..................................................................................................... 2-0
3
UNIVERSAL TRAUMA PATIENT CARE .................................................................................. 3-0
4
AGE GUIDELINES ......................................................................................................................... 4-0
5
ADULT MEDICAL EMERGENCIES .......................................................................................... 5-0
Anaphylaxis / Allergic Reaction ...................................................................................... 5-2
Carbon Monoxide / Smoke Inhalation ............................................................................. 5-3
Chemical Warfare Exposure (Auto-injectors) ................................................................. 5-4
Chest Pain / Suspected Myocardial Event ....................................................................... 5-5
Choking / Airway Obstruction ......................................................................................... 5-6
Congestive Heart Failure/Pulmonary Edema................................................................... 5-7
Diabetic Emergencies ...................................................................................................... 5-8
Emergency Childbirth ...................................................................................................... 5-9
Emergency Childbirth Complications............................................................................ 5-10
Hazardous Materials Exposure (HAZMAT) ................................................................. 5-12
Hyperthermia ................................................................................................................. 5-14
Hypotension (Shock) ..................................................................................................... 5-15
Nausea and Vomiting ..................................................................................................... 5-16
Pain Management........................................................................................................... 5-17
Psychiatric Emergencies/Patient Restraint .................................................................... 5-18
Respiratory Difficulty (excluding CHF) ........................................................................ 5-19
Respiratory Failure (Pharmacological Assisted Intubation) .......................................... 5-20
Sedation.......................................................................................................................... 5-21
Seizures (Prolonged), Status Epilepticus, Eclampsia .................................................... 5-22
Stroke ............................................................................................................................. 5-23
Toxicological Emergencies / Poisoning / Overdoses..................................................... 5-24
6
ADULT ADVANCED CARDIAC LIFE SUPPORT .................................................................... 6-0
Universal Cardiac Arrest Algorithm ................................................................................ 6-2
Asystole............................................................................................................................ 6-3
Bradycardia ...................................................................................................................... 6-4
Pulseless Electrical Activity (PEA) ................................................................................. 6-5
Pulseless Ventricular Tachycardia / Ventricular Fibrillation........................................... 6-6
Tachycardia – Stable ........................................................................................................ 6-7
Tachycardia – Unstable.................................................................................................... 6-8
Post-Resuscitation Care ................................................................................................... 6-9
Therapeutic Hypothermia .............................................................................................. 6-10
7
ADULT TRAUMA EMERGENCIES ............................................................................................ 7-0
Amputation ...................................................................................................................... 7-2
Burns ................................................................................................................................ 7-3
Crush Injuries (thorax, abdominopelvic, extremity) ........................................................ 7-4
8
PEDIATRIC MEDICAL EMERGENCIES .................................................................................. 8-0
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Pediatric Allergic Reaction / Anaphylaxis....................................................................... 8-2
Pediatric Carbon Monoxide / Smoke Inhalation .............................................................. 8-3
Pediatric Chemical Warfare Exposure (Auto-injectors) .................................................. 8-4
Pediatric Chest Pain ......................................................................................................... 8-5
Pediatric Choking / Airway Obstruction.......................................................................... 8-6
Pediatric Diabetic / Glucose Emergencies ....................................................................... 8-7
Pediatric Hazardous Materials Exposure (HAZMAT) .................................................... 8-8
Pediatric Hyperthermia .................................................................................................. 8-10
Pediatric Hypotension .................................................................................................... 8-11
Pediatric Nausea and Vomiting ..................................................................................... 8-12
Pediatric Pain Management ........................................................................................... 8-13
Pediatric Psychiatric Emergencies ................................................................................. 8-14
Pediatric Respiratory Difficulty ..................................................................................... 8-15
Pediatric Sedation .......................................................................................................... 8-16
Pediatric Seizure ............................................................................................................ 8-17
Pediatric Toxicologic Emergencies / Poisoning / Overdoses ........................................ 8-18
9
PEDIATRIC ADVANCED CARDIAC LIFE SUPPORT ............................................................ 9-0
Pediatric Universal Cardiac Arrest Algorithm ................................................................. 9-2
Pediatric Asystole ............................................................................................................ 9-3
Pediatric Symptomatic Bradycardia ................................................................................ 9-4
Pediatric Pulseless Electrical Activity ............................................................................. 9-5
Pediatric Tachycardia - Stable ......................................................................................... 9-6
Pediatric Tachycardia – Unstable .................................................................................... 9-7
Pediatric Ventricular Fibrillation / Pulseless Ventricular Tachycardia ........................... 9-8
Pediatric Post Resuscitation ............................................................................................. 9-9
10
PEDIATRIC TRAUMA ................................................................................................................ 10-0
Pediatric Amputation ..................................................................................................... 10-2
Pediatric Burns ............................................................................................................... 10-3
Pediatric Crush Injuries (thorax, abdominopelvic) ........................................................ 10-4
11
MEDICAL PROCEDURES .......................................................................................................... 11-0
Airway Management ...................................................................................................... 11-2
Automated External Defibrillation (AED)..................................................................... 11-8
Blood and Blood Products ............................................................................................. 11-9
Blood Glucose Determination...................................................................................... 11-11
CPAP Procedure .......................................................................................................... 11-12
Capnography ................................................................................................................ 11-14
Chest Tube Management ............................................................................................. 11-16
Combat Application Tourniquet (CAT)....................................................................... 11-17
Cook-Melker Cuffed Emergency Cricothyrotomy Catheter Set ................................. 11-18
CPR Monitoring Device .............................................................................................. 11-23
ECG Acquisition and Transmission............................................................................. 11-24
Electrical Therapy ........................................................................................................ 11-25
Gastric Tube Insertion.................................................................................................. 11-28
Hemodynamic Monitoring ........................................................................................... 11-30
Intra-Aortic Balloon Pump .......................................................................................... 11-32
Intraosseous Infusion – EZ-IO ..................................................................................... 11-34
Intraosseous Infusion – Manual Type (i.e. Jamshidi, Cooks, Illinois, etc.) ................. 11-36
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Intravenous Access ...................................................................................................... 11-37
IV Fluid Therapy Procedure - Adult ............................................................................ 11-38
IV Fluid Therapy Procedure - Pediatric ....................................................................... 11-39
IVAC Triple Channel Intravenous Fluid Pump ........................................................... 11-40
Mechanical Ventilation ................................................................................................ 11-42
Methods of Medication Administration Procedure...................................................... 11-44
Motion Restriction / Spinal immobilization ................................................................ 11-47
Nasal Atomizer ............................................................................................................ 11-48
Occlusive Dressing ...................................................................................................... 11-49
Oxygen Administration / Pulse Oximetry.................................................................... 11-50
Pelvic Sling for Pelvic Fracture Stabilization .............................................................. 11-51
Pleural Decompression ................................................................................................ 11-52
Pulmonary Artery Catheters ........................................................................................ 11-53
QuikClot Dressing ....................................................................................................... 11-54
Sport Helmet Facemask Removal Procedure .............................................................. 11-55
Taser Removal ............................................................................................................. 11-56
Temporary Transvenous Pacemaker Policy................................................................. 11-57
Tourniquet Procedure................................................................................................... 11-59
Uni-Vent Eagle Transport Ventilator........................................................................... 11-60
Ventriculostomies ........................................................................................................ 11-63
Lucas 2 Chest Compression System ............................................................................ 11-65
12
POLICIES ...................................................................................................................................... 12-0
Against Medical Advice ................................................................................................ 12-2
Cancellation of Ambulances by First Responder Organizations ................................... 12-4
Continuing Education .................................................................................................... 12-6
Dead On-Scene and Termination of Resuscitative Efforts ............................................ 12-8
Demotion, Suspension, and/or Revocation of an EPAB Permit .................................... 12-9
Do Not Resuscitate ...................................................................................................... 12-12
Emergency Medical Dispatch ...................................................................................... 12-14
Emergency 911 Calls from within the Hospital........................................................... 12-15
Exams and Subscales ................................................................................................... 12-16
First Responder Agency and Personnel Credentialing ................................................ 12-18
First Responder Personnel Levels of Care ................................................................... 12-21
Helicopter Utilization and Safety................................................................................. 12-26
Incident Command System .......................................................................................... 12-28
Informed Release at Scene ........................................................................................... 12-30
Medical Professionals on Scene of an Emergency ...................................................... 12-32
Medical Treatment of a MedStar Agency Employee .................................................. 12-33
Medications in the Field/Controlled Substances.......................................................... 12-34
MedStar Ambulance Designations and Levels of Operation ....................................... 12-35
MedStar Personnel Credentialing Process ................................................................... 12-38
MedStar Personnel Permit Levels and Scope of Practice ............................................ 12-42
Miscellaneous Policies and Statements ....................................................................... 12-48
Patient Transportation .................................................................................................. 12-49
Priority Radio Traffic ................................................................................................... 12-52
Protocol Maintenance and Revision ............................................................................ 12-53
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Quality Management Plan............................................................................................ 12-54
Reporting of Equipment Failures ................................................................................. 12-58
Selection of Field Training Officers ............................................................................ 12-59
Supplies and Equipment .............................................................................................. 12-60
Specialty Hospital Designation .................................................................................... 12-62
System Abusers ............................................................................................................ 12-64
Upgrading Ambulance Responses ............................................................................... 12-65
Walk In Patients and “Baby Moses” Events ................................................................ 12-67
13 MEDICAL DIRECTIVES ............................................................................................................ 13-0
On-Board Supply Inventory and Medication Lists…………………………………………………...13-1
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1 EXPLANATION OF THE LEVELS OF CARE
In each protocol, levels of care are listed under the separate headings. The following
describes each provider credential level and their capabilities:
Level 1
1. Emergency Care Attendants
a. First Responder Agency ECA level employee
i. Prohibited from administering medications except oxygen
2. Emergency Medical Technicians
a. First Responder Agency EMT level employee (F-1)
b. MedStar EMT level employee (M-1)
Level 2
1. Emergency Medical Technician – Intermediate
a. First Responder Agency EMT Intermediate level employee (F-2)
b. MedStar Intermediate level employee (M-2)
c. MedStar Basic Paramedic level employee (M-2)
Level 3
1. Emergency Medical Technician – Paramedic
a. First Responder Agency Paramedic level employee (F-3)
b. MedStar Paramedic level employee (M-3) on an ALS-Basic Ambulance
Level 4
a. First Responder Agency Advanced Paramedic level employee (F-4)
b. MedStar Paramedic level employee (M-4) on an ALS Ambulance
Level 5
a. First Responder Agency employee who is also a MedStar M-5 employee
b. MedStar Paramedic level employee (M-5) on a MICU Ambulance.
Level 6
1. Critical Care Emergency Medical Technician – Paramedic
a. MedStar Critical Care Paramedic level employee (M-6) on a Critical Care MICU
Ambulance
Level 7
1. Base Station Physician orders.
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2 UNIVERSAL PATIENT CARE
Universal Patient Care is the general care and treatment provided for each patient
encounter. The following describes Universal Patient Care by provider credential level.
Level 1
1.
2.
3.
4.
ABCs
Oxygen, as indicated
History and physical, vital signs, secondary assessment
Reassurance and position of comfort,
a. If hypotensive, place supine
b. If respiratory difficulty, place in seated upright position
5. Provide protection and maintain body temperature
6. NPO
7. 12-lead ECG acquisition and transmission (if available) in patients ≥30 years of age
(if applicable)
8. Pulse oximetry (if applicable)
9. End tidal capnography (if applicable)
10. Measure blood glucose, as indicated
Level 2
1. All care listed in above section
2. Advanced airway management as indicated if currently qualified and competent
3. Intravenous access and IV fluid therapy as indicated in the IV Fluid Therapy
Procedure
4. Determine patient weight (Broselow in pediatrics)
Level 3-4
2. Cardiac monitor and perform basic ECG rhythm interpretation as indicated
3. 12-lead interpretation as indicated
Level 5-6
2. Transduce Invasive Lines
Level 7
1. Further orders
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3 UNIVERSAL TRAUMA PATIENT CARE
Universal Trauma Patient Care is the care and treatment provided for each trauma patient
encounter. The following describes Universal Trauma Patient Care by provider credential
level.
Level 1-2-3-4-5-6
Universal Patient Care
Spinal immobilization with c-spine precautions as indicated
Assess for associated injuries that may be of a higher priority
For signs and symptoms of an open or closed thoracic injury, refer to appropriate
procedure (i.e. Pleural Decompression, Occlusive Dressing, etc.)
5. Assess neurovascular status before and after bandaging and splinting
6. Control bleeding with direct pressure, dressings, and elevation
a. For uncontrolled external hemorrhage, refer to the QuickClot Procedure
b. For uncontrolled extremity hemorrhage, refer to Tourniquet Procedure
7. Dress open fractures with moist, sterile dressings
8. Splint incomplete fractures/dislocations in normal anatomical position, if possible
9. For femur fractures, apply appropriate traction splint device
10. Grossly angulated fractures with vascular compromise may be straightened for
splinting
11. For signs and symptoms of a pelvic fracture, refer to Pelvic Sling Procedure
12. Pain Management Protocol
13. Providers should remain cognizant of scene times keeping in mind that definitive care
in the trauma patient is at the trauma receiving center. Scene times should be kept
short as possible whenever feasible.
1.
2.
3.
4.
Level 7
1. Further orders
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4 AGE GUIDELINES
Medical Emergencies
Trauma Emergencies
Psychiatric Care
Adult Care Facility
≥ 15 Years
≥ 15 Years2
≥ 13 Years3
Cook Children’s
< 15 Years1
< 15 Years
< 13 Years
1
Under certain circumstances, such as medical patients who are 15 years old or older
and who have established relationships with pediatric specialists, may be transported
to a pediatric care facility. If in doubt, consult with a base station physician.
2
Patients 15 years old and greater should be transported to EPAB recognized traumareceiving facilities.
3
Adolescent patients 13 years and older should be transported to JPS adolescent
psychiatric unit.
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5 ADULT MEDICAL EMERGENCIES
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Anaphylaxis / Allergic Reaction
Level 1-2
1. Universal Patient Care
2. If stinger is present, scrape to remove. DO NOT utilize tweezers or hemostats.
3. Epinephrine auto-injector (0.3 mg), if available, exhibiting hives with dyspnea or
stridor.
a. Levels 3-6 may utilize epinephrine 1:1,000 0.3 mg IM as stated below
4. If wheezing:
a. Ipratropium bromide 500 mcg (0.02%) in 3 mL saline mixed with albuterol
2.5 mg in 3 mL NS nebulized, may repeat once.
b. If the patient is still symptomatic, administer an additional albuterol 2.5 mg in 3
mL nebulized.
5. If SBP ≥ 90, upright position is preferred.
6. Ice packs to affected area to decrease swelling, if indicated
7. Remove constricting jewelry
Localized Reaction
1. Diphenhydramine
2 mg/kg IVP/IM
(maximum 50 mg)
Level 3-4
Localized with SOB
1. Diphenhydramine 2
mg/kg IVP/IM
(maximum of 50
mg)
2. Methylprednisolone
125 mg IVP/IM.
Anaphylaxis / <90 mmHg SBP
1. Epinephrine 1:1000 0.3 mg
IM (may repeat x1 after 5
minutes)
2. If SBP < 90 mmHg, refer to the
IV Fluid Therapy Procedure.
3. Diphenhydramine 2 mg/kg
IVP/IM (maximum of 50 mg)
3. Methylprednisolone 125 mg
IVP/IM.
Level 5-6
2. If SBP <90 mmHg and Anaphylaxis:
a. Epinephrine infusion 2-5 mcg/min. Add epinephrine 0.5 mg to 250 mL and run
at 60 cc/hr on pump. Achieves 2 mcg/min.
b. Dopamine 10-20 mcg/kg/min infusion for persistent hypotension and to
maintain a SBP of 90 mmHg
Level 7
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Carbon Monoxide / Smoke Inhalation
Level 1-2-3-4-5-6
2. CO monitoring (if available)
3. Continuous high flow oxygen 15 lpm by non-rebreather mask or assist ventilations
as needed.
Level 7
5-3
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Chemical Warfare Exposure (Auto-injectors)
Level 1-2
2. Assure scene safety (Refer to the Hazardous Materials protocol if indicated)
3. Refer to the Chemical Warfare Exposure Procedure for patient and self administration.
Level 3-4-5-6
1. For symptomatic chemical exposure (Sarin, Suman, Tabun, and VX) and/or
Organophosphates, administer the appropriate number of initial Mark-I auto injector/s
(as indicated in the chart below) and repeat every 5 minutes until signs of atropinization
occur and SLUDGE signs subside. Each Adult Mark I auto injector consists of:
a. Atropine 2 mg
b. Pralidoxime chloride (2 PAM) 600 mg (max dose of 1800 mg/3 doses)
QUIK
REFERENCE
Type of Exposure
VAPOR-MILD
1.
2.
DERMAL-MILD
1.
VAPOR-MODERATE
1.
DERMALMODERATE
1.
VAPOR-SEVERE
1.
DERMAL-SEVERE
1.
Signs & Symptoms
Miosis Only
Miosis, rhinorrhea, slight dyspnea,
secretions
Increased sweating at the site or
increased fasciculations
Same as mild, plus marked dyspnea
and secretions
Same as for mild exposure, plus:
vomiting, diarrhea, and/or
generalized weakness.
Same as for moderate exposure,
plus: loss of consciousness,
seizures, generalized fasciculations,
flaccid paralysis, and apnea copious
secretions.
flaccid paralysis, and apnea,
copious secretions.
# MARK I
NONE
1 KIT
# CANA
NONE
NONE
1 KIT
NONE
1-2 KIT
NONE
2-3 KIT
NONE
3 KIT
1
3 KIT
1
2. For associated seizures, administer the diazepam auto injector (10mg deep IM), may
repeat every 5 minutes until cessation of the seizure
3. Rapid transport to the closest hospital
Level 7
NOTE: In a mass casualty incident declared by the Incident Commander, auto injectors
may be administered standing order by ALL trained levels of care by following the above
protocol.
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Chest Pain / Suspected Myocardial Event
Level 1
2. Transport to a designated cardiac receiving facility
3. Aspirin 324 mg PO (four 81 mg children’s chewable ASA) unless the patient has a
recent history of bleeding stomach ulcers.
4. If no medications for erectile dysfunction (i.e.: Viagra, Cialis, Levitra, etc.) have been
taken within last 36-hours and SBP ≥110 mmHg, administer a sublingual
nitroglycerin 0.4 mg. May repeat every 5 minutes for a total of 3 doses if the SBP
≥110 mmHg (must obtain a BP prior to administering each dose)
Level 2-3
1. Only one (1) IV attempt for this level
Level 4
NOTE: This level may administer the above nitroglycerin SL if SBP ≥90 mmHg
1. If isolated inferior and/or posterior AMI, perform right sided chest lead ECG tracing,
time permitting.
a. If at least one right sided chest lead indicates ST segment elevation, use caution
with the administration of nitroglycerin
2. An additional two (2) IV attempts may be made for a total of three (3) attempts
3. If the SBP ≥90 mmHg, NTG paste, 1 inch (may be placed after the first NTG dose)
4. For suspected cocaine or methamphetamine overdoses, administer midazolam 2.5
mg IVP.
Normotensive (Systolic BP ≥ 90)
If pain persists after therapy with NTG,
then refer to Pain Management Protocol
Hypotensive (Systolic BP < 90)
If time permits, and condition is not
considered CHF, then refer to IV Fluid
procedure.
Level 5
1. If SBP < 90 mmHg, dopamine 10-20 mcg/kg/min infusion for persistent
hypotension unresponsive to fluid therapy to maintain SBP of ≥90 mmHg
Level 6
1. If SBP > 90 mmHg and chest pain is unresolved, begin nitroglycerine infusion at 20
mcg/min. Titrate infusion up by 5 mcg/min until chest pain is resolved or SBP < 90
mmHg.
Level 7
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Choking / Airway Obstruction
Level 1
2. Follow current AHA recommendations for foreign body airway obstruction
Level 2-3
1. If basic interventions fail, use laryngoscope and Magill forceps to visualize and
remove obstruction.
2. After removal of obstruction, provide airway management and circulatory support as
indicated
1.
Level 4
If unable to see obstruction or clear airway, consider TTO.
Level 5-6
1. If the TTO doesn’t adequately oxygenate the patient, consider the placement of a
Melker device.
Level 7
5-6
E.P.A.B.
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5-7
Effective Date:
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Congestive Heart Failure/Pulmonary Edema
Level 1
2. Assist ventilations with a BVM if the patient is in severe respiratory distress/failure
Level 2-3
1. Seated upright position is preferable
2. If the patient is in severe respiratory distress, apply CPAP (see procedure CPAP
Procedure for indications) starting at 15 lpm to deliver approximately 5 cm H2O.
3. If wheezing:
b. If the patient is still symptomatic, administer an additional albuterol 2.5 mg in 3
mL nebulized.
4. If no medications for erectile dysfunction (i.e.: Viagra, Cialis, Levitra, etc.) have been
taken within last 36-hours and SBP ≥ 90 mmHg, administer a sublingual
nitroglycerin 0.4 mg. May repeat every 5 minutes for a total of 3 doses if the SBP
≥90 mmHg (must obtain a BP prior to administering each dose).
5. Scene time goal is <10 minutes
Level 4-5
1. If SBP ≥ 90 mmHg and If no medications for erectile dysfunction have been taken
within last 36-hours and SBP ≥ 90 mmHg, administer nitroglycerin paste, 1 inch.
This may be applied after the first NTG SL dose.
2. If SBP ≥90, administer captopril 25 mg crushed SL
3. If SBP <90 mmHg, administer dopamine 10-20 mcg/kg/min infusion to maintain a
SBP of ≥90 mmHg
Level 6
1. If SBP > 90 mmHg, begin nitroglycerine infusion at 20 mcg/min. Titrate infusion
up by 5 mcg/min until symptoms resolve or SBP < 90 mmHg.
2. If SBP < 90 mmHg but > 70 mmHg, administer dobutamine 2-20 mcg/kg/min
infusion to maintain SBP > 90 mmHg.
Level 7
5-7
E.P.A.B.
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5-8
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Diabetic Emergencies
Level 1
Glucometer <80 mg/dL & Symptomatic
Hypoglycemia
1. If patient is conscious and with gag,
glucose paste (1 tube = 15 G)
2. Recheck blood glucose
Glucometer ≥300 mg/dL & Symptomatic
1.
Hyperglycemia
Continue to monitor vital signs and
provide reassurance
Level 2
Hypoglycemia
1. Dextrose 50% 25 G slow IVP. May
repeat once after 5 minutes if glucose
<80 mg/dl
Hyperglycemia
1. Refer to the IV Fluid Therapy
Procedure
Level 3-4-5-6
Hypoglycemia
1. If the patient is unconscious and you
are unable to establish an IV, glucagon
1 mg deep IM
3. If patient remains unresponsive
consider stroke, trauma, or
toxicological causes
Hyperglycemia
1. Refer to the IV Fluid Therapy
Procedure
Level 7
NOTE: Glucometer readings may be inaccurate by plus or minus 30 points. If the patient
is symptomatic but still within the normal range, call BSP for orders to treat the patient
5-8
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E.P.A.B.
Emergency Childbirth
Level 1-2-3-4-5-6
1.
2.
3.
4.
5.
Universal Patient Care (oxygen indicated for maternal or fetal distress)
Reassurance and position of comfort or, if indicated, position for imminent delivery
If patient is in labor, check for crowning
Emergency Childbirth Complications Protocol if indicated
NORMAL DELIVERY (head down, no complications):
a. If membranes have ruptured, note color and time.
b. As mother continues to push, more of the fetus head is seen.
c. Put on sterile gloves, mask and gown
d. Place hand on top of fetus’ head to “control” delivery and prevent an “explosive”
delivery.
e. When head delivers check to see if umbilical cord is wrapped around neck, if not, suction
mouth and then the nose with bulb syringe.
f. If umbilical cord is wrapped around neck, clamp cord twice two inches apart and cut
between clamps. Unwrap cord and suction mouth and then the nose with bulb syringe to
clear airway.
g. As shoulders start to deliver, apply gentle traction on the neonate downward and allow
the upper shoulder to deliver. Then apply gentle traction upward and allow lower
shoulder to deliver.
h. Support head and follow through with remainder of delivery; delivering torso, hips and
legs. Once entire neonate is delivered, support and place neonate on a firm surface below
the birth canal.
i. Clamp umbilical cord in two places, unless already done. One clamp 6-8 inches from the
neonate. The second clamp 10-12 inches from the neonate.
j. Cut the cord with a sterile scalpel between the two clamps.
k. Assess APGAR score at 1 minute and 5 minutes post delivery.
l. Dry the newborn and cover head and wrap body to keep warm.
m. Allow placenta to deliver on its own.
1. Transport Considerations:
a. If delivery is not in progress, begin transport
b. If delivery in progress, consider completing delivery, then begin transport
c. If indicated, complete delivery enroute
Level 7
APGAR Scoring of Newborns
SCORE
SIGN
Appearance (Color)
Pulse (Heart Rate)
Grimace (Reflex irritability)
Activity (Muscle tone)
Respiratory (Effort)
0
1
2
Blue, pale
Body pink, extremities blue
Completely pink
Absent
< 100
≥ 100
No response
Cry
Vigorous cry
Flaccid
Some flexion of ext.
Active motion
Absent
Slow, regular
Good active crying
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E.P.A.B.
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Emergency Childbirth Complications
Level 1
Breech Presentation
1. Allow fetus to deliver to level of umbilicus.
2. Gently extract legs downward after buttocks are delivered.
3. After legs clear support fetus on palm of hand and volar surface of the arm.
4. After umbilicus is visualized, extract 4-6 inch loop of umbilical cord to avoid
excessive traction on cord during delivery.
5. Gently rotate fetus to align shoulders in anterior-posterior position and continue with
gentle traction until axilla is visible.
6. Gently guide fetus upward to deliver posterior shoulder.
7. Gently guide fetus downward to deliver anterior shoulder.
8. Ensure that fetal face or abdomen is turned away from maternal symphysis.
9. Head often delivers easily after shoulder delivery.
10. If head does not deliver:
a) Place gloved hand into vagina with the palm towards the fetus face,
b) Form a “V” with the index and middle finger on either side of the fetus nose, and
c) Gently push the vaginal wall away from the fetus face until the head is delivered.
Cord Presentation
1. Position mother with hips elevated as high as possible. The knee-chest position may
relieve pressure on the cord.
2. Instruct mother to “pant” with each contraction.
3. Apply moist sterile dressings to exposed cord to minimize temperature changes and
palpate the cord for a pulse.
4. If no pulses, with gloved hand, gently push the fetus back into the vagina and elevate
the presenting part to relieve pressure on the cord. Do not attempt to reposition the
cord if it spontaneously retracts.
5. Maintain this hand position during rapid transport to maintain a cord pulse.
Premature Birth
1. Keep neonate warm.
2. Frequently suction the neonate’s mouth and nose.
3. Administer humidified blow-by oxygen. Do not allowing oxygen to flow directly
into neonate’s face.
4. Don a new and uncontaminated PPE to protect neonate from contamination.
5. Minimize family member and bystander contact with neonate
Level 2-3
Meconium Staining
1. Prepare advanced airway equipment and meconium aspirator for suctioning and
intubation
2. As baby’s head is delivered, suction the mouth, pharynx, and nose (in this order)
3. If neonate is depressed or meconium is thick or particulate, intubate and suction.
a. Intubate with a 3.0 mm ETT and utilize it as a deep tracheal suction device
suctioning during the removal of the ETT. Repeat intubation with a new 3.0 mm
ETT and repeat the suctioning process.
Post Partum Hemorrhage
1. Follow IV Therapy procedure as indicated
5-10
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E.P.A.B.
Emergency Childbirth Complications - Continued
Level 4
Uterine Inversion (Prolapse)
1. Do not attempt to remove placenta.
2. With mother supine, apply pressure with fingertips and palm of a gloved hand and
push fundus upward through cervix. Leave hand in place.
3. If ineffective, cover all protruding parts with moist, sterile dressings and transport
rapidly
4. Pain management protocol as needed.
Level 5
Eclampsia
1. Cardiac monitor is required
2. Left lateral recumbent position or a knee-chest position
3. Magnesium sulfate infusion 2 grams no faster than 1 gram/min.
a. Draw 4 cc of 50% magnesium sulfate in a 30 cc syringe and draw 26 cc of
Normal Saline and slowly infuse over 2 minutes. May repeat once if seizure is
still present.
Level 6
Eclampsia / Severe PIH
1. If SBP >200 or DBP >120, administer hydralazine 10 mg slow IVP.
Level 7
Post Partum Hemorrhage
1. Uterine massage and oxytocin infusion (10 units in 1,000 mL NS) run wide open to
accomplish uterine contraction and control uterine atony.
5-11
E.P.A.B.
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Effective Date:
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Hazardous Materials Exposure (HAZMAT)
Specific Information Needed
This protocol is intended to guide EMS personnel who do not normally function in
hazardous material scenes. All scenes (MVA, industrial, fire, etc.) should be
considered as being potential hazardous situations. Important information to consider
on ALL HAZMAT scenes is the wind direction, (approach upwind, upslope if
possible, or at 90 degrees perpendicular to the wind direction), where the staging
area is located and confirmation that the fire, police, and HAZMAT team have been
notified of the situation.
1.
2.
3.
4.
5.
6.
7.
1.
2.
3.
4.
Specific Physical Findings
The Base Station Physician should be consulted for all complex exposures. In
addition, EMS Communications can contact poison control for additional
information.
Based on the information from the Communication Center of a possible existing
HAZMAT situation, STAGE several blocks away from the scene. Remember: the
reported location may be inaccurate and response into a contaminated area might
occur.
Position the vehicle at a distance and pointed away from the incident. Additionally,
communicate all actions or intended actions to the Communication Center.
If you arrive before the HAZMAT team, keep all others away! This also includes
unnecessary equipment and people away from the scene. If the crew or the unit
becomes contaminated, stage in an isolated area and notify the proper authorities.
Remember: contaminated or exposed personnel may add to the problem and reduce
their effectiveness to help.
Contaminated patients should not be transported by an air ambulance service given
the potential risk to the aircrew and the aircraft safety.
It is important to remember that a toxic exposure poses a significant risk to both
rescuer and patient; therefore, appropriate scene management and decontamination
are critical.
When the Fire Department HAZMAT team is on scene, the HAZMAT EMS
personnel are in charge of patient care until patient has been decontaminated
and care has be released to the transporting paramedic.
Level 1-2-3-4-5-6
Incident Command System (ICS) will be utilized. The On-Scene Incident
Commander (OIC) will be identified to responding agencies.
No definitive treatment will be given in the exclusion or decontamination zone.
Prior to any patient(s) being received or transported, appropriate decontamination will
be performed and the Base Station Physician must accept the patient.
A patient will not become the responsibility of the transporting agency until such time
that the patient has been decontaminated to the mutual satisfaction of the Fire
Department Senior Office (Incident Commander), the Senior Medical person
(MedStar Lead Paramedic), and the Base Station Physician who is receiving the
patient. Transport will not begin until the patient has been accepted by the receiving
facility. In the event that disagreement between the Base Station Physician and the
5-12
E.P.A.B.
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On-Scene Commander should ensue, the EPAB Medical Director will be contacted.
5. The On-Scene Incident Commander will notify the MedStar On-Scene Lead
Paramedic with patient count and suspected product(s) exposure. The MedStar OnScene Lead Paramedic will communicate with the Communications Center for
hospital pre-alert.
6. Decontamination will take priority over patient care.
Once the patient has become decontaminated:
Level 7
1. Specify that this is a HAZMAT situation with the names of products in the exposure,
if known
2. BSP must be notified about and must accept the patient(s) prior to transport
5-13
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5-14
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E.P.A.B.
Hyperthermia
Level 1-2-3-4-5-6
2. Temperature measurement (rectal preferred in critical cases)
3. Cool with wet towels if temp ≥103°F
Heat Exhaustion
1. Give drinking water, if patient
can tolerate
Heat Stroke
1. Place ice packs on groin, neck and axillae
2. Cool with wet towels or by misting/spraying
with water
3. Avoid overcooling – avoid inducing shivering
Level 7
5-14
E.P.A.B.
Page:
5-15
Effective Date:
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Hypotension (Shock)
Level 1-2-3
Level 4-5
1. If hypovolemic shock:
a. Refer to IV Fluid Therapy Procedure.
2. If cardiogenic shock (with no signs of CHF) or low-resistance shock (from
vasodilatation):
a. Refer to IV Fluid Therapy Procedure
b. If patient remains hypotensive after a minimum of 500 cc of fluid, administer
dopamine 10-20 mcg/kg/min infusion to maintain a SBP of ≥90 mmHg
Level 6
1. If SBP of < 70 mmHg, begin levophed infusion at 2-12 mcg/min until SBP ≥ 90
mmHg.
Level 7
5-15
E.P.A.B.
Page:
5-16
Effective Date:
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Nausea and Vomiting
Level 1-2
Level 3-4
1. Ondansetron 4 mg ODT/IV/IM. Avoid the use in patients with a history of
prolonged QT syndrome.
a. The route of this medication may be determined by the paramedic.
Level 5-6
1. May repeat ondansetron 4 mg ODT/IV/IM once after 5 minutes.
2. If the patient is allergic to or has contraindications to ondansetron, administer
promethazine 12.5 mg slow IV, (dilute with 10 mL of NS) may repeat once in 5
minutes if necessary. If patient complains of pain on administration, stop
administration immediately.
Level 7
5-16
E.P.A.B.
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5-17
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Pain Management
Level 1-2-3
2. Document Pain Scale (see below)
3. Utilize basic pain reduction techniques as necessary
Level 4
1. If the SBP is ≥90, the patient is experiencing acute pain:
a. Administer fentanyl 1 mcg/kg slow IV/IN (maximum single dose of 100 mcg)
- OR -
b. Administer morphine sulfate 2-5 mg IV (preferred in burns) may repeat up to
10 mg total dose
2. Continuous monitoring of capnography and pulse oximetry
3. Refer to Sedation Protocol if indicated
DOCUMENT PAIN SCALE BEFORE AND AFTER EACH ADMINISTRATION!
Level 5-6
1. Additional fentanyl 1 mcg/kg slow IV/IN (maximum single dose of 100 mcg) for a
total of 2 mcg/kg.
2. Additional morphine sulfate in 2 mg increments for total of 20 mg.
3. For muscle spasms refer to the Sedation Protocol.
Level 7
5-17
E.P.A.B.
Page:
5-18
Effective Date:
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Psychiatric Emergencies/Patient Restraint
Level 1-2
1. Maintain scene safety. If scene is unsafe, leave and stage for law enforcement.
2. Consider requesting law enforcement assistance
a. Suggest against the utilization of a Taser if acute agitation.
4. If patient is spitting, apply an approved spit hood.
Level 3-4
1. If the patient is violent and a danger to himself/herself or others:
a. Soft, four point physical restraints – utilize properly manufactured soft restraints
on upper and lower extremities
i. Continuous monitoring required for all restrained patients. Vital signs should
be recorded every 3 minutes to identify any subtle changes in patient
condition.
b. Midazolam 5 mg IN/deep IM/slow IVP if needed to protect the patient and/or
crew;
i. If necessary, you may administer IM through the pants on the lateral thigh
Level 5-6
1. Additional midazolam 5 mg IN/deep IM/slow IVP if needed
2. Haloperidol (Haldol) 5 mg IN/IM
3. Benadryl 25 mg IVP/IM for dystonic reactions
Level 7
1. Additional midazolam
Note: The patient may need to be physically restrained until pharmacologic agents take
effect. Restraints should only be a temporary action because it may increase agitation
and risk of injury to themselves or others. DO NOT place patient in prone position at
any time.
5-18
E.P.A.B.
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5-19
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Respiratory Difficulty (excluding CHF)
Level 1
2. Seated upright position is preferable
3. If wheezing:
4. If the patient is still symptomatic, administer an additional albuterol 2.5 mg in 3 mL
nebulized.
Level 2-3
1. If not considered asthma and the patient is in severe respiratory distress, apply CPAP
starting at 15 lpm (refer to CPAP Procedure)
Level 4-5-6
1. Methylprednisolone 125 mg IVP/IM
2. If wheezing continues despite nebulized updrafts with signs of severe respiratory
distress Epinephrine 1:1,000 0.3 mg IM for patients < 50 years old
Level 7
1. Epinephrine 1:1,000 0.3 mg IM for patients ≥ 50 years old or if underlying cardiac
history
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E.P.A.B.
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5-20
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Respiratory Failure (Pharmacological Assisted Intubation)
Level 1
1. Refer to the appropriate protocol to manage the underlying condition and follow all
listed therapy
3. Reassurance and position of comfort, seated or in upright position preferable.
Level 2-3-4
1. Continuous capnography
Level 5-6
1. Assure adequate ventilation and oxygenation with basic airway maneuvers
If basic airway maneuvers have failed (maximal breathing effort with minimal effect),
SBP ≥90, and pulse oximetry <90%:
1. Prepare equipment and ensure the patient is in an appropriate area for PAI Airway
Management.
Succinylcholine Contraindications
2. Consider atropine 1mg if HR is 60 or lower
Hx of sensitivity to drug
Hx of malignant hyperthermia-ever
AND patient is hypotensive.
Risk of hyperkalemia such as in burns
3. Administer etomidate 0.3 mg/kg as the
more than 24 hours old, or more than 7
induction agent.
days post denervation events, crush
injuries, intra-abdominal infections, or
a. If unable to facilitate intubation,
dialysis patients.
administer succinylcholine 2 mg/kg
Degenerative or neuromuscular
unless contraindicated (substitute
disorders such as MS
rocuronium 1 mg/kg if succinylcholine
contraindicated)
4. Intubate with cricoid pressure or BURP and verify placement.
5. Use AIRWAY RULE OF 5. (ETT, Secure, EtCO2, SpO2, C-Collar)
6. If unable to Intubate, insert a back up airway (i.e. King) and verify placement.
7. Ventilate the patient and secure airway with appropriate method.
8. Monitor capnography continuously.
9. If systolic BP is ≥ 90, administer midazolam 2.5 mg IVP. Repeat every 10-20
minutes for continued sedation after intubation if patient’s systolic BP remains ≥ 90.
10. If patient has been successfully intubated and sedated, administer rocuronium 1
mg/kg IVP for paralysis. Once the capnograph identifies a curare cleft, or the patient
begins to resist the ETT, administer additional midazolam 2.5 mg IVP and
rocuronium 1mg/kg IVP for continued paralysis. Remember to keep the paralyzed
patient properly sedated.
11. If stress response is present (SBP is ≥160 AND HR is ≥90) administer morphine 2-5
mg. May repeated every 3 minutes to a total dose of 20 mg.
12. Consider soft restraints.
Level 7
5-20
E.P.A.B.
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Sedation
Level 1-2-3
Level 4-5
1. Consider sedation for
a. Pacing
b. Cardioversion
c. Severe muscle spasm associated with musculoskeletal injury
2. If patient’s systolic BP ≥ 90 mmHg midazolam 2.5 mg IVP. May repeat every 10-20
minutes for continued sedation.
Level 6
1. Mechanically ventilated patients with a SBP ≥ 90 mmHg, consider propofol infusion
at 5 mcg/kg/min. Titrate by 5 mcg/kg/min until adequate sedation is achieved or
SBP <90 mmHg.
Level 7
5-21
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5-22
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E.P.A.B.
Seizures (Prolonged), Status Epilepticus, Eclampsia
Level 1-2
Level 3-4
1. For prolonged seizures, recurrent seizures without lucid period, or the patient is
actively seizing, administer midazolam 0.3 mg/kg IN (maximum dose of 10 mg) or
2.5 mg IVP. May repeat dose in five minutes if patient continues to seize to a
maximum dose of 10 mg.
Level 5-6
Eclampsia
1. Cardiac monitor is required
2. Left lateral recumbent position.
3. Magnesium sulfate infusion 2 grams no faster than 1 gram/min.
a. Draw 4 cc of 50% magnesium sulfate in a 30 cc syringe and draw 26 cc of
Normal Saline and slowly infuse over 2 minutes. May repeat once if seizure is
still present.
Level 7
5-22
E.P.A.B.
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Stroke
Level 1-2-3-4
2. Transport to a designated Stroke receiving facility
1.
2.
1.
2.
3.
Level 5
Complete the EPAB approved Paramedic Stroke Screen
Notify stroke center early of incoming patient, time of last known normal, and
transport promptly
Level 6
If signs of Cushing’s Triad (widening pulse pressure, irregular respirations, and
bradycardia), avoid antihypertensive medications.
If acute neurological deficits and MAP >130 mmHg, consider Labetalol 20 mg IV
over 2 minutes.
With known intracranial hemorrhage and MAP >130 mmHg, begin cardene infusion
at 5 mg/hr. Titrate up by 2.5 mg/hr every 15 minutes until MAP < 130 mmHg or a
maximum of 15 mg/hr. If MAP drops by 25% or more, decrease by 2.5 mg/hr.
Level 7
5-23
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E.P.A.B.
Toxicological Emergencies / Poisoning / Overdoses
Level 1
2. Flush skin / mucous membranes with appropriate solution, if indicated
Level 2
1. For suspected narcotic overdose,
a. Naloxone 0.4 mg titrated up to 2 mg, slow IVP OR naloxone 2 mg IN (1 mg dose
in each nostril) titrated to maintain a normal respiratory rate
Level 3
1. For symptomatic organophosphate overdose, atropine 1-2 mg IVP, repeat every 5
minutes until signs of atropinization occur and SLUDGE signs subside.
Level 4
1. For suspected cocaine or methamphetamine overdoses, administer midazolam 2.5 mg
IVP.
Level 5-6
1. For symptomatic TCA overdose (QRS complex width ≥ 0.12 seconds and
symptomatic), administer sodium bicarbonate 1 mEq/kg IV bolus
2. For symptomatic calcium channel blocker overdose, atropine 1 mg IVP for
symptomatic bradycardia.
Level 7
1. Sodium bicarbonate drip at 0.5 mEg/kg/min for TCA overdoses with a wide QRS
complex
2. Calcium chloride 1 G slow IVP for symptomatic calcium channel blocker overdose,
administer.
3. Glucagon 2 mg IVP for symptomatic beta blocker overdoses.
4. Activated charcoal 50 G PO for all other recently ingested overdoses.
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E.P.A.B.
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5-25
E.P.A.B.
Page:
6-0
Effective Date:
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6 ADULT ADVANCED CARDIAC LIFE SUPPORT
6-0
E.P.A.B.
Page:
6-1
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6-1
E.P.A.B.
Page:
6-2
Effective Date:
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Universal Cardiac Arrest Algorithm
Level 1
1. Refer to Dead On-Scene Termination of Resuscitative Policy if indicated
2. Immediately perform chest compressions at 100 bpm
a. Perform CPR utilizing the Philips QCPR if available
b. Perform all interventions immediately where patient is found and accessible.
Avoid interruptions in chest compressions
3. Attach AED and follow AED procedure
4. ABC - Check adequacy of CPR
5. Properly insert a King LTD(S) Airway Device
a. Place gastric tube through device if time allows
6. Attach ResQPod (if available)
7. Apply Capnography (if available)
8. Oxygen and assist ventilations at 1 breath every 15 seconds
9. Notify additional responding units of CPR in progress
Level 2
1. Intravenous access procedure
Level 3-4-5-6
1. If unable to establish an IV, perform IO (if available)
2. For suspected arrest following acute agitation administer sodium bicarbonate 1
mEq/kg IV
3. For suspected hyperkalemia administer calcium chloride 1 G IV and sodium
bicarbonate 1 mEq/kg IV at earliest opportunity during ACLS, preferably before
other ACLS medications. Be sure to thoroughly flush the IV tubing between drugs to
avoid precipitation.
Level 7
4. For suspected acidosis administer sodium bicarbonate 1 mEq/kg IV
NOTE: Cardiopulmonary efforts should be attempted on-scene as chest compressions
have been shown to be ineffective during transport in an ambulance.
6-2
E.P.A.B.
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Asystole
Level 1-2
1. Universal Cardiac Arrest Protocol
Level 3-4-5-6
1. Epinephrine 1:10,000 1 mg IV/IO, repeat every 5 minutes
2. Atropine 1 mg IV/IO repeated every 5 minutes to a maximum dose of 3 mg
Level 7
6-3
E.P.A.B.
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Bradycardia
Level 1-2
Level 3-4
1. If patient is symptomatic, consider atropine 0.5 mg IVP every 5 minutes repeat to a
maximum of 3 mg
2. If the patient is unstable, immediately perform transcutaneous pacing, if available,
to achieve capture rate of ≥ 70. Refer to Electrical Therapy Procedure.
3. Refer to Sedation Protocol
Level 5-6
1. If rate increases and hypotension remains, dopamine 10-20 mcg/kg/min infusion
maintain SBP ≥ 90 mmHg
Level 7
1. Epinephrine infusion 2-5 mcg/min. Add epinephrine 0.5 mg to 250 mL and run at
60 cc/hr on pump. Achieves 2 mcg/min.
6-4
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E.P.A.B.
Pulseless Electrical Activity (PEA)
Level 1-2
Level 3-4-5-6
1. Search for other possible causes of PEA (see chart below)
2. Epinephrine 1:10,000 - 1 mg IV/IO, repeat every 5 minutes
3. If PEA rate is < 60, atropine 1 mg IVP/IO or repeated every 5 minutes to a
maximum dose of 3 mg
Level 7
Reasons for PEA
6 H’s
Hypoxia
Hydrogen Ion (Acidosis)
Hypovolemia
Hypothermia
Hypokalemia
Hypoglycemia
6 T’s
Tablets (Overdose)
Tamponade
Tension Pneumothorax
Thrombus (AMI)
Thrombus (PE)
Trauma
6-5
E.P.A.B.
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Pulseless Ventricular Tachycardia / Ventricular Fibrillation
Level 1-2
Level 3-4
1. Defibrillation at 150 J biphasic* or 360 J monophasic every 5 minutes
a. Perform chest compressions immediately after defibrillation for 2 minutes before
reassessing patient
2. Persistent pulseless VT or VF:
a. Epinephrine 1:10,000 1 mg IV/IO every 5 minutes
b. Administer lidocaine 1.5 mg/kg IV/IO. May repeat once in 5 minutes
c. For Torsades De Pointes administer magnesium sulfate 2 G slow IV/IO over 2
minutes
Level 5-6
Persistent VF/Monomorphic VT:
1. Administer procainamide 20 mg/min IV infusion to a maximum of 1 G or until the
QRS widens by 50%.
Level 7
Note: Energy settings may vary according to device manufacturer
6-6
E.P.A.B.
Page:
6-7
Effective Date:
Replaces:
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All Previous
Tachycardia – Stable
Level 1-2-3
1.
Level 4
1. If the HR is greater than 220 minus the patient’s age with complaints of chest pain,
dyspnea, or SBP < 90 mmHg without a significant decrease in LOC
a. For narrow complex tachycardia, administer adenosine 12 mg RAPID IVP
followed by 10 cc NS flush (may repeat in 2 minutes).
b. For suspected cocaine or methamphetamine SVT, administer midazolam 2.5 mg
IVP.
c. For wide complex tachycardias administer lidocaine 1.5 mg/kg IV/IO. May
repeat once in 5 minutes.
Level 5
1. For atrial fibrillation/atrial flutter administer diltiazem 0.25 mg/kg slow IVP
maximum single dose of 25 mg.
1.
Level 6
If diltiazem bolus administered, start diltiazem infusion at 5 mg/hr IV.
Level 7
1. Consider cardioversion
Note: Consult BSP before administering adenosine if a patient is taking an adenosine
uptake inhibitor (persantine) or has drug induced SVT, VTach, sick sinus syndrome, and
WPW.
6-7
E.P.A.B.
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6-8
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Tachycardia – Unstable
Level 1-2-3
Level 4-5-6
1. If the HR is greater than 220 minus the patient’s age with a significant change in LOC
and signs of inadequate perfusion
a. If time allows consider sedation refer to Sedation Protocol
b. Perform synchronized cardioversion refer to Electrical Therapy Procedure
Level 7
6-8
E.P.A.B.
Page:
6-9
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Post-Resuscitation Care
Level 1-2
Level 3-4
1. For return of circulation after defibrillation and in the absence of anti-arrhythmic
administration and ectopy continues consider lidocaine 1.5 mg/kg IVP/IO.
2. Following lidocaine administration, initiate lidocaine infusion of 2-4 mg/min
Level 5
1. For return of circulation following procainamide administration, initiate
procainamide infusion – 1 G mixed in 250 mL NS run at 1-4 mg/min
2. For persistent hypotension following sustained return of circulation, dopamine 10-20
mcg/kg/min infusion to maintain a SBP of ≥ 90 mmHg
Level 6
1. Initiate hypothermia protocol
Level 7
1. Epinephrine infusion 2-5 mcg/min. Add epinephrine 0.5 mg to 250 mL and run at
60 cc/hr on pump. Achieves 2 mcg/min.
6-9
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6-10
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E.P.A.B.
Therapeutic Hypothermia
Level 6
Purpose: Therapeutic Hypothermia (TH) has neuro-protective effects following return of
circulation for patients who have suffered cardiac arrest. The goal is decrease the time to
target temperature by initiating protocol in the out of hospital environment.
Procedure: TH involves the administration of cold intravenous fluids and applying cold
packs to superficial vascular areas of the body with the goal of lowering the body
temperature to 34 degrees centigrade.
Inclusion Criteria:
1. Non-traumatic cardiac arrest with return of circulation.
2. Age >15 years of age.
3. Advanced airway in place with no purposeful movements to pain.
4. ETCO2 >20 mmHg
5. TH must not delay transport to receiving facility.
Exclusion Criteria:
1. Purposeful movements following return of circulation
2. Age < 15 years of age
Procedure:
1. Secure advanced airway and ensure ETCO2 >20 mmHg
2. Administer 30mL/kg of cold normal saline IV, maximum amount 2 Liters.
3. Expose patient and apply ice packs to groin and axilla.
4. Continue physiologic monitoring to ensure ETCO2 remains within therapeutic
range.
5. If patient begins to shiver, administer Etomidate 20 mg IVP.
6. If shivering continues, administer Rocuronium 1 mg/kg IVP.
7. Transport to a TH receiving facility.
6-10
E.P.A.B.
7 ADULT TRAUMA EMERGENCIES
7-0
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7-0
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E.P.A.B.
Page:
7-1
Effective Date:
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7-1
E.P.A.B.
Page:
7-2
Effective Date:
Replaces:
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All Previous
Amputation
Level 1-2-3-4-5-6
1. Universal Trauma Patient Care
2. Use a tourniquet if unable to control bleeding with basic maneuvers
3. Do not delay transport of the patient for prolonged extrication of body part(s) or
tissue.
4. Consider air transportation ONLY for life-threatening amputations.
Care of the Amputated Body Part(s) and Tissue
1. Wrap body part or tissue in sterile gauze moistened with NS
2. Place part into a plastic bag or container
3. Place bag or container into another bag or container filled with ice water
4. Amputated part(s) or tissues should be transported (if retrievable) with the patient
Level 7
1. Call a Trauma Facility for consultation. If referred for reimplantation, request a phone
patch to BioTel for hospital assignment.
7-2
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E.P.A.B.
Burns
Level 1
Universal Trauma Patient Care
Remove patients from exposure (by trained, equipped rescuers)
Stop the burning process
Calculate surface area of burn and depth
Determine burn classification for transport destination
a. Major burns are to be transported to Parkland
7. Assess for injuries that may be a higher priority
8. If chemical burn, refer to the Hazardous Materials Protocol
9. Remove constrictive clothing and jewelry
10. Apply sterile dressings and splints as indicated
1.
2.
3.
4.
5.
6.
Level 2-3-4-5-6
1. Parkland Burn Formula (Kg x BSA / 4 = total amount to be infused in 60 minutes)
2. Record infused volume
Level 7
Nomenclature
Traditional
nomenclature
Depth
Clinical findings
Superficial thickness First-degree
Epidermis involvement
Erythema, minor pain, lack of
blisters
Partial thickness —
superficial
Second-degree
Superficial (papillary) dermis
Blisters, clear fluid, and pain
deep
Second-degree
Deep (reticular) dermis
Whiter appearance
Full thickness
Third- or Fourthdegree
Dermis and underlying tissue and
possibly fascia, bone, or muscle
Hard, leather-like eschar, purple
fluid, no sensation (insensate)
Major Burn Criteria
Partial thickness burns greater than 10% BSA
Burns that involve the face, hands, feet, genetalia, perineum, and major joints
Full thickness burns in any age group
Electrical burns, including lightning injury
Chemical burns
Inhalation injury
Burn injury in patients with preexisting medical disorders that may complicated
management, prolong recovery, or affect mortality
8. Any patients with burns and concomitatnt trauma (such as fractures) in which the
burn injury poses the greatest risk of morbidity or mortality. In such cases, if the
trauma poses the greater immediate risk, the patient’s condition may be stabilized
initially in a trauma center before transfer to a burn center. Physician judgment will
be necessary in such situations.
1.
2.
3.
4.
5.
6.
7.
7-3
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7-4
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E.P.A.B.
Crush Injuries (thorax, abdominopelvic, extremity)
Level 1-2-3-4-5-6
1. Universal Trauma Patient Care
Level 7
1. For continued entrapment and prior to extrication consider sodium bicarbonate 1
mEq/kg slow IVP and calcium chloride 1 G slow IVP. Be sure to thoroughly flush
the IV tubing between drugs to avoid precipitation.
7-4
E.P.A.B.
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7-5
E.P.A.B.
8
Page:
8-0
Effective Date:
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All Previous
PEDIATRIC MEDICAL EMERGENCIES
All Pediatric Protocols; the dose of any medication should NEVER exceed
the normal adult dose.
IV attempts should be limited to two (2) with the pediatric patient. If
additional attempts are required because the patient is experiencing a life
threatening illness/injury, consider an IO.
Level 2 and above are required to utilize a Broselow Tape.
8-0
E.P.A.B.
Page:
8-1
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8-1
E.P.A.B.
Page:
8-2
Effective Date:
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Pediatric Allergic Reaction / Anaphylaxis
Level 1-2
2. If stinger is present, scrape to remove. DO NOT utilize tweezers or hemostats.
3. Epinephrine auto-injector (For 15-29 kg patients use EpiPen Jr. For ≥ 30 kg
patients use EpiPen), if available and exhibiting acute signs of anaphylaxis (urticaria,
dyspnea, wheezing, or stridor).
a. Levels 3-6 may utilize Epi 1:1000 as stated below
4. Remove constricting jewelry
5. If wheezing:
a. If < 10 kg, ipratropium bromide 250 mcg (0.02%) in 1.5 mL saline mixed
with albuterol 1.25 mg in 1.5 mL NS nebulized, may repeat once.
b. If ≥ 10 kg, ipratropium bromide 500 mcg (0.02%) in 3 mL saline mixed with
albuterol 2.5 mg in 3 mL NS nebulized, may repeat once.
i. If patient is still wheezing, may administer one additional albuterol updraft
without the ipratropium bromide (same dose as above)
Localized Reaction
1.Diphenhydramine
2mg/kg IVP/IM
(maximum 50 mg)
Level 3-4-5-6
Localized with SOB
1. Diphenhydramine
2mg/kg IVP/IM
(maximum 50 mg
total)
2. Methylprednisolone
1 mg/kg IVP/IM
1.
2.
3.
4.
5.
Level 7
1. Epinephrine infusion 0.05 mcg/kg/min
8-2
Anaphylaxis /
SBP <70+2 x age in years
Epinephrine 1:1000 0.01
mg/kg IM maximum single
dose is 0.3 mg
If no IV and patient is
hypotensive, establish IO access
Follow IV Fluid
Administration Procedure
Diphenhydramine 2mg/kg
IVP/IM (maximum 50 mg
total)
Methylprednisolone 1 mg/kg
IVP/IM
Page:
8-3
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E.P.A.B.
Pediatric Carbon Monoxide / Smoke Inhalation
Level 1-2-3-4-5-6
1. Universal Care Protocol
2. CO monitoring (if available)
3. Continuous high flow oxygen by NRB at 15 lpm or ventilate with a BVM as needed
Level 7
8-3
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8-4
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E.P.A.B.
Pediatric Chemical Warfare Exposure (Auto-injectors)
1.
2.
3.
Level 1-2
Assure scene safety (Refer to the “Hazardous Materials” protocol if indicated)
Refer to the Chemical Warfare Exposure Procedure for patient and self administration.
Level 3-4-5-6
1. For symptomatic chemical exposure (Sarin, Suman, Tabun, and VX) and/or
Organophosphates, administer the appropriate number of initial ATROPEN auto
injector/s (as indicated in the chart below) and repeat every 5 minutes until signs of
atropinization occur and SLUDGE signs subside.
ATROPEN DOSING:
1. Children weighing between 18-40 kg should receive the ATROPEN 1.0mg dose
2. Children weighing less than 18 kg should receive the ATROPEN 0.5mg dose
Type of Exposure
VAPOR-MILD
1.
2.
DERMAL-MILD
1.
VAPOR-MODERATE
1.
DERMALMODERATE
1.
VAPOR-SEVERE
1.
DERMAL-SEVERE
1.
2.
3.
Signs & Symptoms
Miosis Only
Miosis, rhinorrhea, slight dyspnea,
secretions
Increased sweating at the site or
increased fasciculations
Same as mild, plus marked dyspnea
and secretions
Same as for mild exposure, plus:
vomiting, diarrhea, and/or
generalized weakness.
flaccid paralysis, and/or apnea
copious secretions.
flaccid paralysis, and/or apnea,
copious secretions.
# MARK I
NONE
1 ATROPEN
# CANA
NONE
NONE
1 ATROPEN
NONE
1-2 ATROPEN
NONE
2-3 ATROPEN
NONE
3 ATROPEN
1. ≥14 years old
1 CANA
(Valium 10mg)
2. <14 years old
Valium
0.2mg/kg IM/IV
1. ≥14 years old
1 CANA
(Valium 10mg)
2. <14 years old
Valium
0.2mg/kg IM/IV
3 ATROPEN
For associated seizures, administer the Diazepam auto injector (10 mg deep IM),
may repeat every 5 minutes until cessation of the seizure
Rapid transport to the closest hospital
Level 7
NOTE: In a mass casualty incident declared by the Incident Commander, auto injectors
may be administered standing order by ALL trained levels of care by following the above
protocol.
8-4
E.P.A.B.
Page:
8-5
Effective Date:
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Pediatric Chest Pain
Level 1-2-3
2. If wheezing:
3. If patient is still wheezing, may administer one additional albuterol updraft without
the ipratropium bromide (same dose as above)
Level 4-5-6
1. If known sickle cell patient, morphine sulfate 0.1 mg/kg slow IVP (maximum
single dose 5 mg) may repeat up to total dose of 10 mg.
Level 7
8-5
E.P.A.B.
Page:
8-6
Effective Date:
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All Previous
Pediatric Choking / Airway Obstruction
Level 1
2. Follow current AHA recommendations for foreign body airway obstruction
Level 2-3-4-5-6
1. If basic interventions fail, use laryngoscope and Magill forceps to visualize and
remove obstruction.
2. After removal of obstruction, provide airway management and circulatory support as
indicated
Level 7
8-6
E.P.A.B.
Page:
8-7
Effective Date:
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All Previous
Pediatric Diabetic / Glucose Emergencies
Level 1
Glucometer <40 mg/dl & Symptomatic
Hypoglycemia
1. If patient is conscious with gag reflex,
glucose paste (1/2 to 1 tube = 7.5-15 G)
Glucometer ≥300 mg/dl &
Symptomatic
Hyperglycemia
1. Continue to monitor vital signs and
provide reassurance
Level 2
If IV established in an unconscious patient:
1. Refer to IV Fluid Therapy Procedure.
1. Dextrose 25% 0.5 g/kg slow IVP repeat
once after 5 minutes if blood glucose <
40 mg/dL
a. Expel 25cc of the 50 cc’s in the
dextrose 50% prefilled syringe.
b. Draw up 25cc’s of NS into the
dextrose 50% prefilled syringe having
a grand total of 50cc’s.
Level 3-4-5-6
Glucometer <40 mg/dl & Symptomatic
Glucometer ≥300 mg/dl &
Symptomatic
Hyperglycemia
2. Refer to IV Fluid Therapy Procedure.
Hypoglycemia
1. If no IV, Glucagon 0.1 mg/kg IM
Level 7
8-7
E.P.A.B.
Page:
8-8
Effective Date:
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All Previous
Pediatric Hazardous Materials Exposure (HAZMAT)
Specific Information Needed
This protocol is intended to guide EMS personnel who do not normally function in
hazardous material scenes. All scenes (MVA, industrial, fire, etc.) should be
considered as being potential hazardous situations. Important information to consider
on ALL HAZMAT scenes is the wind direction, (approach upwind, upgrade if
possible, or at 90 degrees perpendicular to the wind direction), where the staging
area is located and confirmation that the fire, police, and HAZMAT team have been
notified of the situation.
1.
2.
3.
4.
5.
6.
7.
Specific Physical Findings
The Base Station Physician should be consulted for all complex exposures. In
addition, EMS Communications can contact poison control for additional
information.
Based on the information from the Communication Center of a possible existing
HAZMAT situation, STAGE several blocks away from the scene. Remember: the
reported location may be inaccurate and response into a contaminated area might
occur.
Position the vehicle at a distance and pointed away from the incident. Additionally,
communicate all actions or intended actions to the Communication Center.
If you arrive before the HAZMAT team, keep all others away! This also includes
unindicated equipment and people away from the scene. If the crew or the unit
becomes contaminated, stage in an isolated area and notify the proper authorities.
Remember: contaminated or exposed personnel may add to the problem and reduce
their effectiveness to help.
Contaminated patients should not be transported by an air ambulance service given
the potential risk to the aircrew and the aircraft safety.
It is important to remember that a toxic exposure poses a significant risk to both
rescuer and patient; therefore, appropriate scene management and decontamination
are critical.
When the Fire Department HAZMAT team is on scene, the HAZMAT EMS
personnel is in charge of patient care until patient has been decontaminated and
care has be released to the transporting paramedic.
Level 1-2-3-4-5-6
1. Incident Command System (ICS) will be utilized. The On-Scene Incident
Commander (OIC) will be identified to responding agencies.
2. No definitive treatment will be given in the exclusion or decontamination zone.
3. Prior to any patient(s) being received or transported, appropriate decontamination
will be performed and the Base Station Physician must accept the patient.
4. A patient will not become the responsibility of the transporting agency until such time
that the patient has been decontaminated to the mutual satisfaction of the Fire
Department Senior Office (Incident Commander), the Senior Medical person
(MedStar Lead Paramedic), and the Base Station Physician who is receiving the
patient. Transport will not begin until the patient has been accepted by the receiving
facility. In the event that disagreement between the Base Station Physician and the
On-Scene Commander should ensue, the EPAB Medical Director will be contacted.
8-8
E.P.A.B.
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5. The On-Scene Incident Commander will notify the MedStar On-Scene Lead
Paramedic with patient count and suspected product(s) exposure. The MedStar OnScene Lead Paramedic will communicate with the Communications Center for
hospital pre-alert.
6. Decontamination will take priority over patient care.
Once the patient has become decontaminated:
Level 7
1. Specify that this is a HAZMAT situation with the names of products in the exposure,
if known
2. BSP must be notified about and must accept the patient(s) prior to transport
8-9
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8-10
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E.P.A.B.
Pediatric Hyperthermia
Level 1-2-3-4-5-6
3. Temperature measurement (rectal preferred in critical cases)
4. Cool with wet towels if temp ≥103°F
Heat Exhaustion
1. Give drinking water, if patient
can tolerate
Heat Stroke
1. Place ice packs on groin, neck and axillae
2. Cool with wet towels or by misting/spraying
with water
3. Avoid overcooling – avoid shivering
Level 7
8-10
E.P.A.B.
Pediatric Hypotension
Level 1
Level 2-3-4-5-6
1. Refer to IV Therapy Procedure
Level 7
1. Epinephrine 0.05 mcg/kg/min
2. Dopamine 10-20 mcg/kg/min
8-11
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8-11
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E.P.A.B.
Page:
8-12
Effective Date:
Replaces:
February 25, 2010
All Previous
Pediatric Nausea and Vomiting
Level 1-2-3-4-5-6
Level 7
1. For pediatric patients 2 years of age or older: Ondansetron 0.15 mg/kg (minimum
single dose of 2 mg) ODT/IV/IM to a max dose of 4 mg.
a. Each halved tablet will be considered 2 mg of ondansetron.
8-12
E.P.A.B.
Page:
8-13
Effective Date:
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Pediatric Pain Management
Level 1-2-3-4
2. Document Pain Scale (see below)
3. Utilize basic pain reduction techniques as necessary
Level 5-6
1. Continuous monitoring of capnography and pulse oximetry
2. Refer to Sedation Protocol if indicated
3. Fentanyl 1 mcg/kg IVP/IN (maximum single dose of 100 mcg)
- OR -
4. Morphine sulfate 0.1 mg/kg per dose slow IVP (maximum single dose 5 mg) may
repeat up to total dose of 10 mg.
DOCUMENT PAIN SCALE BEFORE AND AFTER EACH ADMINISTRATION!
Level 7
8-13
Page:
8-14
Effective Date:
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E.P.A.B.
Pediatric Psychiatric Emergencies
Level 1-2-3-4-5-6
1. Maintain scene safety. If scene is unsafe, leave and stage for law enforcement
2. Consider requesting law enforcement assistance
Level 7
1. Midazolam 0.1 mg/kg slow IVP/IM/IN to a max of 2.5 mg
8-14
E.P.A.B.
Page:
8-15
Effective Date:
Replaces:
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All Previous
Pediatric Respiratory Difficulty
Level 1-2-3
2. Reassurance and position of comfort, seated or in upright position is preferable
3. If wheezing:
4. If patient is still wheezing, may administer one additional albuterol updraft without
the ipratropium bromide (same dose as above)
Level 4-5-6
1. Methylprednisolone 1 mg/kg IVP/IM.
2. If not improving with nebulized treatments (capnography and pulse oximetry values)
a. Epinephrine 1:1000 0.01 mg/kg to a maximum of 0.3 mg IM (without
underlying myocardial event)
Level 7
8-15
E.P.A.B.
Page:
8-16
Effective Date:
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All Previous
Pediatric Sedation
Level 1-2-3-4-5-6
Level 7
1. Midazolam 0.1 mg/kg slow IVP/IM/IN to a max single dose of 2.5 mg
8-16
E.P.A.B.
Page:
8-17
Effective Date:
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All Previous
Pediatric Seizure
1.
2.
3.
4.
5.
6.
Level 1-2
Remove excess clothing in the hyperthermic patient
Temperature measurement
Appropriate cooling measures
Provide protection
Measure blood glucose level as indicated
Level 3-4-5-6
1. If the patient is actively seizing and it has lasted ≥5minutes or if status epilepticus,
administer midazolam 0.3 mg/kg IN or midazolam 0.1 mg/kg slow IVP/IM/IO to
a maximum single dose of 2.5 mg.
2. If the patient seizes again, or may repeat once.
Level 7
1. Midazolam 0.1 mg/kg slow IVP/IO/IM/IN to a max of 2.5 mg
8-17
E.P.A.B.
Page:
8-18
Effective Date:
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February 25, 2010
All Previous
Pediatric Toxicologic Emergencies / Poisoning / Overdoses
Level 1
1. Assure scene safety (Refer to the Hazardous Materials Procedure if indicated)
3. Flush skin / mucous membranes with appropriate solution, if indicated
Level 2
1. For suspected narcotic overdose, naloxone 0.1 mg/kg , slow IVP/IN titrated to maintain
a normal respiratory rate
Level 3-4-5-6
1. For symptomatic organophosphate overdose, atropine 1-2 mg IVP, repeat every 5
minutes until signs of atropinization occur and SLUDGE signs subside.
Level 7
1. Pediatric 4.2% sodium bicarbonate 1mEq/kg IV for symptomatic TCA overdose
2. Calcium chloride 2 mg/kg slow IVP for symptomatic calcium channel blocker
overdose
3. For suspected cocaine or methamphetamine overdose administer midazolam 0.3 mg/kg
IN or midazolam 0.1 mg/kg slow IV/IM maximum single dose of 2.5 mg.
8-18
E.P.A.B.
Page:
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Effective Date:
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8-19
E.P.A.B.
Page:
9-0
Effective Date:
Replaces:
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9 PEDIATRIC ADVANCED CARDIAC LIFE SUPPORT
IV attempts should be limited to two (2) with the pediatric patient. If
Level 2 and above are required to utilize a Broselow Tape
9-0
E.P.A.B.
Page:
9-1
Effective Date:
Replaces:
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9-1
Page:
9-2
Effective Date:
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E.P.A.B.
Pediatric Universal Cardiac Arrest Algorithm
1.
2.
3.
4.
5.
6.
7.
Level 1
Immediately perform chest compressions above 100 bpm
a. Perform all interventions immediately where patient is found and accessible.
Avoid interruptions in chest compressions.
Attach and follow AED and follow AED procedures
ABC - Check adequacy of CPR
Oxygen and assist ventilations
Apply capnography (if available)
Notify additional responding units of CPR in progress
History and physical, vital signs, secondary assessment
Level 2
1.
2.
3.
4.
5.
Airway management as indicated
Intravenous access (2 attempts only)
IV Fluid Therapy Procedure
Determine actual or Broselow weight
Measure blood glucose as indicated without delaying resuscitative measures
Level 3
1. If unable to establish an IV, perform IO (if available)
2. Cardiac monitor
Level 4-5-6
1. Place gastric tube after intubation if time allows
Level 7
1. Further therapy orders
NOTE: Cardiopulmonary efforts should be attempted on-scene as chest compressions
have been shown to be ineffective during transport in an ambulance.
9-2
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9-3
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E.P.A.B.
Pediatric Asystole
Level 1-2
1. Pediatric Universal Cardiac Arrest Protocol
Level 3-4-5-6
1. Epinephrine 0.01 mg/kg 1:10,000 IV/IO every 5 minutes
Level 7
2. Pediatric 4.2% sodium bicarbonate 1 mEq/kg IV bolus
9-3
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9-4
Effective Date:
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E.P.A.B.
Pediatric Symptomatic Bradycardia
Level 1-2-3
2. Chest compressions, if the patient is not perfusing well and:
a. Heart rate < 80 in < 2 years of age, or
b. Heart rate < 60 in ≥ 2 years of age
Level 4-5-6
1. Epinephrine 0.01 mg/kg 1:10,000 IV/IO, may repeat once in 5 minutes if needed.
2. Atropine 0.02 mg/kg IV/IO maximum single dose of 1 mg. Minimum single dose
is 0.1 mg may repeat once in 5 minutes
BSP Orders
9-4
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9-5
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E.P.A.B.
Pediatric Pulseless Electrical Activity
Level 1-2
Level 3-4-5-6
1. Epinephrine 0.01 mg/kg 1:10,000 IV/IO, repeat every 5 minutes
Level 7
2. Pediatric (4.2%) sodium bicarbonate 1 mEq/kg IV/IO bolus.
Reasons for PEA
6 H’s
Hypoxia
Hydrogen Ion (Acidosis)
Hypovolemia
Hypothermia
Hypokalemia
Hypoglycemia
6 T’s
Tablets (Overdose)
Tamponade
Tension Pneumothorax
Thrombus (AMI)
Thrombus (PE)
Trauma
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Pediatric Tachycardia - Stable
Level 1
Level 2-3-4
1. If heart rate ≥ 220 minus the patient’s age bpm refer to the IV Fluid Therapy
Procedure
2.
Level 5-6
If the HR is ≥ 220 minus the patient’s age without a significant decrease in LOC
a. If narrow complex tachycardia then administer adenosine 0.1 mg/kg RAPID
IVP followed by 10 cc NS flush
b. For suspected cocaine or methamphetamine SVT, administer midazolam 0.1
mg/kg IVP with a maximum single dose of 2.5 mg.
Level 7
1. Adenosine 0.2 mg/kg rapid IVP (if first patient is awake and does not respond to
first dose)
2. Synchronized cardioversion at 0.5 J/kg doses should be doubled until a maximum
of 4 J/kg has been reached or the rhythm has converted
Note: Consult with BSP before administering adenosine if a patient has drug induced
SVT, VTach, sick sinus syndrome, or WPW.
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Pediatric Tachycardia – Unstable
Level 1-2-3
Level 4-5-6
1. If the HR is ≥ 220 minus the patient’s age with a significant decrease in LOC and
signs of inadequate perfusion
a. Consider Pediatric Sedation Protocol
b. Synchronized cardioversion at 0.5 J/kg doses should be doubled until a
maximum of 4 J/kg has been reached or the rhythm has converted
Level 7
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Pediatric Ventricular Fibrillation / Pulseless Ventricular Tachycardia
Level 1-2
1.
2.
3.
4.
5.
Level 3-4-5-6
For witnessed arrests immediately defibrillate 2 J/kg
For unwitnessed arrests or unsuccessful defibrillation, perform a minimum of 1
minute of chest compressions prior to any medications or electrical therapy.
1:10,000 epinephrine 0.01 mg/kg IV/IO, repeat every 5 minutes
Defibrillate 4 J/kg between drug administrations
Lidocaine 1 mg/kg IV/IO repeat once at 5 minutes to a maximum of 2 mg/kg
BSP Orders
1. Pediatric (4.2%) sodium bicarbonate 1mEq/kg IV
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Pediatric Post Resuscitation
Level 1-2-3
Level 4-5-6
1. For successful conversion with return of circulation after defibrillation and in the
absence of anti-arrhythmic administration and ectopy continues, consider lidocaine 1
mg/kg IV/IO
BSP Orders
1. Following lidocaine administration, lidocaine drip (120 mg mixed in 100 mL NS) at
20-50 mcg/kg/min
2. Persistent Hypotension After Fluid therapy:
a. Epinephrine infusion 0.05 mcg/kg/mi
b. Dopamine infusion 10-20 mcg/kg/min
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10 PEDIATRIC TRAUMA
IV Attempts should be limited to two (2) with the pediatric patient. If
Level 2 and above are required to utilize a Broselow Tape.
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Pediatric Amputation
Level 1-2-3-4-5-6
2. Assess for associated injuries that may be of a higher priority
3. Do not delay transport of the patient for prolonged extrication of body part(s) or
tissue.
4. Consider air transportation ONLY for life-threatening amputations.
Care of the Amputated Body Part(s) and Tissue
1. Wrap body part or tissue in sterile gauze moistened with NS
2. Place part into a plastic bag or container
3. Place bag or container into another bag or container filled with ice water
4. Amputated part(s) or tissues should be transported (if retrievable) with the patient
Level 7
1. Call Cook Childrens Medical Center for consultation. If referred for reimplantation,
transport to Dallas Childrens.
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E.P.A.B.
Pediatric Burns
Level 1
Remove patients from exposure (by trained, equipped rescuers)
Stop the burning process
Calculate surface area of burn and depth
Determine burn classification for transport destination
a. Major burns to be transported to Parkland
6. Assess for injuries that may be a higher priority
7. If chemical burn, refer to the Hazardous Materials Protocol
8. Remove constrictive clothing and jewelry
9. Apply sterile dressings and splints as indicated
1.
2.
3.
4.
5.
Level 2-3-4-5-6
1. IV Fluid Therapy Procedure
2. Record infused volume
Level 7
1. Consult BSP for patients that have questionable burns
Nomenclature
Traditional
nomenclature
Depth
Clinical findings
Superficial thickness
First-degree
Epidermis involvement
Erythema, minor pain, lack of blisters
superficial
Second-degree
Superficial (papillary) dermis
Blisters, clear fluid, and pain
deep
Second-degree
Deep (reticular) dermis
Whiter appearance
Full thickness
Third- or Fourthdegree
Dermis and underlying tissue and possibly Hard, leather-like eschar, purple fluid, no
fascia, bone, or muscle
sensation (insensate)
Major Burn Criteria
Partial thickness burns greater than 10% BSA
Burns that involve the face, hands, feet, genetalia, perineum, and major joints
Full thickness burns in any age group
Electrical burns, including lightning injury
Chemical burns
Inhalation injury
Burn injury in patients with preexisting medical disorders that may complicated management,
prolong recovery, or affect mortality
16. Any patients with burns and concomitatnt trauma (such as fractures) in which the burn injury
poses the greatest risk of morbidity or mortality. In such cases, if the trauma poses the
greater immediate risk, the patient’s condition may be stabilized initially in a trauma center
before transfer to a burn center. Physician judgment will be necessary in such situations.
9.
10.
11.
12.
13.
14.
15.
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Pediatric Crush Injuries (thorax, abdominopelvic)
Level 1-2-3-4-5-6
2. Assess for associated injuries that may be of a higher priority
Level 7
1. For continued entrapment and prior to extrication consider sodium bicarbonate 1
mEq/kg IV to a maximum of 50 mEq. Be sure to thoroughly flush the IV tubing
between drugs to avoid precipitation.
2. Calcium chloride 2-4 mg/kg slow IVP
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10-5
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11 MEDICAL PROCEDURES
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Airway Management
Level 1
OROPHARYNGEAL AIRWAY
1. Clear the airway of vomitus, blood, or other secretions
2. Measure from the corner of mouth to tip of earlobe to determine appropriate size
3. Open the patient’s mouth using a cross-finger technique
4. If indicated, push the tongue out of the way using a tongue blade
5. Insert the oropharyngeal airway with its tip pointed up or to the side following the normal
curvature of the oral cavity
6. Rotate the airway so its tip points downward into the oropharynx
7. Confirm proper airway placement
NASOPHARYNGEAL AIRWAY
1. Select the correct nasal airway size (the tube length should extend between the patient’s nose
and the fleshy area surrounding the ear (Tragus))
2. Lubricate the airway and insert the device with the beveled tip rotated toward the nasal
septum. The airway should gently follow the natural curvature of the nasal passage.
3. If resistance is encountered, rotate the tubing slightly or insert in the other nare.
4. Confirm proper airway placement
BAG-VALVE-MASK (BVM) VENTILATION
1. Select the correct size mask and bag, attach oxygen and set at 15-25 LPM.
2. Open that patient’s airway
3. If the patient is unresponsive insert an oropharyngeal or a nasopharyngeal airway.
4. Place the mask onto the patient’s face, ensuring a good seal.
5. In the perfusing patient, begin ventilations as soon as possible at a rate of:
a. Adults and children – 1 ventilation every 5 seconds
b. Infants – 1 ventilation every 3 seconds
c. Premature neonate – 1 puff every 2 seconds
6. In the non-perfusing patient (full cardiopulmonary arrest), ventilate at a rate of:
a. Adults – 1 ventilation every 15 seconds
b. Children and infants – 1 ventilation every 5 seconds
c. Premature neonate – 1 puff every 2 seconds
7. Recheck the oxygen level of the source periodically.
8. Ventilatory Rates:
a. Respiratory Arrest- titrate your ventilatory rate to keep the EtCO2 level between 35-45
mmHg.
KING AIRWAY LTD-S
Indications:
1. In adult patients suffering from full cardiopulmonary arrest
2. It is intended for airway management in patients over 4 feet in height (122 cm)
3. Alternative advanced airway in adult patients
Contraindications:
1. Responsive patients with an intact gag reflex
2. Patients with known esophageal disease
3. Patients who have ingested caustic substances
Warnings:
1. High airway pressures may divert gas either to the stomach or to the atmosphere.
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2. Intubation of the trachea cannot be ruled out as a potential complication of the
insertion of the King LTD-S. After placement, perform standard checks for breath
sounds and utilize an appropriate carbon dioxide monitor as required by the
Protocols.
3. Lubricate only the posterior surface of the King LTD-S to avoid blockage of the
aperture or aspiration of the lubricant.
Cautions:
1. The King LTD-S is not intended for re-use.
Procedure:
1. Preoxygenate the patient, if possible
2. Utilize the correct size of King LTD-S utilizing the manufacture’s recommendation.
3. Test cuff and inflation system for leaks by injecting the maximum recommended
volume of air into the cuffs.
4. Lube the distal end of the tube with proper lubrication.
5. Place patient’s head in a neutral or “sniffing” position
6. Open the patient’s mouth using a tongue-jaw lift maneuver
7. With the King LTD-S rotated laterally 45-90 degrees such that the blue orientation
line is touching the corner of the mouth, introduce tip into mouth and advance behind
the base of the tongue.
8. As tube tip passes under tongue, rotate tube back to midline (blue orientation line
faces chin).
9. Without exerting excessive force, advance tube until base of connector is aligned with
teeth or gums.
10. Using the syringe provided, inflate the cuffs to 60 cm H2O or to “just seal” volume.
Typically the inflation volumes are as follows:
a. Size 3 40-55 mL
b. Size 4 50-70 mL
c. Size 5 60-80 mL
11. Attempt to ventilate backing out the King LTD-S until breath sounds are heard.
12. If breath sounds are not heard, remove the King LTD-S and utilize an oral airway and
BVM.
13. Confirm proper airway placement and assesses the quality of ventilations.
Level 2 - 3
ORAL ENDOTRACHEAL INTUBATION only if properly trained and permitted
Indications:
1. Respiratory or cardiac arrest
2. Unconsciousness without a gag reflex
3. Decreased minute volume, due to decreased respiratory rate or volume
4. Possible airway obstruction
Contraindications:
1. None in the presence of hypoxia, unresponsive to ventilation, need for advanced airway or
cardiopulmonary arrest
Procedure:
1. Preoxygenate the patient, if possible
2. Assemble and check equipment
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E.P.A.B.
3. If no suspected c-spine injury, position the head in a “sniffing” position. For suspected spinal
injury, use a second person to maintain in-line position of head.
4. Insert the laryngoscope blade into the right side of the patient’s mouth and sweep the tongue
to the left
5. Move the blade toward midline and advance until its distal end is positioned at the base of the
tongue
6. The tip of curved blades should be placed in the vallecula while the tip of straight blades
should be extended beyond the epiglottis.
7. Lift the epiglottis either directly or indirectly, visualizing the vocal cords.
8. Slip the endotracheal tube and stylet past the vocal cords about ½ to 1 inch. Gentle,
downward pressure on the cricoid cartilage (Sellick’s maneuver) may assist.
9. While holding onto the tube, attempt and assess ventilations
10. If the chest rises and breath sounds are present, inflate the distal cuff with 5 to 10 mL of air
11. Confirm proper airway placement and assesses the quality of ventilations
12. Record capnographic change, breath sound locations and chest rise and fall
13. Secure tube with an endolock device
14. Continuously reassess breath sounds
15. If ETT intubation is unsuccessful after one attempt, insert a King Airway.
a. An “ETT Attempt” is defined as passing the endotracheal tube past the teeth.
Level 4
NASOTRACHEAL INTUBATION only if properly trained and permitted
Indications:
1. Patients who may have a spinal injury
2. Patient who is clenched
3. Patients with a gag reflex
4. Patients who cannot be ventilated by any other means
Contraindications:
1. Suspected nasal or facial fractures
2. Suspected basilar skull fracture
3. Significantly deviated septum
4. Nasal obstruction
Procedure:
Preoxygenate the patient, if possible
Assemble and check equipment (lubricate tube), attach BAAM whistle-tip
Place patient’s head and neck in a relaxed or neutral in-line position
Select the larger, non-occluded nostril
Insert the tube (without a stylette) with BAAM whistle-tip into the nostril
As the tube is advanced into the posterior pharynx, the patients respiratory sounds can be
heard as the tube reaches the epiglottis
7. With the patient’s next inhaled breath, advance the tube rapidly into the glottic opening and
continue passing it through the vocal cords.
8. While holding onto the tube, attempt and assess ventilations
9. If the chest rises and breath sounds are present, inflate the distal cuff with 5 to 10 mL of air
10. Confirm proper airway placement and assesses the quality of ventilations
11. Record capnographic change, breath sound locations and chest rise and fall
12. Secure tube with cloth adhesive tape
13. Continuously reassess breath sounds
1.
2.
3.
4.
5.
6.
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TRANSTRACHEAL OXYGENATION (TTO) only if properly trained and permitted.
Standing Order with severe hypoxia in a Crash Airway situation
Indications:
1. Massive orodontal / facial trauma
2. Other means of ventilation have been exhausted
Contraindications:
1. Patient in which a less invasive method would be effective
2. Pediatric patients
Procedure:
1. Assemble and check equipment
2. Ensure that the patient is supine. (If spinal injury is suspected, inline stabilization shall be
provided).
3. Stabilize the larynx using the thumb and middle finger of one hand. With the other hand,
palpate the small depression below the cricothyroid cartilage, sliding the index finger down to
locate the cricothyroid membrane.
4. Using a 10 gauge over-the-needle catheter with a 5cc syringe attached, puncture the
cricothyroid membrane at a 90 degree angle.
5. After puncturing, change the angle of the needle to a 45-60 degree angle towards the patient’s
carina, applying negative pressure to the syringe.
6. Advance the over-the-needle catheter and remove the needle and syringe.
7. Hold the hub of the catheter to prevent accidental dislodgement during ventilation.
8. Confirm proper placement and assess oxygenation.
9. Connect the oxygen tubing from the hub of the catheter to the flow modulator.
10. Place oropharyngeal and nasopharyngeal airway to allow gas escape.
11. Record findings: Pulse oximetry readings and breath sounds.
12. Secure catheter
13. Continuously reassess breath sounds and oxygenation.
NOTE: This procedure requires 100% review by the medical director. Please call 817-9231500, extension 205 within 1 hour of performing this procedure and leave your name, medic
number, date, and incident number. You will be contacted to review your chart.
Level 5-6 with Crash Airway Permit
CRASH AIRWAY MANAGEMENT
Crash airway management should be performed only if all of the following findings are
present. Patient is not a candidate for crash airway management if any of the following
findings are not present
Indications:
1. Adult patient,
2. Head injury present,
3. GCS ≤ 8,
4. Clenched teeth,
5. Patient is hypoxic despite efforts to oxygenate,
6. There is a failure of airway maintenance or protection (secretions difficult to manage or
anatomy is distorted),
7. There is a failure of ventilation or oxygenation (less invasive methods have been exhausted or
cannot be utilized because of anatomical distortions or trismus), and
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8. Deteriorating clinical course.
Contraindications:
3. Midazolam use is contraindicated if systolic blood pressure is less than 90 mmHg
Procedure:
•
(Utilize the Paramedic Worksheet For Crash Airway
•
to determine if a patient meets criteria)
• Risk of hyperkalemia such as in burns
1. Consider Transtracheal Oxygenation (Standing
more than 24 hours old, or more than
Order if significant hypoxia & conditions allow)
7 days post denervation events, crush
2. Prepare equipment and ensure the patient is in an
injuries, or intra-abdominal infections.
appropriate area for Crash Airway Management.
• Degenerative or neuromuscular
3. Assure at least 1 IV line or IO is functioning and
secure
4. Consider atropine 1 mg if HR is 60 or lower AND patient is hypotensive.
5. Administer etomodate 0.3 mg/kg IV/IO as the induction agent.
6. Succinylcholine 2 mg/kg if not contraindicated. (Substitute rocuronium 1 mg/kg if
contraindicated.)
7. Stop ventilating the patient with the BVM.
8. Apply Cricoid Pressure
9. Intubate with cricoid pressure or BURP and verify placement.
10. Use AIRWAY RULE OF 5. (ETT, Secure, EtCO2, SpO2, C-Collar)
11. If unable to Intubate, insert King LTD-S and verify placement.
12. If unable to insert the King airway, insert Melker airway and verify placement.
13. Secure airway with appropriate method.
14. Monitor capnographic waveform and ventilate titrating to capnography levels as described
in the Capnography Procedure.
15. Following intubation with Succinylcholine, administer rocuronium 1 mg/kg IV/IO.
16. If stress response is present (SBP is greater than 160 AND HR is greater than 90) administer
morphine 2-5 mg IV/IO. May be repeated every 3 minutes to a total dose of 10 mg with
sustained stress response.
17. If systolic BP is ≥ 90, administer midazolam 2.5 mg IV/IO for continued sedation, may
repeat if necessary every 10-20 minutes.
18. Consider soft restraints.
Respiratory Failure (Pharmacological Assisted Intubation-PAI)
If the patient is in Respiratory Failure (maximal breathing effort with minimal effect),
SBP ≥90, and Pulse Oximetry ≤90% with proper BVM ventilations, the Primary
Paramedic may perform Pharmacological Assisted Intubation:
Indications:
1. Adult patient,
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2. Respiratory Failure
3. Patient is hypoxic despite efforts to oxygenate (SpO2 ≤ 90%)
4. There is a failure of airway maintenance or protection (less invasive methods have been
exhausted or cannot be utilized because of anatomical distortions or trismus),
5. Deteriorating clinical course.
Contraindications:
3. Midazolam use is contraindicated if systolic blood pressure is less than 90 mmHg
Procedure:
1.
Prepare equipment and ensure the patient is in an appropriate area for PAI Airway
Management.
2.
Establish IV.
3.
Consider atropine 1 mg IV/IO if HR is 60 or
lower AND patient is hypotensive.
•
Administer etomidate 0.3 mg/kg IV/IO as the
4.
•
induction agent.
• Risk of hyperkalemia such as in burns
more than 24 hours old, or more than
a. If unable to facilitate intubation, administer
7 days post denervation events, crush
succinylcholine 2 mg/kg IV/IO unless
injuries, or intra-abdominal
contraindicated (substitute rocuronium 1
infections.
mg/kg IV/IO if Succinylcholine
• Degenerative or neuromuscular
contraindicated)
5.
Intubate with cricoid pressure or BURP and
verify placement.
6.
Use AIRWAY RULE OF 5. (ETT, Secure, EtCO2, SpO2, C-Collar)
If unable to Intubate, insert an alternative airway (i.e. King) and verify placement.
7.
8.
Ventilate the patient, verify proper placement, and secure airway with appropriate
method.
9.
Monitor capnography continuously.
10.
If systolic BP is ≥ 90, administer midazolam 2.5 mg IV/IO for continued sedation, may
repeat if necessary every 10-20 minutes.
11.
If patient has been successfully intubated and sedated after the above drug regiment but
begins “bucking the tube”, administer rocuronium 1 mg/kg IVP for continued paralysis.
If stress response is present (SBP is greater than 160 AND HR is greater than 90)
12.
administer morphine 2-5 mg IV/IO. May repeated every 5 minutes to a total dose of 10
mg.
13.
Consider soft restraints.
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Automated External Defibrillation (AED)
Level 1-2-3-4-5-6
Goal:
1. Deliver first defibrillation when indicated by device
Indications:
1. Patient is unresponsive, apneic, and pulseless
2. Patient weight ≥ 90 pounds
a. If AED is acceptable for Pediatrics, may use pediatric AED pads to children ≥ 1
year of age
Relative Contraindications:
1. Trauma, except for drowning or electrocution
Absolute Contraindications:
1. Do not apply on patient lying in water
2. Do not apply the pads directly on a cardiac pacemaker. Utilize the Anterior/Posterior
placements.
Procedure:
1. Carry AED in on all medical emergencies
2. Check responsiveness, airway, breathing, and circulation
3. If unresponsive, apneic, and pulseless, apply and activate AED following
manufactures recommendations
4. Analyze the patient’s rhythm
5. If shock is advised, clear the rescuers from the patient, and defibrillate the patient
6. If no shock is advised, follow current AHA BCLS guidelines
* Energy settings may vary according to device manufacture’s recommendation
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Blood and Blood Products
Level 6
Purpose: To provide guidelines for the administration, transport and documentation of
patients receiving blood and/or blood products.
Procedure:
1. A written consent is required for administration of any blood product. The consent is
to be obtained by the sending facility, and a copy should be included in the patient’s
chart.
2. Every patient receiving blood or blood products is to have a recipient band in place.
3. If product is infusing at time of initial patient contact, verify facility transfusion
checklist.
a. Patient’s name and social security number/hospital number matched with
transfusion record form (attached to product bag).
b. Type and number on transfusion record form matched with product bag.
c. Pre-transfusion temperature, pulse, respirations and blood pressure are
documented on transfusion record form.
d. Nurse administering product has signed, dated and timed the transfusion record
form.
e. All original copies of the transfusion slip should remain with the patient. Sending
facility should make a copy of this for their records.
4. If CCT is going to initiate the transfusion of blood or blood products during transport,
verify the order and facility transfusion checklist with patient’s primary RN prior to
transport.
5. Obtain necessary equipment, ie. Tubing, filters, etc. from sending facility to
administer transfusion.
6. Prior to administering blood or blood products enroute, the CCT will complete the
facility’s pre-transfusion checklist and document accordingly on the product slip and
in the CCT run report.
7. Blood or blood products may NOT be piggybacked into an existing IV line. When
administering via a multi-lumen central venous catheter it is suggested that the most
“distal” lumen be utilized.
8. Vital signs including temperature should be obtained and recorded 15 mins., 45 mins.
and then 1 hour, at a minimum, after initiating the transfusion until completed. If
patient spikes a temperature 2 degrees greater than baseline, discontinue the blood
infusion.
9. If the transfusion is completed enroute, it is the CCT responsibility to document on
the transfusion slip the date and time completed, amount given, whether or not the
blood is warmed, if a reaction occurred and post-transfusion vital signs. All
completed bags and tubing should be turned over to the receiving facility with the
patient.
10. It is the receiving facility’s responsibility to return the transfusion slip to the sending
facility’s blood bank.
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E.P.A.B.
WHOLE BLOOD, PACKED RBC’S, AND FROZEN RBC’S
1. Verify transfusion checklist.
2. Prime Y-type blood tubing with Normal Saline and begin infusion slowly.
3. Attach blood bag to Y-type blood tubing. Clamp tubing to saline. Open clamp to
blood and adjust flow to run slowly for the first 15 minutes. If no adverse reaction,
increase flow based on patient condition and transfusion times.
a. 1-1/2 – 3 hours Whole Blood
b. 1-1/2 – 3 hours Packed RBC’s
c. 2 hours maximum Washed Packed Cells
4. Monitor vital signs as previously outlined.
5. Monitor for signs/symptoms of adverse reaction. If adverse reaction noted, stop
infusion and refer to Anaphylaxis and Allergic Reaction Protocol.
6. Blood tubing should be changed after each unit. EXCEPTION: If emergent situation
and several units of blood are being administered rapidly, tubing should be changed
every 4 hours or every other unit.
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Blood Glucose Determination
Level 1-2-3-4-5-6
Indications:
1. When required by protocol
Contraindications:
1. None
Precautions:
1. Bleeding disorders
Procedure:
1. Use universal precautions
2. Prepare site with alcohol and allow alcohol to dry
3. Prepare glucometer and test strip according to manufactures recommendations
4. Collect blood sample
5. Introduce sample to glucometer according to manufactures recommendations
6. Record the blood glucose level and time of reading
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CPAP Procedure
Level 2-3-4-5-6
Continuous Positive Airway Pressure (CPAP) has been shown to rapidly improve vital
signs, gas exchange, the work of breathing, decrease the sense of dyspnea, and decrease
the need for endotracheal intubation in the patients who suffer from severe shortness of
breath from congestive heart failure and acute cardiogenic pulmonary edema.
Indications:
1. Patients experiencing significant shortness of breath from suspected congestive heart
failure and cardiogenic pulmonary edema or COPD without relief from a nonrebreather.
Requirements:
1. Is awake and oriented
2. Is ≥ 15 years of age and is able to fit the CPAP mask
3. Has the ability to maintain an open airway (GCS=15)
4. Has a systolic blood pressure ≥ 90 mmHg
5. Uses accessory muscles during respirations
6. Sign and symptoms consistent with CHF/Cardiogenic Pulmonary Edema
7. SpO2 is ≤ 90% on a non-rebreather
Contraindications:
1. Patient is not breathing, has inadequate respiratory effort, or has agonal respirations
2. Patient is unconscious or semiconscious
3. Patient is suspected of having a pneumothorax
4. Penetrating chest trauma
5. Asthma
6. Persistent vomiting
7. Active upper GI bleeding or history of recent gastric surgery
8. Patient has a tracheostomy
Precautions:
1. Has impaired mental status and is not able to cooperate with the procedure
2. Had failed past attempts at noninvasive ventilation
3. Complains of nausea or vomiting
4. Has excessive secretions
5. Has a facial deformity that prevents the use of CPAP
Procedure:
1. Maximize an upright sitting position
2. Assess capnography and pulse oximetry continuously
3. If BP < 90 mmHg systolic, contact BSP prior to beginning CPAP
4. Use 5 – 10 cmH20 CPAP titrated by adjusting the flow of oxygen to the Boussignac
CPAP system.
a. 15 lpm flow = 5 cmH2O,
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b. 20 lpm flow=7.5 cmH2O,
c. 25 lpm flow=10 cmH2O
5. Explain the procedure to the patient
a. Patient may require coaching for CPAP to be used effectively.
i. Example: “You are going to feel some pressure from the mask but this will help
you breathe easier. Do you feel the air blowing against your face?”
6. Place the Boussignac CPAP System over the patient’s mouth and nose.
7. Secure the mask with the head strap.
8. Check around the mask for leaks and adjust appropriately.
9. Instruct the patient to breath in through their mouth and nose slowly and exhale
through their mouth as long as possible
a. Count slowly and aloud to four then instruct to inhale slowly.
10. Attach cardiac monitor
11. Continue to coach the patient to keep the mask in place and readjust as needed.
12. Continuously monitor the patient’s level of consciousness and respiratory rate and
work of breathing.
a. If respiratory status or level of consciousness deteriorates, immediately
discontinue the device and consider BVM and/or intubation.
b. If capnography drops below 35 mmHg or continues to increase, immediately
discontinue the device and consider BVM and/or intubation.
13. Documentation on the patient care record should include:
a. Liters per minute of oxygen flow
b. SpO2 every 5 minutes
c. EtCO2 every 5 minutes
d. Vital signs every 5 minutes
e. Response to treatment
f. Any adverse reactions
g. Any improvement
Special Notes:
1. CPAP should not be used in children under 15 years of age
2. Advise the receiving facility as soon as possible so they may prepare for the patient
3. Ensure a smooth transition of your patient into the Emergency Department
4. CPAP should be continued in the Emergency Department until the emergency
physician advises removal
5. Monitor the patient for gastric distension which may lead to vomiting
6. Lift the mask to administer nitroglycerin to avoid the spray from being dispersed on
the patient and EMS crew
7. Removal of CPAP may result in worsening respiratory distress
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Capnography
Level 1-2-3-4-5-6
Indications:
11. Patients with an advanced airway placement (ETT, King Airway, Combitube, etc.)
12. Non-intubated patients with major medical or traumatic complications:
13. When required by protocol
Procedure:
2. Advanced airway patient
a. When you have performed advanced airway, immediately attach the ETT filter
line between the airway and the BVM prior to administering your first ventilation.
b. Your first ventilation should be monitored with capnography and auscultated with
a stethoscope over the epigastrum.
c. Normal capnography levels in the perfusing patient should read between 35-45
mm Hg.
2. Non-intubated patient
a. Place the nasal cannula filter line on the patient either under the non-rebreather or
with the oxygen nasal cannula (combination device is preferred).
b. Normal levels should read between 35-45 mm Hg in the perfusing patient
Interpretation:
7. Capnography levels:
a. Less than 35 mm Hg may reveal
a. Hyperventilation
b. Decreased metabolic rate
c. Hypoperfusion
d. Airway obstruction
e. Air trapping
f. Cardiac arrest
b. Greater than 45 mm Hg may reveal:
1. Hypoventilation
2. Increased metabolic rate
3. Hypertension
4. Return of spontaneous circulation post cardiac arrest
5. Acidosis
Waveforms
a. Normal is a square shape
b. Bronchospasm has a increasing alveolar plateau (“shark fin”) and/or a
rounded shape
c. Pulmonary embolus may have a “notched” alveolar plateau
d. Paralytic medication wearing off has a “notched” alveolar plateau called a
curare cleft
e. ETT cuff is not inflated adequately or the ETT is too small in pediatrics has a
delayed down stroke or Phase IV
f. Rebreathing CO2 will have a rising baseline that doesn’t return to zero.
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Trending
a. Increasing levels may indicate the same conditions causing high levels
b. Decreasing levels may indicate the same conditions causing low levels
c. Sudden drop in the level may indicate a sudden drop in cardiac output
d. Cessation of waveforms may indicate apnea or a lost ETT
Normal Waveform
Bronchospasm
Notched Waveform
(PE or Paralytic Effect)
Loss of Waveform
(ETT dislodged or Apnea)
Trending Waveforms
Increasing CO2
Decreasing CO2
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Chest Tube Management
Level 6
Purpose: To provide guidelines to the CCT Team regarding the care and management of
patients with chest tubes in place.
Description: If injury, surgery or any disruption in the integrity of the lungs and chest cavity
occurs, placement of a chest tube is warranted. The chest tube is a drain. It serves to remove
air, fluid, or blood from the pleural space, to restore negative pressure to the pleural space, to
re-expand a collapsed lung, and to prevent reflux of drainage back into the chest.
Procedure:
1. Inspect the patient’s chest wall to ensure that all connections are tight and that the
tubing is not kinked. Also check the skin around the insertion site for subcutaneous
emphysema. Be sure that the tube is properly secured.
2. Note color, consistency and amount of drainage.
3. Note any air leak in the water chamber. Ask the sending facility staff RN if there has
been a prior leak.
4. Mark Pleur-evac (or other drainage system) with a pen at the current level of drainage
in the system.
a. Be alert to sudden changes in the amount of drainage. A sudden increase
indicates hemorrhage or sudden patency of a previously obstructed tube. A
sudden decrease indicates chest tube obstruction or failure of the chest tube or
drainage system.
5. Adjust wall suction to create a gentle rolling of bubbles in the water seal chamber or
until suction indicator in appropriate range. Vigorous bubbling results in water loss.
6. Verify the level of the suction control chamber is at the level prescribed by the
physician (usually 20 cm).
7. The suction hose should be clamped during travel time between suction devices. The
hose can then be unclamped and re-connected to suction in the CCT unit. In the
newer models of collection devices, a stopcock may be present for this purpose.
8. Position patient in semi-fowlers (if condition allows) to enhance air and fluid
evacuation. NEVER raise the chest tube above the chest or the drainage will backup
into the chest. Avoid any dependent loops as drainage problems and tube obstruction
may occur. The tubing should be coiled flat on the bed and from there fall in a
straight line to the chest drainage system.
9. Transport the chest tube after placing patient in the truck on the floor and secure with
3” tape, so the pleur-evac is not knocked over during transport.
10. Dislodgment of the chest tube - If the chest tube falls out or is accidentally pulled
out, it is important to quickly seal off the insertion site. Use a gloved hand until
petroleum gauze is available. Petroleum gauze is necessary to prevent air from
entering the pleural cavity. Apply petroleum gauze as a 3-sided occlusive dressing.
11. Dislodgment from the Drainage system (Pleurovac)-If the chest tube becomes
disconnected from the Pleurovac or other collection device, clamp the chest tube
(using Kelly clamps) until corrective action can be taken.
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Combat Application Tourniquet (CAT)
Level 1-2-3-4-5-6
The Combat Application Tourniquet (C-A-T®) was designed for America’s military
soldiers. A tourniquet can make the difference between life and death in uncontrolled
arterial hemorrhage. A tourniquet should not be the first line in hemorrhage control but
should be used when other methods are ineffective. They should be thought of early with
arterial bleeding to prevent serious blood loss.
Indications:
1. Severe Uncontrollable Extremity Hemorrhage
2. Other methods of hemorrhage control are ineffective
Contraindications:
1. Bony fracture under application site
2. Non-external hemorrhage
Procedure:
1. Open CAT package
2. Wrap CAT around extremity proximal to bleeding site, do not cover joints
3. Pass Self Adhering Band through inside slit of the Friction Adapter Buckle
4. Pass Band through outside slit of Buckle
5. Pull Self Adhering Band tight and Secure back onto itself
6. Twist Tension Rod until bleeding stops
7. Lock Tension Rod in the Windlass Clip
8. Secure Tension Rod with the Windlass Clip Strap
9. Make note of Application Time
10. Continuously reassess for hemostasis
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E.P.A.B.
Cook-Melker Cuffed Emergency Cricothyrotomy Catheter Set
Level 5-6 and T
Indications:
1. Patients who require emergent invasive airway management
Requirements:
1. In conjunction with Crash Airway
Contraindications:
1. Anytime a less invasive maneuver would allow ventilation of the patient
2. Pediatric patients (less than 15 years of age)
3. Tracheal transection
Precautions:
1. Patients in need of cricothyrotomy may have significant spinal injury. In patients
who have sustained significant trauma, the cervical spine should be immobilized
throughout the procedure, if possible
2. Aseptic technique should be utilized
3. Consider utilizing local anesthetic in the conscious patient
4. Fractured larynx or significant damage to the cricoid cartilage
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E.P.A.B.
References:
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CPR Monitoring Device
Level 1-2-3-4-5-6
Purpose:
1. During CPR, a monitoring device will be utilized to monitor compressions and
ventilations. Type of devices may be, but not limited to the Philips QCPR and the
Zoll Real CPR Help.
Indications:
1. Cardiopulmonary arrests in adult patients. It may only be utilized on pediatric
patients if the device has approved pediatric settings.
Contraindications:
1. Pediatric patients with an adult device.
Precautions:
1. Assure that the device is in the proper location and all manufacturer recommendations
and instructions are being utilized.
Procedure:
12. Put the device on the manufacturers instructed location on the patient’s chest.
13. Perform chest compressions following current CPR standards outlined in these
Protocols.
14. Follow the voice prompts/instructions that is given by the device (i.e. compress
harder, compress deeper, etc.)
15. Attach the EtCO2 device to the King Airway LTD-S or the ETT. This will register
the ventilations provided to the patient.
16. Follow the voice prompts/instructions that are given by the device for ventilations.
Follow current ventilation care guidelines outlined in these Protocols.
17. Download all information as stated in the manufacturer recommendations and your
agency’s instructions to be attached to the patient care form.
18. The downloaded data must be submitted to EPAB in the monthly CQI submissions.
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E.P.A.B.
ECG Acquisition and Transmission
Level 1-2-3-4-5-6
Goals:
1. Early identification of MI to expedite continued care
2. Eliminate contraindications for various treatments
3. To acquire and transmit the 12-Leads to the receiving facility
Indications:
1. Patients with chest pain or signs / symptoms suggestive of an acute myocardial
infarction or myocardial ischemia, CVA, or CHF
2. Abdominal pain in patients ≥ 35 years of age
3. Prior to receiving nitrates, antiarrhythmics, pacing or cardioversion (if time allows)
4. Drug overdose
5. When indicated in protocol
Contraindications:
None
Procedure:
1. Prep skin. Use the tincture benzoin if the patient is diaphoretic.
2. Prepare cables/leads and attach to the chest as such:
V1 4th Intercostal space right side of the sternum
V2 4th Intercostal space left side of the sternum
V3 Directly between Leads V2 and V4
V4 5th Intercostal space at midclavicular line (on right side for V4R
V5 Level with V4 at left anterior axillary line
V6 Level with V5 at left midaxillary line
3. Place limb leads on right & left inside surface of the distal forearms and right and
left inside surface of the distal legs. May be placed more proximal if distal positions
not accessible.
4. For an isolated Inferior and/or Posterior AMI, perform right sided chest lead
acquisition. Prepare cables/leads and attach to the chest as such on the right side:
V1 & V2 Leave disconnected
V3R
Directly between Leads V1 and V4R
V4R
5th Intercostal space at midclavicular line
V5R
Level with V4R at right anterior axillary line
V6R
Level with V5R at right midaxillary line
Acquiring a 12/16-Lead ECG:
1. Enter appropriate age for patient and other pertinent data (if time allows)
2. Press “12-Lead” to obtain 12-Lead ECG report.
3. If right-sided acquisition, V1-V2 will print dotted line indicating right sided printout.
Transmit ECG to appropriate receiving facility as described in SOP.
NOTE: When placing electrodes on female patients, always place leads V3-V6 under
the breast rather than on the breast.
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Electrical Therapy
Level 3-4-5-6
Emergent Cardiac Pacing
Indications:
1. Hemodynamically unstable bradycardia (blood pressure < 90mm Hg systolic, change
in mental status).
2. Symptomatic bradycardia in the patient who has had a denervated heart.
Contraindications:
1. Severe hypothermia with a temperature less than 86 degrees F.
2. Infants and children weighing less than 90 pounds
Procedure:
1. Prep skin. Clip or shave excess hair and attach appropriate pads.
2. Place one electrode over the upper right anterior chest and the other electrode on the
left lower chest wall.
a. Do not place electrodes over implanted devices
3. Attach monitoring leads and adjust the gain up or down until you have an adequate
QRS height, which the pacemaker may mark. If this is not successful, select another
lead or move the electrodes until sensing occurs.
4. Power the pacemaker module by pressing the “PACER” soft key and confirm the
presence of QRS markers on the ECG.
5. If not already defaulted, set your initial pacing rate at 70 beats per minute.
6. Press the “START / STOP” button to begin pacing: Increase the mA in increments
until vertical pacing spikes are observed.
7. Increase in 5 mA increments per beat until electrical capture occurs or until the unit
reaches maximum output. Do not reduce mA once capture occurs.
a. Electric capture is recognized by the presence of a consistent and widened QRS,
ST segment, and T wave immediately after pacer spike.
8. Assess the patient for mechanical capture and response to pacing. Pulses should be
assessed at the right femoral or right carotid artery to avoid confusion between the
jerking muscle contractions cause by the pacemaker and a pulse.
9. Refer to Sedation Protocol.
10. Closely monitor the patient for any changes.
Unsynchronized Defibrillation
Indications:
1. Ventricular fibrillation
2. Ventricular tachycardia without a pulse
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Contraindications:
1. None in the presence of life-threatening VF or pulseless VT, unless defibrillation
energy could be transferred to bystander or provider(s) due to direct patient contact or
hazardous environment
Procedure:
1. Turn the defibrillator / monitor on.
2. Confirm that the rhythm seen on the monitor coincides with a pulseless patient in VF
or VT.
3. Apply conductive gel or paste to paddle electrodes, or place hands-off electrodes on
the patient’s chest.
4. Select the energy level to be delivered.
5. Charge the defibrillator to the desired energy.
6. If using paddles, place them firmly on the patient’s unclothed chest using
approximately 25 lb. Of pressure on each paddle.
7. Make certain all personnel are clear of the patient.
8. Deliver energy per protocol.
9. Observe the patient and monitor display for results.
10. Reassess patient.
11. Defibrillation of Patients with Permanent Pacemakers
a. Place the defibrillator paddles or electrodes as far away from the pulse generator
as possible.
b. No adjustment in defibrillator energy is indicated.
13. Defibrillation of Patients with Implantable Cardioverter Defibrillators (ICD)
a. If an unconscious patient receives shocks from his/her ICD, but pulseless VT or
VF persists, an electrical countershock should be delivered.
b. Avoid placement of electrodes or paddles over the ICD (most often located in the
lower left abdominal cavity).
c. No adjustments in defibrillator energy are indicated.
d. External defibrillation will not damage ICD circuitry if recommended energy
levels are used and paddle or electrode placement directly over the ICD is
avoided.
Level 4-5-6
Synchronized Cardioversion
Indications:
1. Unstable tachycardia as indicated by protocol
Contraindications:
1. Repetitive, self-terminating, short-lived tachycardias (i.e., runs of non-sustained VT)
Procedure:
1. Determine that the patient is unstable.
2. Depress the synchronize button on the machine, observing for R wave markers on
each QRS complex. If they do not appear, or appear elsewhere on the ECG, adjust
the ECG size or gain up or down until they appear on each R-wave.
3. If markers still do not appear, select another lead or reposition the ECG electrodes.
4. Select the appropriate energy level required as follows:
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ADULTS:
1. Supraventricular rhythms (PSVT / Afib / A. flutter):
a. 100 J, 200 J, 300 J, and 360 J monophasic.*
b. 100 J, 150 J biphasic.*
OR
2. Monomorphic Ventricular Tachycardia:
a. 100 J, 200 J, 300 J, and 360 J monophasic.*
b. 100 J, 150 J biphasic*
PEDIATRICS:
1. Ventricular Tachycardia and Supraventricular rhythms (PSVT / Afib / A. flutter):
Begin with 0.5 J /kg, doubling doses to a maximum of 4 J/kg* is reached
2. Apply self-adhesive pads in the sternum / apex position, ensuring firm contact with
the patient’s skin.
3. Charge the defibrillator to desired energy level.
4. Clear all personnel from direct patient contact.
5. Depress and hold both discharge buttons until electrical charge is delivered.
6. Reassess the patient and any rhythm changes seen on the monitor.
7. If rhythm deteriorates into VF / pulseless VT, switch to asynchronous mode and
immediately defibrillate
* Energy settings may vary according to device manufacture’s recommendation
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Gastric Tube Insertion
Level 1-2-3-4-5-6
Indications:
1. Adult and pediatric cardiac arrest after advanced airway has been performed.
2. When requested by BSP
Contraindications:
1. Actual or suspected laceration or perforation of the esophagus.
2. Suspected fractures of the cribriform plate, evidenced by severe maxillofacial trauma.
3. Ingestion of a caustic substance.
4. Anticoagulant use or disorders of coagulopathy
Procedure:
1. Utilize Universal Precautions.
2. For Nasogastric Tube:
a.
Select appropriate sized tube according to patient size and measure the correct
length for insertion.
b.
TO MEASURE: While holding the distal end of the tube, measure the distance
from the patient’s earlobe to the bridge of his/her nose, and additionally from
there to a point just below the xyphoid.
c.
Mark this length with a piece of tape
d.
Have the patient sit upright and lean slightly forward (if able to do so), with the
neck slightly flexed.
e.
Lubricate the distal 3 to 6 inches of the tube and select the most widely patent
nostril.
f.
With your free hand, support the back of the patient’s head and gently move it
forward into a slightly flexed position while you insert the tip of the tube into
the selected nostril.
g.
Advance the tube STRAIGHT BACK into the nostril. If resistance is felt, rotate
the tube slightly to help advance the tube into position.
h.
As the tube reaches the posterior nasopharynx the patient is likely to slightly
gag.
i.
If the patient is able to do so, have the patient attempt to swallow
j.
Continue to insert the tube past the glottic opening and into the esophagus.
Continue to insert the tube into the nostril until the pre-measured mark reaches
the front edge of the nostril.
k.
After confirmation that the tube is placed correctly and has not curled up into
the oropharynx, aspirate 20 to 30 mL of air into a 60mL syringe. While
listening over the epigastrum, inject the air into the tube and listen for
“gurgling” to indicate proper placement of the tube. Attempt to aspirate and
observe for gastric contents.
l.
If no sounds are heard over the epigastrium and you notice fogging or misting in
the tube, immediately withdraw the tube and oxygenate your patient.
m. If tube placement has been confirmed, securely tape the proximal end of the
tube where it enters the nostril to the bridge of the nose.
n.
IF THE PATIENT IS UNCONSCIOUS: The procedures are the same, but the
luxury of the patient sitting and swallowing while inserting the tube is not
present. The tube also tends to coil up into the oropharynx and pharynx much
easier in the unconscious person and careful observation of tube placement is
crucial.
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3. For insertion in the King LTD-S Airway
a. Lubricate the gastric tube (up to an18 French) prior to inserting into the gastric
access lumen.
b. Insert the gastric tube until resistance is met or the connector meets the access
lumen.
4. After the tube is firmly secured, connect the proximal end to suction device and
aspirate as needed.
5. For intubated patients, place orogastric tube in lieu of nasogastric tube
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Hemodynamic Monitoring
Level 6
Purpose: To provide guidelines for the transfer of patients with pulmonary artery
catheters and/or arterial catheters.
Description: Hemodynamic monitoring involves the observation of how the
cardiovascular system responds to illness, injury, and therapeutic intervention.
Procedure: Hemodynamic monitoring by means of intravascular catheters is extremely
useful in the diagnosis and management of many cardiovascular and pulmonary
disorders. Intra-arterial pressure monitoring is more accurate than noninvasive blood
pressures in patients who are obese, hypotensive, peripherally vasoconstricted or severely
hypertensive. All patients who are transported by the Critical Care Transport Unit that
have invasive pressure lines will be monitored continuously with the use of the Phillips
MRX monitor. There will be some occasions when it is justified that CCT does not
monitor the patient’s Arterial Line. These situations are for very stable patients with a
very short transport distance and the invasive line is incompatible with CCT’s equipment.
All pulmonary artery catheters will be monitored during transport. The following
standards will be achieved on all patients meeting the criteria for hemodynamic
monitoring.
2. Assess the pressure waveform displayed on the sending facility monitor.
3. When indicated (poor waveform, poor pressure readings), obtain a pre-transport strip of
waveform from sending facility's monitoring equipment as well as a post- transport strip
from receiving facility's monitoring equipment.
4. Obtain current pressure readings from the monitor and patient care records.
5. The L-6 will evaluate the pressure line for compatibility with the CCT equipment. If the
line is not compatible, the pressure line must be changed to facilitate monitoring by the
CCT unit during the transport.
6. Flush the invasive line prior to changing over to CCT equipment to assure patency.
7. Once line has been changed over, flush any visible air out of line via stopcock before
flushing to patient.
8. The pressure bag will be inflated to 300 mm/Hg.
9. The pressure cable will be connected to the monitor and the patient end will be connected
to the transducer port on the pressure tubing.
10. The transducer will be placed at the Phlebostatic axis (4th intercostals space, midaxillary) line and taped securely.
11. All excess tubing will be coiled and taped in an orderly fashion.
12. The pressure line will be zeroed and calibrated to the monitor.
13. The waveform will be identified by the labels provided in the monitor (PA, ART).
14. The waveform will be assessed on the monitor, a pressure reading will be obtained and a
strip will be printed showing the waveform. The strip will be identified as to the type of
tracing.
15. Pulmonary artery pressures will be documented in conjunction with the secondary
survey, as well as every 15 minutes for the duration of the transport. The pulmonary
artery catheter should never be wedged during transport. Pressures can be documented
more frequently.
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16. Arterial pressures will be documented in conjunction with the secondary survey, as well
as every 10 minutes for the duration of the transport.
17. The types and sites of these invasive lines will be documented in the medical record.
18. All distal pulses, capillary refill times, skin temperature, and sensation will be assessed
and documented on extremities used.
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Intra-Aortic Balloon Pump
Level 6
Purpose: To provide guidelines to the CCT regarding the specialized care and management
of the Intra-aortic balloon pump (IABP) patient during inter-facility transport. MedStar’s
CCT will utilize a nurse or perfusionist from the sending facility to maintain the IABP and
will work together to facilitate transport.
Procedure:
3. Review the most recent 12-lead ECG. Select lead with greatest R-Wave amplitude. Place
patient in this lead on cardiac monitor for continuous monitoring during transport. Limit
chest artifact. ECG Leads for the IABP will be secured to the patient’s chest and
maintained during transport. Lead selection may need to be changed in order to get the
best R-wave and capture on the balloon pump (If ECG triggered).
4. Arterial line shall be maintained on the IABP. Assure that the transducer is directly
connected to the pump and in working order. Maintain adequate arterial tracing. If radial
site is used, secure arm with arm board to protect site during transport. Secure tubing.
5. Evaluate balloon insertion site. Note balloon size in the medical record. Check dressing
site appearance. Monitor site frequently (every 15 minutes and as needed) during
transport. Instruct patient to keep affected leg straight. Use a sheet restraint for additional
reinforcement.
6. Establish baseline condition. Evaluate hemodynamics and clinical condition.
Hemodynamic assessment will include: temperature; blood pressure; respiration rate and
quality; heart rate and rhythm; arterial blood pressure; Augmented pressures, MAP; CVP;
PAP; augmented diastolic pressure (ADP). Document findings including patient's weight.
7. Evaluate pulses, both radial sites as well as posterior tibial and dorsalis pedis to facilitate
subsequent localization during transport, also capillary filling times and extremity
temperature.
8. Review lab values and trends.
o
9. Maintain H.O.B. at lowest point tolerated by patient, never to exceed 30 .
10. Evaluate and closely monitor urinary output. All patients will have an in-dwelling
catheter.
11. Maintain IABP at prescribed timing/ratio (i.e.: 1:1; 1:2; 1:4). Evaluate effects.
Document hemodynamics. Document: IABP type, model and trigger (ECG, A-Line)
Precautions:
11. Never leave balloon pump inactive in patient for more than 20-30 minutes (i.e., not
inflating and deflating). Thrombosis formation could occur after 30 minutes. Utilize 60
cc syringe to manually fill and deflate balloon.
12. Balloon leak: Observe tubing for blood. If blood is observed in the pneumatic tubing,
shut off the balloon pump and leave intact. Maintain sterile technique and notify the
physician and receiving facility immediately.
13. IABP Failure: Evaluate patient's condition and hemodynamics. Troubleshoot the device
and make every effort to correct the problem and maintain the patients safety. If IABP is
inoperable for greater than 20-30 minutes, inflate IABP manually with 60 cc syringe
every 3-5 minutes to avoid clot formation (Inflate with 10cc less than balloon size).
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14. Assure IABP battery is charged and Helium tank level is sufficient for transport. The
balloon pump should be plugged into the ambulance inverter or generator outlets during
transport.
15. Assure there is ample tubing length for transfer and loading the patient into the
ambulance. Secure the IABP tubing at patient end and stretcher end, but not mid-line.
Put loop in tubing if length permits.
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Intraosseous Infusion – EZ-IO
Level 3-4-5-6
INDICATIONS:
EZ-IO AD® (40 kg and over), EZ-IO PD® (3 – 39 kg), and EZ-IO LD®(excess tissue over the access site)
Indications:
1. Unsuccessful IV attempts AND:
a.
b.
Patients in cardiopulmonary or respiratory arrest
Severe illness or injury requiring immediate fluid or drug administration and no other route
available (i.e. IN, IM, SQ, etc)
NOTE: In the above settings, an IO may be considered prior to peripheral IV attempts if IV access is
impossible or unlikely to be successful.
NOTE: In major trauma patients, IO access is very unlikely to be needed due to short scene and transport
times.
Contraindications:
1. Hemodynamically stable, alert patients
2. Available or secure IV line
3. Fracture of the bone selected for IO infusion (consider alternate site)
4. Excessive tissue at insertion site with the absence of anatomical landmarks (consider alternate site)
5. Previous significant orthopedic procedures (IO within 24 hours, prosthesis - consider alternate tibia)
6. Infection at the site selected for insertion (consider alternate site)
7. Known bleeding disorder
CONSIDERATIONS:
1.
2.
3.
4.
5.
6.
Flow rates:
Due to the anatomy of the IO space you will note flow rates to be slower than those achieved with IV
catheters.
Ensure the administration of an appropriate rapid syringe bolus (flush) prior to infusion NO FLUSH =
NO FLOW
a. Rapid syringe bolus (flush) the EZ-IO AD and LD® with 10 mL of NS
b. Rapid syringe bolus (flush) the EZ-IO PD® with 5 mL of NS
c. Repeat syringe bolus (flush) as needed
To improve continuous infusion flow rates always use a syringe, pressure bag or infusion pump
Insertion of the EZ-IO AD® & EZ-IO PD® in conscious patients has been noted to cause mild to
moderate discomfort (usually no more painful than a large bore IV). However, IO Infusion for
conscious patients has been noted to cause severe discomfort
Prior to IO syringe bolus (flush) or continuous infusion in alert patients, SLOWLY administer
Lidocaine 2% (Preservative Free) through the EZ-IO hub.
a. EZ-IO AD and LD® Slowly administer 20 – 40 mg Lidocaine 2% (Preservative Free)
b. EZ-IO PD® Slowly administer .5 mg /kg Lidocaine 2% (Preservative Free)
PRECAUTIONS;
The EZ-IO AD, LD, & PD® are not intended prophylactic use
EQUIPMENT:
EZ-IO® Driver
EZ-IO AD, LD, or PD® Needle Set
Alcohol or Betadine Swab
EZ-Connect® or Standard Extension Set
10 mL Syringe
Normal Saline (or suitable sterile fluid)
Pressure Bag or Infusion Pump
2 % Lidocaine (preservative free)
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PROCEDURE: If the patient is conscious, advise of EMERGENT NEED for this procedure
and obtain informed consent
1.
2.
3.
4.
Wear approved Body Substance Isolation Equipment (BSI)
Determine EZ-IO® Indications
Rule out Contraindications
Locate appropriate insertion site
a. Proximal tibia
b. Humeral head (adults)
5. Prepare insertion site using aseptic technique
6. Prepare the EZ-IO® driver (Power or Manual) and appropriate needle set
8. Stabilize site and insert appropriate needle set
9. Remove EZ-IO® driver from needle set while stabilizing catheter hub
10. Remove stylet from catheter, place stylet in shuttle or approved sharps container
11. Confirm placement; DO NOT ASPIRATE FOR BONE MARROW as it may occlude the IO needle
12. Connect primed EZ-Connect®
13. Slowly administer appropriate does of Lidocaine 2% (Preservative Free) IO to conscious patients
14. Syringe bolus (flush) the EZ-IO® catheter with the appropriate amount of NS.
15. Utilize pressure (pressure bag or infusion pump) for continuous infusions where applicable
16. Begin infusion
17. Dress site, secure tubing and apply wristband as directed
18. Monitor EZ-IO® site and patient condition
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Intraosseous Infusion – Manual Type (i.e. Jamshidi, Cooks, Illinois, etc.)
Level 3-4-5-6
Indications:
1. Unsuccessful IV attempts AND:
a.
b.
Patients in cardiopulmonary or respiratory arrest
Severe illness or injury requiring immediate fluid or drug administration and no other route
available (i.e. IN, IM, SQ, etc)
NOTE: In the above settings, an IO may be considered prior to peripheral IV attempts if IV access is
impossible or unlikely to be successful.
NOTE: In major trauma patients, IO access is very unlikely to be needed due to short scene and transport
times.
Contraindications:
1. Hemodynamically stable, alert patients
2. Available or secure IV line
3. Fracture of the bone selected for IO infusion (consider alternate site)
4. Excessive tissue at insertion site with the absence of anatomical landmarks (consider alternate site)
5. Previous significant orthopedic procedures (IO within 24 hours, prosthesis - consider alternate tibia)
6. Infection at the site selected for insertion (consider alternate site)
Procedure:
1. Employ universal precautions
2. Assemble and prepare supplies
3. Locate and prep appropriate insertion site
4.
5.
6.
7.
8.
9.
a.
Proximal tibia
b.
Humeral head (adults)
Introduce IO needle in the skin, directed away from the epiphyseal plate
Using a gentle boring or screwing motion, advance the needle until it penetrates the marrow, denoted
by a decrease in resistance or a “pop” sound
Remove stylette and aspirate marrow contents. Sometimes marrow can not be aspirated
Attach IV line to hub and infuse fluid or medications into the Intraosseous space
Secure the needle to the overlying skin
Monitor the calf to ensure that there is no leakage of fluid
These are all different types of Manual IO needles
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Intravenous Access
Level 2-3-4-5-6
Indications:
1. Patients who require IV fluids or medications.
2. Patients who are or may become unstable
Contraindications:
1. Use caution in patients with bleeding disorders or patients on blood thinners
Catheter Selection
1. 20 gauge is preferred on medical patients
2. 14-18 gauge when rapid fluid replacement is needed
Procedure:
Intravenous Catheterization
1. Employ Universal Precautions
2. Assemble and prepare the supplies.
3. Utilize the proper drip set for your patient’s condition.
4. Clean site using aseptic technique
5. Perform venipuncture using aseptic technique
6. Attach IV tubing to the catheter hub.
7. Confirm flow of the IV fluid. STOP if any infiltration occurs.
8. Secure the catheter and IV tubing.
9. Adjust the flow rate.
Saline Lock:
1. Prepare your equipment
2. Follow steps 1 through 4 as outlined above
3. Remove protective cap on the Luer lock device and carefully twist it onto the hub
4. Confirm the lock has been secured tightly and no fluid leaks
5. Flush with 3 cc NS (confirm there is NO infiltration)
6. Secure the catheter and saline lock.
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E.P.A.B.
IV Fluid Therapy Procedure - Adult
Level 2-3-4-5-6
Indications:
1. Adult patients exhibiting signs and symptoms of hypovolemia
2. Patients who are unstable
Contraindications: Pump failure (except cardiac arrest)
Fluid Choices Normal Saline
Note: The fluid goals for medical and trauma patients are a little different. In all cases,
fluid is administered in increments of 250 mL in the adult patient.
Fluid Schedule for Medical Patients:
Level 2
Up to 250 mL of NS IV/IO
Level 3
Level 4
Level 5-6
1.
2.
Fluid Schedule for Trauma Patients:
Level 2-3-4-5-6
Controlled external hemorrhage:
a. Administer 250 mL NS IV/IO. May repeat bolus for a total of 500 mL to
maintain a SBP ≥ 90 mmHg.
Uncontrolled external or internal hemorrhage:
a. If SBP < 90 mmHg, administer 250 mL NS IV/IO. Titrate to maintain SBP of
70-80 mmHg up to a total of 500 mL NS.
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E.P.A.B.
IV Fluid Therapy Procedure - Pediatric
Level 2-3-4-5-6
Indications:
1. Hypovolemic pediatric patients exhibiting signs and symptoms of poor perfusion
with NO signs of pump failure (excluding cardiac arrest). This procedure applies
to patient conditions necessitating fluid resuscitation to maintain end-organ
perfusion.
a. Traumatic injury or medical conditions resulting in any of the following
hypovolemic symptoms.
i.
Decreased level of consciousness
ii.
Abnormal neurological deficits (Combative, disoriented, confusion, GCS
< 15)
iii. Delayed capillary refill
iv.
Tachycardia
v.
Respiratory arrest
vi.
Cardiac arrest secondary to hypovolemic cause
vii.
Crush injury to trunk/torso
viii. Abdominal trauma
ix. High speed impact (MVC ≥ 40 mph – MCC ≥ 20 mph – MPC ≥ 20 mph)
x. Death in same passenger compartment
xi. Ejection from vehicle
xii. Significant compartment intrusion
xiii. Extrication ≥ 20 minutes
xiv. Fall ≥ 3 x patient height
Contraindications: Pump failure (excluding cardiac arrest)
Fluid Choices: Normal Saline
Note: ANY administration of a fluid bolus in pediatrics MUST be followed by
maintenance fluid infusion on an IV pump. Below is the Bolus/Maintenance schedule.
Level 2-3
1st Bolus:
NS 20 mL/kg IV/IO
Level 4
2nd Bolus:
NS 20 mL/kg IV/IO
Level 5-6
3rd Bolus:
NS 20mL/kg IV/IO
Maintenance Infusion (4/2/1 Rule)
Levels 2-3-4-5-6
0 – 10 kg: 4 mL/kg/hr
10 – 20 kg: 40 mL/hr + 2 mL/kg/hr for each kg over 10
>20 kg: 60 mL/hr + 1 mL/kg/hr for each kg over 20
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E.P.A.B.
IVAC Triple Channel Intravenous Fluid Pump
Level 3-4-5-6
Indications:
1. Patients who require non-routine IV fluids, medications, or physician prescribed
flow rates or volumes-to-be-infused.
Contraindications:
1. None
Procedure:
1. Preparing for Infusion:
a. Employ Universal Precautions
b. Assemble and prepare the supplies. Use only approved infusion sets with the
device.
c. Attach IV tubing to the infusion solution bag or bottle and prime the set properly
to eliminate all bubbles as follows:
i. Ensure the cassette slide clamp is pushed in completely so tubing is not
occluded.
ii. Invert the cassette so tubing is up. Slowly open the regulating clamp and
establish fluid flow to fully prime the set. Gently tap the cassette and ‘Y’
sites as necessary to remove all air. Gently massage the pressure dome to
ensure no air bubbles are trapped.
2. Load the set as follows:
a. Close regulating clamp before inserting and removing the cassette to reduce the
risk of free flow.
b. Press the “On/Off-Recharge” button to turn pump on. Instrument information
page is momentarily displayed, then the standard display page is displayed (you
may also press the “Standard Display” button on the top row of buttons).
c. With tubing down, use a 45 degree, upward motion to insert cassette into
channel.
d. Push on clear portion of cassette until completely seated. Then push slide clamp
flush with the entire cassette.
e. Pull down gently on tubing collar. Press with thumb to seat tubing collar in
recess beneath cassette. NOTE: 3 beeps sound when inserted properly.
f. Open regulating clamp
3. Program the infusion as follows:
a. Select the A, B, or C channel by pressing the respective lettered button across the
bottom row of buttons. The selected channel’s programming page is displayed.
b. With the programming page displayed, press “Select” to choose value to be
changed. The value is then highlighted.
c. Scroll through values using the up (↑) and down (↓) arrows, or the fast up (FAST
↑) and fast down (FAST ↓) arrows.
d. Highlight remains until “Enter” is pressed. If “Enter” is not pressed, the entry
incomplete advisory will sound.
e. Press “Enter” to accept new value. Highlight moves to next programmable value
if channel status is “Stopped” or “Standby”. If status is “Infusing”, highlight
remains on selected value.
f. Set the primary rate (drip rate to be infused at). Set the primary volume
remaining [displayed as “Pri VolRem (VR)] (amount of solution to be infused).
The Primary Time Remaining [displayed as “Pri Time (TR)”] is automatically
calculated, based on VR and Rate. Primary Volume Infused [displayed as “Pri
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VolInf (VI)”] gives realtime results of how much solution has been infused. This
value can be cleared by following prompts.
g. Press “START/STOP” button. The infusion starts or stops immediately, unless
the channel’s programming is incomplete, or if an advisory, alarm, or fault
condition exists on selected channel.
h. To place a channel on Standby during infusion, press appropriate channel button,
then press “START/STOP” to stop infusion. Press STANDARD DISPLAY”
button, then press “Standby”.
i. To resume infusion from Standby status, press appropriate channel button, then
press “START/STOP” button to start infusion.
4. Secure the IV tubing to the patient and existing vascular access. Be aware of length
of tubing travel when moving patient to avoid infiltration or decannulation. This is
especially important when infusing through a central, subclavian, PICC, Huber Port,
or other surgical vascular access line. Ensure sterility at the access port by cleaning
or replacing port accesses and Luer adapters with alcohol prep or by using a new
port adapter.
5. Begin the infusion as ordered by transferring physician or EPAB approved
physician.
Complications:
1. STOP infusion if any infiltration occurs throughout duration of use.
2. To access alarm information, press “Quiet”, then press the affected channel button.
Alarm information is displayed for that channel. Take appropriate action(s)
3. NOTE: IV pumps operate under positive pressure delivery system and will continue
to infuse if infiltration occurs. The pumps are not programmed to diagnose
infiltration or stop infusion if distal occlusion or infiltration occurs. The Transport
ALS provider must confirm patency of infusion site throughout transport.
4. NOTE: The Transport ALS provider is responsible for confirming compatibility of
multiple medication infusions.
5. NOTE: Operating the pump near equipment which radiates high-energy
electromagnetic and radio frequencies (portable radios, cellular phones, etc.) may
cause false alarm conditions. If this happens, reposition the pump away from the
source of the interference; or turn off the pump and manually regulate the flow with
the administration set regulating clamp.
6. NOTE: It is normal for IV Infusion Devices to produce non-hazardous currents when
infusing electrolytes. These currents vary at a rate proportional to the infusion device
flow rate. When the ECG monitoring system is not functioning under optimal
conditions, these currents may occur as artifacts, simulating actual ECG readings. To
determine if ECG abnormalities are caused by patient condition or the ECG
equipment, place the infusion device on hold. If the ECG readings become normal,
the ECG equipment requires attention. Proper setup of the ECG equipment should
eliminate these artifacts. Reference the appropriate ECG monitoring system
documentation for instructions on setup and maintenance.
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Mechanical Ventilation
Level 6
Purpose: To provide a positive force in the airway to inflate the lungs with oxygenated
air. Mechanical ventilation is necessary for patients who are unable to provide enough
force for their own respirations, such as patients with compromised lungs or chest wall
and apneic or nearly apneic patients.
Mechanical Ventilator Settings
2. Tidal Volume (VT): If this mode is not predetermined by the sending physician, will be
set at 5 to 10 ml/kg of patient body weight.
3. Mode of Ventilation: There are several modes available - this setting should be selected
by the sending physician depending on the patient’s needs. If no mode is selected by the
sending physician, the CCT will place the patient on A/C (assist control). It is the
responsibility of the CCT to accurately document the clinical indications for the mode of
ventilation that is selected.
4. Respiratory Rate: If the rate is not set at the sending facility, the CCT crew will evaluate
the patient’s condition, diagnosis, recent ABG, capnography, and intrinsic respiratory rate
prior to selecting the setting. Generally a rate of 10-12 per minute will be sufficient to
maintain adequate minute ventilation on adult patients.
5. FiO2: FiO2 should be sufficient to maintain pulse oximetry at or above 95%.
6. PEEP-Positive End Expiratory Pressure: Initiation of PEEP should be considered on
patients who fail to maintain adequate oxygenation in spite of increased FiO2 and/or
ventilatory rate. Initial PEEP value should be 5 cm H2O and titrated in increments of 1
cm H2O.
h. Continuous observation and assessment is mandatory for patients who are placed
on PEEP (vitals, lung sounds, etc.).
Transport Considerations: All patients who are transported by the Critical Care
Transport Unit will be monitored closely for the following:
2. Pulse oximetry will be continuous and these patients will maintain an O2 saturation of
95% or above. The pulse oximeter readings will be documented on the patient care
record (PCR) prior to departure from the sending facility and every 15 minutes
throughout the duration of the transport. Report from the sending facility should
include the patient's normal range of SpO2. This will set the parameters for the CCT
team regarding SpO2. Some patients will not have, nor maintain an SPO2 of 95% or
greater due to their underlying pulmonary condition. Documentation of the reason
for the variance from the CCT standard of care is essential.
3. Capnography- will be continuously monitored in all intubated patients. Trached
patients will have capnography/capnometry monitored when indicated. Examples
would be abnormal vital signs and/or changes from normal condition. Titrations in
respiratory rate and/or tidal volume may be made in order to maintain EtCO2 at
normal range of 35-45 mmHg or level prescribed by physician or patient condition.
4. Ventilator settings will be documented on the run sheet, as well as any changes that
are made during the transport.
5. Endotracheal or tracheal suctioning will be performed using aseptic technique when
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E.P.A.B.
6.
7.
8.
9.
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necessary to maintain a patent airway; the type, color and amount of secretions will
be documented on the run sheet.
Sedation: Patients that require sedation and/or a paralytic to maintain adequate
oxygenation and reduce anxiety will be provided with medication as per protocol.
Tracheostomy Patients: The CCT Team will ensure that all patients whose airway is
maintained by a tracheostomy tube will be provided with the obturator and an
additional tracheostomy tube prior to leaving the sending facility.
AMBU Bag: The CCT will ensure that a bag valve mask (BVM) resuscitator is kept
with the patient at all times. This will ensure adequate ventilation management in the
event of mechanical ventilator failure.
Communication: Communicate with a vent patient, prior to switching to the CCT
vent, the differences they will experience. Continue to talk with the patient and
attempt to alleviate anxiety/restlessness.
All premature infants requiring ventilatory support will be accompanied by
one of the following: Neonatal nurse practitioner, RRT, CRTT, or the
sending/receiving neonatologist.
GOALS:
1. To maintain pulmonary management of the ventilator dependant patient during transport.
2. To maintain or improve the patient’s level of care.
3. To prevent complications of oxygen toxicity/dependence by providing the appropriate
FiO2.
4. To provide quality patient care utilizing the transport team approach.
5. To prevent complications of positive pressure ventilation.
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E.P.A.B.
Methods of Medication Administration Procedure
Level 1-2-3-4-5-6
Purpose:
1. Throughout protocols and procedures, the provider will administer medications to
patients. This procedure is to define and describe the basics of each route of
administration.
Indications:
1. As stated in protocol.
Contraindications:
1. Conditions that exist which outweigh the reason to administer the medication. This
may be a simple allergy, a drug interaction, or concomitant medical condition.
Expected Side Effects:
1. Tolerable and expected effects of the medication that are not desirable, but are not
dangerous.
Possible Adverse Effects:
1. Intolerable effects of the medication that may indicate over-dosage, toxicity, or just
an anomalous occurrence in some patients. Adverse effects usually require dosage
adjustment or stopping of the medication, and frequently additional therapies to
counteract the adverse effect.
Methods of Administration:
1. The following are methods of medication administration listed in these protocols:
a. Level 1
i. Nebulized
ii. By Mouth (PO)
iii. Auto-injector
iv. Sublingual (SL)
v. Oral Dissolving Tablet (ODT)
b. Level 2
i.
Intravenously (IV)
c. Level 3-4-5-6
i. Intranasal (IN)
ii. Transdermal
iii. Subcutaneous Injection (SQ)
iv. Intramuscular Injection (IM)
v. Intraosseous (IO)
vi. Medication infusion
2. The following are the time parameters of administering the specific medications:
a. Slow IVP – over 2-3 minutes
b. Rapid IVP – over 2-3 seconds
c. Wide open IV (WO) – straight stream of fluid flowing through the IV drip
chamber
d. To Keep Open (TKO) – 1 cc per minute
If at any time the patient complains of pain during the administration procedure, stop the
administration immediately.
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E.P.A.B.
Procedures for each Method of Administration: Follow all current National and State
standard of care procedures for each. Specifics on each are as follows:
1. Nebulized
a. Place the specific amount of medication into the nebulizer medication container
b. Adjust the oxygen flow to achieve the desired misting effect (usually between 610 liters per minute) and wait for a slight mist to exit the end of the tube
c. Instruct the patient to place the mouth piece to their mouth and breathe normally.
May also be administered through mask.
2. By Mouth (PO)
a. Place the medication in the oral cavity using the following criteria:
i. Aspirin should be chewed and swallowed. You may allow the patient to use a
small amount of water to assist the patient in swallowing the tablets.
ii. Glucose Paste may both be given to the conscious patient to swallow or to the
semiconscious patient by placing it on a tongue depressor and placed in the
mouth between the cheek and gum to be absorbed.
3. Auto-injector
a. Remove the cap from the auto-injector
b. Place the tip of the auto-injector against the injection site and push the injector
firmly against the injection site
c. Hold the auto-injector against the site for 10 seconds
d. Remove the auto-injector and apply pressure.
4. Sublingual (SL)
a. Instruct the patient to open their mouth and lift their tongue
b. Place the medication under the tongue.
5. Oral Dissolving Tablet (ODT)
a. Instruct the patient to open their mouth and stick out their tongue
b. Place the medication on top of the tongue
c. Instruct the patient to let the medication dissolve prior to swallowing if possible.
6. Intranasal
a. Load the appropriate size syringe with the selected medication.
b. Attach the nasal atomizer on to the syringe
c. Place atomizer 1.5 cm into the selected nostril
d. Briskly compress they syringe to administer the loading dose of medication.
e. Remove and repeat into the other nostril, if necessary, until all of the medication
has been administered.
7. Transdermal
a. Apply the ordered medication to the application paper
b. Place the paper onto the upper lateral portion of the thorax.
8. Injections
a. Select the appropriate administration site:
Deltoid Muscle
Type: IM
Size: 23 to 25 G, 5/8” to 1”
Range: 0.5 to 2 mL
Vastus Lateralis Muscle
Type: IM
Size: 23 to 25 G, 5/8” to 1 ½”
Range: 1 to 5 mL
Dorsogluteal Muscle
Type: IM
Size: 20 to 23 G, 1 ½” to 3”
Range: 1 to 5 mL
Arm, Abdomen, Thigh
Type: SC
Size: 25 to 27 G, ½” to 5/8”
Range: 0.5 to 1.5 mL
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Ventrogluteal Muscle
Type: IM
Size: 20 to 23 G, 1 ½” to 3”
Range: 1 to 5 mL
Forearm
Type: ID
Size: 26 to 27 G, 3/8”
Range: 0.001 to 1 mL
E.P.A.B.
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b. Subcutaneous Injection
i. Pinch the skin between two fingers. Holding syringe at a 45 degree angle,
insert the needle below the skin using a sharp and controlled motion
ii. Aspirate for blood return. If present, discontinue administration
iii. Administer correct dose of medication at the proper push rate.
c. Intramuscular Injection
i. Stretch skin and hold tight. Hold the syringe at a 90 degree angle to the skin
and insert the needle into the muscle tissue with a steady sharp and controlled
motion
ii. Release the tension on the skin
iii. Aspirate for blood return. If present, discontinue administration
iv. Administer correct dose of medication at the proper push rate.
9. Intravenously
a. Assure the proper dose and concentration of the medication
b. Correctly draw up the medication and dispel the air
c. Assure the patency of the IV
d. Occlude the IV flow
e. Administer the medication at the proper rate described in this policy
10. Intraosseous
a. Assure the proper dose and concentration of the medication
b. Correctly draw up the medication and dispel the air
c. Do not aspirate bone marrow as this may clog the IO
d. Occlude the IV flow
e. Administer the medication at the proper rate described in this policy.
11. Continuous Medication Infusion
a. Assure the proper does and concentration of the medication mixture
b. Prepare the medication for administration:
i. Epinephrine: 1 mg 1:1,000 in 500 mL or a 2 mcg/mL mix
ii. Dopamine: 400 mg in 250 mL or a 1600 mcg/mL mix
iii. Lidocaine: 1000 mg in 250 mL or a 4 mg/mL mix
c. Place the medication drip on the IV Medication Pump (see procedure for its
proper use).
d. Interfacility transfers: Any continuous medication infusion not covered in
protocol requires BSP approval prior to patient transport.
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Motion Restriction / Spinal immobilization
Level 1-2-3-4-5-6
Indications:
Patients who present with the following should be immobilized by these criteria alone:
1. Significant blunt or penetrating trauma to the torso
2. Significant injury above the clavicles
3. Falls ≥15 feet
4. Occupants in vehicles with a fatality
5. Presence of significant mechanism of injury
Patients involved in an incident in which a cervical spine injury is possible and who
present with one or more of the following criteria should be immobilized:
1. Altered Level of Consciousness
2. Evidence of alcohol or drug intoxication
3. Presence of a painful distracting injury
4. New onset of neurological deficits
5. Spinal pain or tenderness
Note:
Sports injuries which utilized shoulder pads and a helmet should use this procedure in
conjunction with the Helmet Removal procedure.
Absolute Contraindications:
1. Hazardous environmental conditions with potential for injury/death to responder or
patient (i.e. fire, high water, etc.)
2. Severe orthopnea in supine position.
3. Kyphosis or lordosis that cannot be overcome with padding.
Procedure:
1. Using manual stabilization by one responder, place patient in neutral spinal alignment
(unless there is excessive pain, crepitus, or physiological resistance to movement.
Then splint in position found.)
2. Second responder verifies neutral alignment, sizes collar appropriately and applies.
3. Consider KED if neurological deficit, or if axial skeleton alignment will be
compromised during transport.
4. Place patient on long spine board, maintaining neutral alignment of spine.
5. Pad voids with pillows or other soft material.
6. Secure patient to the board using TigerStraps. Begin securing straps from feet. Place
top chest strap under the arm directly against chest wall. Secure remaining straps.
7. If moving patient requires elevation of either end of board, consider alternate means
of motion restriction. (SKED or stokes).
8. Move the patient to a stable transport platform. DO NOT TAPE THE HEAD TO
THE BOARD UNTIL PATIENT IS ON A STABLE TRANSPORT PLATFORM.
(On the stretcher on a firm surface, or in the ambulance.)
9. Secure the head to the board with the supplied tape, or medical tape if necessary.
(Under chin of c-collar, and above head to corners of board.)
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Nasal Atomizer
Level 2-3-4-5-6
Indications:
1. When adult and pediatric patient requires the administration of intranasal
medications.
Contraindications:
1. Extreme hemorrhage blocking the nasal cavity.
2. Sinusitis with complete blockage of the nasal cavity.
Procedure:
1. Utilize Universal Precautions.
2. Assess ABCs
3. Load the appropriate size syringe with the selected medication.
4. Attach the nasal atomizer on to the syringe
5. Place atomizer 1.5 cm into the selected nostril
6. Briskly compress the syringe to administer the loading dose of medication.
7. Remove and repeat into the other nostril, if necessary, until all of the medication has
been administered.
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Occlusive Dressing
Level 1-2-3-4-5-6
Indications:
1. In the presence of an open chest pneumothorax; “sucking” chest wound
Contraindications:
1. None in the emergency setting.
Precautions:
1. A buildup of pressure increasing the risk of a tension pneumothorax.
Procedure:
1. Apply a sterile occlusive dressing to the open laceration.
2. Place a gauze dressing over the occlusive dressing and bandage in place on the superior,
medial, and inferior sides.
3. Leave the lateral side open to act as a flutter valve, allowing excess pressure to escape.
4. Monitor the patient for the development of a tension pneumothorax. If it develops,
removed the dressing and bandage to release the thoracic pressure. Once the tension
pneumothorax has been relieved, replace the dressing and three-sided bandage.
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Oxygen Administration / Pulse Oximetry
Level 1-2-3-4-5-6
Indications:
1. As indicated in protocol
2. Titrate the oxygen administration so that the pulse oximeter maintains an oxygen
saturation of at least 95%
3. In COPD titrate the oxygen administration to maintain an oxygen saturation of 90%.
Precautions:
1. Pulse oximetry: Inaccurate in cyanide and carbon monoxide poisoning and low
perfusion states
Procedure:
Pulse Oximeter
1. Locate a desirable site to place the oximeter probe (the finger, toe, or ear lobe)
2. Remove debris, dirt, nail polish or other foreign material from the location
3. Warm the area if indicated. Cool extremities can interfere with the reading.
4. Place the probe on the area, turn the machine on, and note the reading.
Nasal Cannula
1. Advise the patient of the procedure, if able.
2. Select the appropriate size cannula for the patient.
3. Connect the nasal cannula tubing to the regulator and set the flow rate between 2-5
Lpm. Titrate the FiO2 to SpO2 readings.
4. Insert the two prongs into the patient’s nares, with the tab down.
5. Position the tubing over and behind each ear and gently secure by sliding the adjuster
under the chin.
6. Check the cannula’s placement periodically to ensure it has not dislodged. A nasal
cannula delivers up to 44% oxygen.
Nonrebreather Mask
1. Advise the patient of the procedure, if possible.
2. Select the appropriate size mask for the patient.
3. Connect the mask tubing to the regulator and set the flow rate between 10-15 LPM.
Titrate the FiO2 to SpO2 readings.
4. Fill the reservoir bag completely by pressing down on the rubber valve gasket that
covers the one-way valve between the mask and the reservoir.
5. Place the mask on the patient once the reservoir bag is completely filled. Secure it by
placing the elastic band around the back of the patient’s head.
6. Check the reservoir bag periodically to ensure that it remains filled during inhalation.
A nonrebreather delivers up to 95% oxygen.
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Pelvic Sling for Pelvic Fracture Stabilization
Level 1-2-3-4-5-6
Indications:
1. “Open Book” pelvic fracture
a. Both lower extremities will look like frog legs, being laid out laterally
2. “Closed Book” pelvic fractures
Contraindications:
1. Proximal femur fractures
Procedure:
1. Commercial Pelvic Splint (Sam’s Pelvic Splint, Boundtree etc.)
a. Slide device beneath arch of lower back
b. Slide device down to center over the greater trochanters
c. Secure Velcro to opposing side
d. Pull adjustable strap until appropriate tension is reached
e. Secure strap to maintain tension
Precautions after application
1. The development of a pressure sore may develop with longer applications.
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Pleural Decompression
Level 4-5-6
Indications:
1. Signs and symptoms of tension pneumothorax
Contraindications:
1. Simple pneumothorax without evidence of a tension pneumothorax
2. Hemothorax
Procedure:
1. Prepare your equipment. Assemble the needle and syringe.
2. Place patient on pulse oximeter, if time and patient condition allows.
3. Identify the landmark by palpating the sternomanubrial junction (Angle of Louis) at
the junction of the upper and middle thirds of the sternum. By moving the fingers
laterally, the second rib is palpated. sPalpate the upper edge of the third rib in the
midclavicular line. This is the point of entry.
4. Place the tip of the needle against the skin at the midclavicular line and hold it so the
hub is held just lower than the tip.
5. Insert needle, pointing posteriorly but slightly upward, sliding it over the top curve
of the third rib.
6. When chest decompression occurs a rush of air may be heard.
7. Remove needle leaving catheter in place.
8. Auscultate the chest and reassess the patient’s respiration and other vital signs.
9. Periodically reassess for reaccumulation of a tension pneumothorax. Perform an
additional decompression if indicated.
10. Additional decompressions may be performed laterally from the initial site, if
necessary.
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Pulmonary Artery Catheters
Level 6
Purpose: To provide guidelines for monitoring and troubleshooting PA Catheters during
transport.
Procedure:
1. Obtain and record the Pulmonary Artery Pressure (PAP) Systolic/Diastolic, mean
Pulmonary Artery Pressure (PAP), Pulmonary Artery Capillary Pressure (PCWP)
before leaving facility and q 15 minutes or as ordered by physician during transport.
The Pulmonary Artery Capillary Pressure (PCWP) will only be obtained at the
sending facility.
c. Normal Mean Values:
i. Pulmonary Artery Pressure (PAP) Systolic 15-30 torr Diastolic 4-12 torr
ii. Pulmonary Artery Capillary Pressure (PCWP): 4-10 torr
iii. Central Venous or Right Atrial Pressure (CVP): 0-12 torr
(Therapeutic ranges may be somewhat higher than the above values)
d. Exceptions:
i. The optimal mean PCWP (wedge) may be 15-20 torr in patients with
compromised left ventricular function, post-op stress or post MI.
ii. For patients with COPD and respiratory failure, expect PCWP pressures in the
range of 30-50 torr. PCWP should be normal in pure pulmonary hypertension.
2. Trends in PAP and PCWP pressures are the most significant factors in detecting
significant physiological changes in the patient’s condition. Be sure to obtain history
of these values prior to transport.
3. Inspect and document the insertion site. Note and document the PA insertion depth.
4. Calibrate the transducer at the beginning of the transfer before the patient is
transferred over to the stretcher and with any major position changes.
5. Maintain pressurized flush system at 300 mmHg.
6. If change in waveform occurs, contact Medical Control for direction.
7. Follow set parameters for specific IV vasoactive drips as ordered by transferring
physician or see protocol for IV vasoactive pharmaceutical titrations and/or
communicate with the online physician.
8. CCT must document all interventions that take place regarding PA catheter.
9. Label all pressure tracings and document the tracings on the patient care report.
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QuikClot Dressing
Level 1-2-3-4-5-6
QuikClot® hemostatic agent is a molecular sieve, sifting molecules by size. When
QuikClot® comes into contact with blood in and around a wound, it rapidly takes in the
smaller water molecules from the blood. The larger platelet and clotting factor molecules
remain in the wound in a highly concentrated form. This promotes extremely rapid
natural clotting and prevents severe blood loss. Additionally, the nano-engineered
particles provide key surface chemistry, rapidly enhancing the body's natural coagulation
process.
Indications:
1. Severe External Hemorrhage
Contraindications:
1. Any known allergy to QuikClot
Procedure:
1. Remove clothing to expose source of bleeding
2. Open QuikClot package
3. Apply QuikClot dressing directly to site
4. Apply Direct Pressure over QuikClot while elevating site if possible
5. Apply additional dressing over QuikClot if needed
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Sport Helmet Facemask Removal Procedure
Level 1-2-3-4-5-6
Purpose:
1. To ensure safe management of spine related injuries in patients participating in a
sport requiring a helmet and shoulder pads
Indications:
1. A patient wearing of a protective helmet and shoulder pads who has suffered a spinal
injury and the patient’s airway may not be secured.
Contraindications:
1. This procedure must be used with caution as improper procedures could cause further
spinal injury.
Procedure:
1. Proper spinal immobilization of the patient should be performed. See the Motion
Restriction/Spinal Immobilization procedure.
2. The facemask of the sports helmet is secured to the helmet with plastic loop-straps
that are to be cut or removed to properly assess and maintain the patient’s airway.
a. The Inter Association Task Force does not recommend the use of a screwdriver, a
knife, box cutter, Durasheers, or EMT scissors to remove facemasks. These
should be utilized as a last resort. If a screwdriver is used, inside brackets (Image
5) can rust or slip if the helmet is not properly cared for.
b. If available, providers should seek guidance from the athletic trainer on-site to
remove the facemask with an Anvil Pruner, a Trainer’s Angel, or equivalent tool
to cut the loop-straps on the sides of the helmet. (Images 1-4). Four cuts are
needed to release the loop strap clasp on the new Revolution helmets.
c. The loop straps on top of the helmet can be removed the same way as those on the
side of the helmet. (Image 4 and 6)
3. Maintain proper spinal alignment and immobilization on the backboard with the
patient’s helmet and shoulder pads in place. (Image 6 & 7)
4. If an assessment of the patient’s trunk is necessary, loosen the shoulder pads for
access, assessment, and treatment. Remove only if absolutely necessary.
5. If either the helmet or the shoulder pads must be removed from the patient, both
should be removed and the patient properly spinally immobilized.
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Taser Removal
Level 1-2-3-4-5-6
Indications:
1. Removal of Taser probes when a person has been Tased by law enforcement officers.
Contraindications:
1. Do not remove probes that have penetrated the face, eye, neck, areola/nipple,
genitalia, or hands or those that simply fail to remove. These patients should be
transported immediately and probes removed by a physician.
Precautions:
1. It is recommended that all patients that have been tasered by law enforcement be
transported to the Emergency Department for further evaluation.
2. Cardiac monitoring and 12-lead ECG are highly recommended
3. For suspected drug overdose see Toxicological Emergencies Protocol
4. For continued violent patient see Psychiatric Emergencies Protocol
Procedure:
1. Obtain from the law enforcement officer the number of times patient was tasered and
for how long each time (i.e. full 5 seconds each time).
2. Stretch surrounding skin around probes till taught.
3. Grasp probe firmly and pull straight out from embedded area, wipe with alcohol swab
and apply band-aid.
4. Discard probe in sharps container. Repeat procedure for second probe.
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Temporary Transvenous Pacemaker Policy
Level 6
Purpose: To outline instructions in the proper hookup of a temporary pacemaker
generator to external pacer wires and provide guidelines in its maintenance.
Procedure:
5. Place a new battery in the temporary pacemaker and test it prior to use. Remove
battery from pacemaker when finished with transport.
6. Connect pacer wires to Temporary Pacemaker Cables with leads/heartwires - the
patient cable with lead or heartwire plugs into socket on top of unit. In the absence of
patient cables, temporary transvenous leads plug directly into the two smaller sockets.
7. Match the positive (+) and negative (-) leads to the positive (+) and negative (-)
sockets or clips (as applicable). There may be instances where the leads are reversed
in polarity to obtain capture. CCT will connect in the same manner as the sending
facility.
8. Set the pacemaker controls
a. Set the sensitivity (the highest number is least sensitive; the lowest is most
sensitive)
9. Demand mode - (withholds its pacing stimulus after sensing a spontaneous
depolarization) set the sensitivity value to detect intrinsic activity.
a. Set pacemaker’s rate 10 bpm slower than patient’s intrinsic rate (the sense
indicator will flash regularly)
b. Reduce milliamps (output) to the minimum value (this avoids risk of competitive
pacing).
c. Increase the sensitivity value until the ECG indicates that the pacemaker is
delivering its output pulses asynchronously. (The sense indicator will stop
flashing indicating a loss of sensing. The pace indicator will start flashing.
Capture is not likely to occur at the minimum milliamps (output) value.
d. Decrease the sensitivity value until the ECG indicates that sensing has been
restored. This value is the sensitivity threshold for the chamber being sensed.
(The sense indicator will start flashing, indicating that sensing has been restored;
and the pace indicator will stop flashing.)
e. Set sensitivity value to half (1/2) the sensitivity threshold value. This provides a
safety margin, allowing for threshold variation while maintaining sensing.
f. Restore original pulse generator rate and output values.
10. If asynchronous mode is indicated (stimulates at a fixed, preset rate independently of
the electrical and/or mechanical activity of the heart) turn sensitivity dial to ASYNC(NOT THE PREFERRED MODE FOR CCT).
a. Set the rate and milliamps (output)
b. Set the milliamps (output) at 5 and the rate at 60 or as directed by the physician
orders.
11. Turn the pacemaker ON
12. Check the monitor to ascertain that capture (depolarization of the atria and/or
ventricles) is obtained- if not, increase the milliamps slowly until capture is obtained,
this is the threshold (minimum electrical stimulus needed to consistently elicit a
cardiac depolarization). Then set the milliamps at two (2) x the threshold.
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More on setting stimulation threshold:
a. Assure the patient is connected to pacemaker and being monitored on ECG.
b. Set pulse generator rate at least 10 ppm faster than the patient’s intrinsic rate (The
pace indicator will be flashing regularly at the set rate).
c. Decrease the milliamps (output) until 1:1 capture is lost (the pace and sense
indicators will be flashing intermittently).
d. Increase the milliamps (output) to restore 1:1 capture. This value is the
stimulation threshold for the chamber being paced. (the pace indicator will be
flashing; and the sense indicator will have stopped flashing.)
e. Set output value to 2-3 times the threshold value. This safety margin will allow
for threshold variation while maintaining capture.
f. Restore original pacemaker rate value (60 or physician prescribed rate).
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Tourniquet Procedure
Level 1-2-3-4-5-6
Indications:
1. Severe uncontrollable extremity hemorrhage
2. Other methods of hemorrhage control are ineffective
Contraindications:
1. Bony fracture under application site
Procedure:
1. Locate appropriate equipment
a. Blood pressure cuff
b. Triangular bandage
2. Wrap around extremity proximal to bleeding site, do not cover joints
3. Increase tension until bleeding is controlled
4. Make note of application time
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E.P.A.B.
Uni-Vent Eagle Transport Ventilator
Level 6
Indications:
1. Patients who require ventilatory assistance for extended time periods (such as interfacility
transfers and long-distance/extended ETA transports).
2. Ventilatory assistance includes the use of assist control (A/C or ACV), synchronized
intermittent mandatory ventilation (SIMV), and continuous positive airway pressure
ventilation assistance (CPAP).
Contraindications:
1. Unsecured airway in A/C and SIMV modes.
2. Operation and application in a hazardous materials/flammable/combustible/WMD
environment or with a contaminated/contagious patient. This model of ventilator is not
appropriately sealed or filtered for these environments and/or patients.
Preparing for operation:
1. For use with external oxygen: connect high pressure oxygen hose between OXYGEN
inlet port and a 50-PSI external oxygen source (DISS Port). Use only medical-grade
oxygen.
Ensure your portable oxygen cylinder is full and has a regulator with at least one
available DISS port. The portable oxygen cylinder should only be used while the
ambulance's main oxygen tank is unavailable.
2. Connect disposable ventilator circuit to its respective gas outlet, transducer, and
exhalation valve connectors on the Eagle Ventilator's connector panel. Observe
directions included with disposable ventilator circuit.
3. Verify battery level. If needed, connect to approved power supply appropriate for the
ventilator and charge the battery. The power supply may be 12VDC or 110/120VAC.
The BATTERY LOW/FAIL alarm will activate when there is 30 minutes or less of
operating time remaining. The LCD will display BATTERY, BATTERY LOW/FAIL, or
BATTERY LOW/FAIL - RECHARGE/REPLACE BATTERY PACK. If no external
compressed air is attached, the ventilator will automatically initiate 100% FIO2 (the
internal air compressor shuts down to conserve power). To override this alarm, switch
the AIR/OXYGEN MIXER control set point to 100% FIO2.
Operation:
1. The ventilator undergoes a self-checking process every time its MODE Selector Switch is
turned from OFF to ACV, SIMV, or CPAP; or from CAL to ACV, SIMV, or CPAP. After
the initial SELF-CHECK is performed, self-checking is not repeated if the operator turns
the MODE Selector Switch to another operating mode position. (NOTE: if external
oxygen is to be connected, gas pressure must be at least 40-PSI at the time SELFCHECK is performed.) Operations begin immediately following SELF-CHECK. If the
ventilator fails the SELF-CHECK, an VENTILATOR FAIL alarm will occur. Return the
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E.P.A.B.
MODE Selector Switch to its OFF position and then repeat this procedure. If SELFCHECK fails again, place the ventilator out of service. Various self-checks and
monitoring are performed during routine operations. Refer to the OPERATION
MANUAL for further information.
2. Activate the ventilator and select the following as appropriate per patient (NOTE:
Interfacility transports should use the current hospital settings as closely matched as
possible, or based on physician orders at time of transfer.):
Select operating mode: ACV, SIMV, or CPAP
Set VENTILATION RATE (1-150 breaths per minute; disabled during CPAP
mode use)
Set INSPIRATION TIME (default mode should be preset to 1:2 I:E ratio) (0.1-3.0
seconds in 0.1 second increments)
Set TIDAL VOLUME
Set AIR/OXYGEN MIXER for FIO2 (21% and 100%)
Control panel settings can tailor operations to include the use of turning ON or
OFF or further options:
Pressure Plateaus (ACV and SIMV modes only) (5-90 cm/H2O)
PEEP (All modes) (1-20 cm/H2O)
SIGH (ACV and SIMV modes only) (once every 100 ventilations or 7
minutes, whichever occurs first for a duration of 150% of inspiration time,
not to exceed 3 seconds)
Control Ventilation (apnea backup of all modes)
3. Connect ETCO2 waveform capnography and the ventilator circuit (as per instructions
included in the disposable circuit kit) to the patient's airway adjunct or CPAP mask.
4. Refer to the OPERATION MANUAL for further operations, settings, alarms, and
troubleshooting issues.
5. Verify lung sounds every 5 minutes, and before and after moving the patient.
Complications:
1. Please refer to the OPERATION MANUAL to troubleshoot operations, settings, alarms,
and other issues.
NOTES:
1. Battery life is shortened if a compressed air source is not provided as the ventilator will
use an internal compressor to mix oxygen and air for FIO2 settings.
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2. Ventilator should remain plugged into an approved power supply appropriate for the
ventilator to maintain battery charge.
3. Do not use any grease or oil near ventilator. Routine maintenance of internal components
is not necessary.
4. The ventilator is not waterproof. If operated in a wet environment, users should take
precautions and protect the ventilator by covering it with a protective barrier (such as a
small tarp, plastic sheet, etc.). Refer to #8 below when covering the ventilator.
5. Do not clean with chlorinated hydrocarbon cleansers or alcohol based cleaners. The
ventilator's external housing, carry case, and pressure hose connectors may be cleaned as
necessary with a clean, damp, soapy cloth, then wiped clean with a lint-free cloth.
6. The compressor inlet filter housing is located to the right of the connector panel on the
side edge of the bottom cover. Remove filter using a pair of tweezers or similar tool.
Examine the filter for dirt, lint, or general wear. Replace if necessary. DO NOT attempt
to clean this filter. Do not operate internal compressor without filter in place.
7. Verify the gas pressure remaining in your ambulance's main and portable oxygen
cylinders periodically and have plan to have alternate cylinders available as needed.
8. DO NOT block or connect the ventilator circuit hose to the Internal Compressor Air
Filter port.
9. Internal components are susceptible to damage from static discharge.
10. DO NOT include a "pop-off" or PEEP valve during ventilator use. The ventilator can
control PEEP settings internally.
11. Ensure the OPERATION MANUAL is available at all times during use to assist in
ventilator setup, operations, and troubleshooting.
* This procedure is intended only for the Impact Instrumentation, Inc. Uni-Vent (TM) Eagle (TM)
Model 754 Portable Ventilator. Subsequent modifications or separate procedures may be
designated for other devices as needed. Verify you are using the most current procedure manual
before operation.
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Ventriculostomies
Level 6
Purpose: To provide a general guideline for the care and transfer of a patient with a
ventriculostomy. Use clinical discretion and physician consultation as appropriate.
Procedure:
2. Maintain patient’s head position per physician’s order (usually 30 degrees).
3. Check and document dressing site and appearance.
4. Confirm in physician orders, level of drain and any other patient specifics in regards
to monitoring.
d. Drainage:
i. Review physician’s order to place ventriculostomy to drain as ordered or to
monitor.
ii. To place the system to drain, the stopcock at the zero level is opened to the
drainage bag side. The drip chamber is placed so that the zero level is at the
rd
5.
6.
7.
8.
foramen of Monroe (Point of communication between the 3 and lateral
ventricles of the brain). Anatomical landmark for foramen of Monroe is the
external auditory canal.
iii. The Buretrol will be moved so the pressure line is at the ordered level of
drainage.
The system must be secured on a pole at all times. The system is adjusted to obtain
the zero level.
Monitoring only: No measurements should be collected during transport.
If tubing becomes occluded during transport, do not flush or manipulate line. Notify
receiving staff upon arrival.
Document on PCR drainage amount, color, ICP and any other pertinent information.
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E.P.A.B.
Page:
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Lucas 2 Chest Compression System
Level 1-2-3-4-5-6
Indications:
3. Adult cardiopulmonary arrest
Contraindications:
1. If it is not possible to position the LUCAS safely or correctly on the patient’s chest.
2. Too small patient: If you cannot enter the PAUSE mode or ACTIVE mode when the
pressure pad touches the patient’s chest and LUCAS alarms with 3 fast signals.
3. Too large patient: If you cannot lock the upper part of LUCAS to the Back Plate
without compressing the patient’s chest.
Procedure:
This
Intentionally
Left
Blank
1. Position the LUCAS
bagPage
with the
green top nearest
rescuer
2. Open bag pulling on red tab
3. Push ON/OFF button for 1 second
4. Remove Back Plate and place under the patient immediately below the armpits while
minimizing manual compression interruptions.
5. Attach LUCAS support leg nearest you to the back plate.
6. Stop manual compressions
7. Attach the other support leg to the Back Plate.
8. Pull up once to unsure adequate support leg position.
9. Push the ADJUST button the push the Suction Cup down with two fingers against
chest on top of the QCPR device.
10. Ensure lower edge of suction sup is above the lower end of the sternum.
11. Push PAUSE button to lock the Start Position and remove fingers from suction cup.
12. Push ACTIVE continuous button to start the compressions.
13. Position Stabilization Strap behind neck and adjust to maintain suction cup above the
lower end of the sternum.
14. During rhythm evaluation or pulse check, push PAUSE button then push ACTIVE
continuous button again to restart compressions.
15. If Suction Cup readjustment is needed, push PAUSE and then ADJUST button
16. Reposition Suction Cup and above procedure starting at #9.
17. Follow appropriate Cardiac Arrest protocol
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Medical Control for the MedStar System
Page:
12-0
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12 POLICIES
Clarification about common terminology referring to personnel:
Throughout all policies and protocols, the term “Lead Medic” refers to the designated
medic in charge of the ambulance. The phrase “under the direct supervision of a Lead
Medic” means:
1. That both the person performing care and a Lead Paramedic are in the patient
compartment of the ambulance; or
2. The person performing care while on a scene, but not during transport, has been
delegated a specific task or procedure by a Lead Paramedic.
Throughout all policies and protocols, the terms “First Responder Personnel” refer to
personnel who are on duty as First Responders and not assigned to an ambulance.
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Against Medical Advice
1.
2.
3.
4.
5.
Purpose. Alert and oriented adults have the right to refuse treatment and/or
transport to a medical facility regardless of their medical condition. However, this
decision must be an informed one. The patient must understand the possible
consequences of his/her decision.
Scope. This policy applies to MedStar and First Responder DSHS
certified/licensed medics.
Types of AMAs. There are two types of AMAs:
a.
Basic Life Support (BLS). A BLS AMA is one that may be completed by a
Level 1-2. The patient must meet the specific criteria listed in this policy to
be considered a BLS AMA.
b.
Advanced Life Support (ALS). An ALS AMA is one that must be
completed by a Level 3-4-5-6. Any patient whose condition falls outside of
the BLS AMA criteria will be considered an ALS AMA.
Criteria. The following criteria will determine if a BLS AMA may be completed.
All questions must be answered “No” for a person to qualify for a BLS AMA. If
any of the criteria are answered “Yes,” an ALS AMA must be completed.
a.
Is the person disoriented or confused? This question may be answered
“No” only if he or she is alert and oriented to:
i.
Person,
ii.
Place,
iii. Time,
iv.
AND Event,
v.
Or appropriate orientation.
b.
Was there any loss of consciousness? This question may be answered “No”
only if there is no evidence that the person experienced no loss or changes in
level of consciousness. Evidence may include information from witnesses.
c.
Is there any evidence of alcohol or drug use? This question may be
answered “No” only if:
i.
The person does not appear to be under the influence of any medications
or drugs that could impair judgment.
d.
Is there any high risk complaint of illness, pain or injury? This question
may be answered “No” only if:
i.
The person has no possibility of experiencing any significant injury or
illness; or
ii.
The person has no recent history of a possible illness or injury that has
resolved within the last hour such as, but not limited to, recent loss or
change in level of consciousness, seizure, dyspnea, or chest pain.
e.
Is there a significant mechanism of injury? This question may be
answered “No” only if there:
i.
Are no signs that the force involved in the event was of sufficient
magnitude to cause a potential injury;
ii.
A motor vehicular accident (any type of vehicle) did not cause the death
of an individual in any of the vehicles involved in the incident.
f.
Was there any ALS treatment performed on the patient? This question
may be answered “No” only if no ALS treatment or any medications were
administered to the patient.
Against Medical Advice. If a patient refuses transport in an ambulance, the refusal
will be documented on the patient record. If the patient appears to need treatment
and a concern exists regarding the patient’s ability to make an informed medical
decision (i.e., a minor, disoriented patient, etc.), the following procedure applies:
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a.
6.
7.
8.
9.
10.
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The patient will be advised of his/her medical condition and the necessity of
being transported and treated at an appropriate medical receiving facility.
b.
If an ambulance is responding, first responders must cancel the ambulance.
If there is any uncertainty regarding the patient’s needs or ability to make an
informed decision, an ambulance should be allowed to respond or should be
requested.
c.
If indicated, contact the local law enforcement agency for assistance. Upon
local law enforcement arrival, the medic is to inform the law enforcement
representative of the patient’s medical condition and the necessity for further
treatment and transportation to a medical receiving facility.
d.
When findings or history are strongly suggestive that an AMA could result in
probable harm or demise, it will be considered an ALS AMA and the
paramedic should make every effort to communicate the need for transport
and further treatment at a medical facility. The paramedic should inform the
patient of potential consequences of refusing transportation to a medical
receiving facility. In this case, First Responder paramedics should
allow/arrange for the patient to be evaluated by a MedStar ambulance Lead
paramedic.
e.
If the patient continues to refuse transportation, the patient will be requested
to sign an AMA form. The medic completing the AMA must carefully
document their assessment, their efforts, and information provided to the
patient.
Refusal of Treatment: In the event a patient refuses treatment outlined in protocol
but is accepting transport a specific notation of such should be made in the patient
care record.
Refusal to Sign the AMA: All efforts should be made to have the patient sign the
AMA form. If they continue to refuse to sign the AMA, proper documentation
should be made describing the refusal and it must also be signed by the appropriate
individual.
Witness Signature: A witness should be a non-biased individual, if available, who
actually witnesses the patient’s signature. If possible, a police officer should be
selected to sign as a witness.
AMA Of Minors
a.
A minor is a person under 18 years of age who is not and has not been
married or who has not had his/her disabilities of minority removed for
general purposes in accordance with the Texas Family Code.
b.
If there is no parent, legal guardian or other person authorized by law to give
consent to medical treatment available, any person not considered legally an
adult cannot refuse transport to a medical facility. They shall be transported
or be turned over to law enforcement personnel.
Quality Assurance Review. The First Responders shall submit the monthly
QA/QI reports to EPAB.
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Cancellation of Ambulances by First Responder Organizations
1. Purpose. This policy establishes the circumstances under which MedStar ambulances
should be cancelled by EPAB approved first responder personnel and the procedure
for cancellation of MedStar Ambulance.
2. Scope. This policy applies to EPAB approved First Responder personnel.
3. Policy.
a. Situations under which a First Responder personnel should cancel
ambulances. A MedStar ambulance should be cancelled by the First Responder
personnel for the following situations:
i.
Assist a Citizen: This means that, upon arrival, first responders determine
that a person needs assistance of a non-medical nature and there is no need
for an ambulance. The appropriate documentation should be completed by
the First Responding Organization.
ii. False Calls: This means that a call is for a false location or persons at that
location did not call for an ambulance and do not need an ambulance.
iii. Unable to Locate: This means that, after attempts to identify other
possible locations and potential errors have been ruled out, the patient or
the location to which units have been dispatched may not exist or cannot be
found with the information provided.
iv. No Patient Found: This means that, upon arrival and after every
reasonable effort to find the patient, no patient can be found.
v.
Mutual Aide being utilized: If a response to a call is significantly delayed,
the first responder agency may elect to utilize mutual aide to respond to
their scene. This agency must contact MedStar’s dispatch center to cancel
the responding MedStar ambulance. The proper patient care form must be
completed.
vi. Dead on Scene: This means that, upon arrival, a first responders have
identified that a patient is dead as described in the appropriate policy.
vii. Against Medical Advice (AMA):
The First Responding Organization
is to complete the proper AMA documentation as required by EPAB and
will cancel the responding unit prior to their arrival.
viii. Release at Scene (RAS):
The First Responding Organization will
complete the proper RAS documentation as required by EPAB and will
cancel the responding unit prior to their arrival.
4. Procedure.
a. Cancellation of ambulances from the scene. First responders who are
responding or who are not on scene may not cancel a MedStar Ambulance. Only
first responders who are on scene may cancel a MedStar Ambulance. The only
exception is in case where first responders are unable to find the location to
which they have been dispatched as described in this policy.
b. Cancellation of ambulances while they are responding. FROs should cancel
the ambulance by notifying their dispatch center. The dispatch center should
relay the cancellation notice to the MedStar communications center.
c. Cancellation of ambulances as they arrive on scene. Ambulances may be
cancelled when they arrive at the scene if the first responders have already
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determined that there are no patients on scene or if patients are refusing
transport.
5. Quality Assurance Review. The First Responders shall submit the monthly QA/QI
reports to EPAB.
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Continuing Education
1. Purpose. The Medical Director requires personnel to complete specified quantities
of continuing education each year. The purpose of this procedure is to standardize
the administration and documentation of continuing education within the MedStar
System. A thoroughly planned process helps assure that CE is timely, appropriate,
and accurately recorded.
2. Scope. This procedure applies to Continuing Education provided within the
MedStar System by all member agencies and the MedStar Ambulance Operations.
3. Procedure
a. Annual CE Plan
i. Any agencies within the MedStar system that provide their own continuing
education are required to develop an annual CE plan, which shall be
approved by the Medical Director or designee. At minimum, the Annual CE
Plan shall address the following areas.
ii. An instructor list and their qualifications;
1. Copies of the training program syllabus or policies that regulate training
within the agency;
2. The annual plan may undergo minor revisions from year to year
negating the need for a complete revision with the approval of the
Medical Director or designee.
3. If the agency submits an Ongoing CE Program Application to the Texas
Department of State Health Services, the application and its attached
components must be submitted to EPAB to comply with this policy.
iii. CE Content Approval. EPAB holds a Texas DSHS CE number and awards
CE hours for MedStar courses. In order to be awarded CE hours, all Texas
DSHS rules and regulations must be followed and submitted to EPAB. This
should include, but is not limited to:
1. Name of the course
2. Objectives
3. Exam
4. Exam Key
5. Lecture Outline
6. PowerPoint or other visual mediaReferences/Resources
b. CE Content Areas. Continuing education will be provided in the content areas
required by the following:
1. Texas Department of State Health Services ;
2. National Registry, if applicable; and the
3. Emergency Physicians Advisory Board.
c. Card Courses: All card classes required by EPAB (i.e. BCLS, ACLS,
PALS/PPC, PHTLS/BTLS, etc.) must have an EPAB approved hands-on
megacode examination. If a person submits a non-EPAB approved card course
certificate, they will have to complete an EPAB approved hands-on megacode
examination. Without this megacode, that course may not meet the
requirement.
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d. Continuing Education Record Keeping
i. All agencies will comply with all Texas Department of State Health
Services regulations regarding CE records.
ii. The Medical Director or designee shall have access to all EMS related
training-records with reasonable notice.
iii. If CE hours are awarded by EPAB, the following documentation is required:
1. Roster
2. Exam
3. Evaluation
4. Copies of the Course Completion Certificates
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Dead On-Scene and Termination of Resuscitative Efforts
1.
2.
3.
4.
5.
6.
Purpose. This policy establishes the process for classification of a patient as
“DOS” (Dead on Scene) or as “Possible DOS.”
Scope. Except as described in 4(c), this policy applies to all Levels of EPAB
Permit.
DOS: No radio transmission involving the BSP is required for the following:
a.
Dependent lividity;
b.
Decapitation;
c.
Rigor mortis;
d.
Decomposition;
e.
Incineration; or
f.
Pulseless patients with blunt trauma that is not the result of a mechanism of
injury caused by a primary cardiac arrest.
Possible DOS: All patients that do not meet the above criteria and that present
without vital signs or with injuries assumed to be incompatible with life, REQUIRE
BSP contact to determine whether or not a DOS classification will be issued.
a.
In cases where signs of blunt trauma are present, but the Lead paramedic
suspects that the arrest is the result of a primary cardiac arrest, the patient
should be treated as a possible DOS.
b.
In the case of a possible DOS, first responders and MedStar personnel will
initiate CPR until the BSP has been contacted and a decision has been made
to Terminate Resuscitative Efforts.
Termination of Resuscitative Efforts. In patients with non-traumatic cardiac
arrest who have received FULL ACLS for a minimum of 30 minutes, and remain
pulseless may be pronounced dead. In such cases, the EMS personnel may not
leave the scene until the police department is on-scene. Termination of field
resuscitative efforts should not occur:
a.
In pediatric patients;
b.
In an exposure setting such as hypothermia;
c.
When there has been a return of a pulse during the resuscitative effort;
d.
In a setting where the family is uncomfortable with the termination of field
resuscitation efforts; or
e.
In a public setting (the patient should not be left in a public place
unattended).
Special Circumstances. Special circumstances requiring BSP orders for
termination of resuscitative efforts included:
a.
When unable to obtain an advanced airway and/or IV/IO access, therefore
preventing FULL ACLS;
b.
If the lead medic feels uncomfortable about performing the termination of
resuscitative efforts by standing order.
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E.P.A.B.
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Replaces:
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Demotion, Suspension, and/or Revocation of an EPAB Permit
1.
2.
3.
4.
Purpose. This policy is a process to permit, suspend, and revoke personnel within
the MedStar system as required by Uniform EMS Ordinance.
Scope. This procedure applies to all personnel who are rendering patient care in the
MedStar System under the Medical Director’s license. The Medical Director
approves and permits personnel for practice in their respective medical roles as
defined in protocol.
Overview. The objective of this policy is to define the actions that may be taken by
the Medical Director or designee, if a medic deviates from the EPAB Protocols,
Procedures, or Policies and/or fails to meet the current clinical standards during
training, evaluation, and testing. Each incident will be reviewed in a timely manner,
and a final decision will be made by the Medical Director. Actions that could be
taken include demotion, suspension, or revocation of the person’s EPAB permit.
The Process. The following process is a guideline used by EPAB.
a.
Discovery. Under the ordinance, any person may submit a complaint or
concern to EPAB for investigation. EPAB may also discover a concern of an
individual that has clinical significance. The following are some of the ways
EPAB may discover a possible deficiency in clinical knowledge:
i.
Chart Reviews- Performed by EPAB or MedStar’s designated
personnel
ii.
Radio Report Audits- A question in the radio report warrants
investigation
iii.
Interviewing Sessions- Interviews with the Medical Director and
EPAB staff, and/or the individual’s employer (MedStar Operations
Department personnel and Fire Department personnel)
iv.
Facility Staff- Hospitals, Specialty Facilities, etc may report a concern
or complaint which will warrant investigation.
b.
Actions to be taken.
Once an issue or concern is discovered, the Medical
Director or designee may take no action on the individual’s EPAB permit or
perform the following actions based on the severity of the issue or concern
until further investigation is completed:
i.
Suspend the person’s EPAB permit; or
ii.
Demote the level of the EPAB permit.
c.
Investigation Process: EPAB will then conduct an investigation of the
report.
i.
Notify the individual’s Employer/Department: The Agency will be
notified by EPAB when discovery of an issue or concern has been
made.
ii.
Documents reviewed: EPAB will review all applicable data including
but not limited to, patient care forms, radio reports, clinical audit files,
and past clinical issues. MedStar and/or the First Responding Agency
should submit related information within 24 hours of the request to
EPAB, if requested
iii.
Meeting at EPAB: A meeting between the Medical Director and/or the
designee, the individual, and their EMS Representative will be
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E.P.A.B.
5.
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scheduled at the earliest convenience of everyone involved. If
discovery of the issue or concern was during an EPAB interview, this
may serve as this meeting.
d.
Actions Taken by EPAB: The Medical Director and/or designee may take
the following actions:
i.
Suspension: The person’s EPAB permit may be suspended
immediately, or following the investigation process if the circumstances
warrant it.
ii. Demotion: A MedStar Lead Paramedic may be demoted immediately or
after the investigation, to a lower status. The demotion may be to lower
level of credentialing status. The First Responder medic may also be
demoted to a lower of credentialing status.
iii. Revocation of Permit. Personnel permitted to work by EPAB, do so
with the understanding that they are functioning as an extension of the
Medical Director, and under his or her authority as a physician.
Therefore, if the Medical Director believes that any individual permitted
by EPAB should not function with that authority, the Medical Director
may revoke or suspend their permit.
e.
Time Period:
The duration of any status change will be determined by the
Medical Director.
Remediation, Reinforcement and Recertification. Persons that have had their
permit suspended, demoted, or revoked may, at the discretion of the Medical
Director, receive a temporary permit to work in a limited capacity while undergoing
a remediation plan. EPAB may develop the remediation plan or EPAB may have
their EMS Coordinator submit a remediation plan for approval. The person will
complete all components of the remediation plan prior to continuing in the process.
The individual will be monitored by their EMS Coordinator during this time to
ensure compliance with the Medical Director’s expectations.
a.
The remediation plan may consist of, but is not limited to:
i.
A research paper
ii. Being re-assigned to a Field Training Officer
iii. Clinical Rotations:
1. Hospital
2. Ambulance
3. Specialty Procedure Facility
iv. Mega-Code Scenarios
v.
Skills Verifications
vi. Clinical Interview
b.
The individual may be called to have an interview with the Medical Director
and/or the designee for:
i.
Further education
ii. Skills verifications;
iii. Mega-code Scenarios;
iv. Other Evaluations.
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E.P.A.B.
6.
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Final Resolution of the EPAB Permit: The individual’s permit may be approved
for reinstatement by the Medical Director once the individual has satisfactorily
completed the remediation period, and has interviewed with the Medical Director.
The Medical Director may, but is not limited to:
a.
Reinstatement of the EPAB permit;
b.
Continued Suspension or demotion;
i.
At this time, an additional remedial plan may be established by the
Medical Director and/or designee.
ii. Revocation of the EPAB permit; or
c.
Complete termination of Medical Director/medic relationship
.
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Do Not Resuscitate
1.
2.
3.
4.
5.
6.
7.
Purpose. Chapter 166 of the Health and Safety Code establishes Out-of-Hospital
Do-Not-Resuscitate (OOH DNR) Orders. The chapter allows the development of a
local DNR policy that complies with the State-wide DNR protocol adopted by the
Board of Health.
Scope. This policy applies all EPAB approved EMS personnel in the MedStar
system. This policy applies to all out-of-hospital events including cardiac arrests
that occur during inter-facility transports.
DNR Form and Identification of Patients.
a.
EMS personnel may only accept the original or a copy of the standardized
DNR Order form developed by the Texas Department of State Health
Services.
b.
EMS personnel may accept an approved OOH DNR bracelet or necklace
(identification device) as proof that an OOH DNR order form has been
executed by or issued on behalf of the person wearing the identification
device.
c.
When presented with a “DNR Order,” EMS personnel should make every
effort to identify the patient as the person for whom the OOH DNR Order has
been executed or issued. Relatives, friends, neighbors, documents, ID
bracelets, or other identification may be used as sources of identification.
Honoring an OOH DNR Order.
a.
When presented with a DNR Order, EMS personnel are to review the form to
make sure that it is correctly completed and signed as required by the Health
and Safety Code. If the order appears valid, the OOH DNR Order shall be
honored.
b.
EMS personnel are not required to honor an OOH DNR Order that does not
comply with the Health and Safety Code.
c.
EMS personnel may honor OOH DNR Orders executed in another state if
there is no reason to question the authenticity of the order of identification
device.
Revocation of an OOH DNR Order.
a.
The patient may revoke an OOH DNR Order, or the patient may direct
someone in his or her presence to destroy the order and remove the patient’s
identification device.
b.
A qualified relative, legal guardian or patient’s agent having medical power
of attorney (or a person acting on behalf of any of these persons) may revoke
the OOH DNR Order.
c.
The patient’s physician may revoke the OOH DNR Order.
d.
In case of a revocation of the OOH DNR Order, EMS personnel shall
document the name of the person who revoked the order, the date, time, and
location of the revocation.
e.
Upon revocation of the OOH DNR Order, EMS personnel shall provide care
for the patient as required by protocol.
Disputes related to OOH DNR Orders. In case a dispute arises regarding an
OOH DNR Order, EMS personnel shall contact a BSP for direction, shall contact
their supervisor for assistance, and shall report the incident to the Medical Director
or designee.
Pregnant Persons and OOH DNR Orders. EMS personnel may not withhold
cardiopulmonary resuscitation or certain other life-sustaining treatment from a
person known to be pregnant.
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E.P.A.B.
8.
9.
Page:
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Reporting Requirements. All First Responder agencies and the MedStar
Operations shall comply with the OOH DNR reporting requirements set forth by the
Texas Department of State Health Services.
Other presented DNR paperwork. If other forms of DNR orders are presented to
EMS personnel, an EPAB BSP must be contacted for direction.
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E.P.A.B.
Page:
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Emergency Medical Dispatch
1.
2.
3.
4.
5.
Purpose. As required by the Uniform EMS Ordinance, EPAB establishes standards
for dispatch protocols. Accordingly, EPAB must assure that Emergency Medical
Dispatch personnel are qualified to perform the tasks indicated to comply with the
protocols.
Scope. This policy applies to the MedStar Operations.
Qualifications:
a.
EMD Certification. Personnel who answer 911 calls must maintain current
Emergency Medical Dispatcher certification from a nationally recognized
program and must meet all continuing education, performance, and
performance improvement requirements to maintain that certification.
b.
EMS Certification. Emergency medical dispatch personnel are not required
to hold additional EMS certifications.
c.
CPR Card. Emergency medical dispatch personnel must hold a current CPR
card from a nationally recognized organization that includes Adult, Child,
Infant CPR and First Aid for Choking, and Automated External Defibrillation.
EMD Protocol. The MedStar Communication Center shall follow EMD protocols
from a nationally recognized organization. Such protocols shall be approved by the
medical director and shall be reviewed at least annually.
Performance Improvement. The MedStar Communication Center shall
implement a performance improvement process to monitor compliance with
protocols.
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E.P.A.B.
Emergency 911 Calls from within the Hospital
1.
Purpose. The Uniform EMS Ordinance mandates that the EPAB shall establish
guidelines for response to and the transportation of all patients. This policy
addresses when a patient calls for an ambulance within a hospital.
2. Scope. This policy applies when a person contacts the MedStar Communications
Center within a hospital requesting an ambulance for care. This policy will describe
the procedure to follow when providing care to this patient.
3. Appropriate action to follow. If a person within a hospital contacts the
Communications Center requesting an ambulance, the following procedure will be
followed:
a. Properly EMD the call: The call will be screened utilizing current procedures
and then confirm that the patient is calling from within the hospital.
b. Provide instructions: If the person is calling from within the hospital, they
should be instructed to immediately report to the Triage Nurse or the Charge
Nurse and inform them that they have contacted 911 requesting an ambulance.
Explain to the person that an ambulance may not be dispatched by their request
and that it has to be requested by the hospital personnel.
c. Contact the Hospital: The Communications Specialist should immediately
contact the charge nurse of that ED or hospital by phone and advise them of the
situation.
d. If the person is outside of the hospitals: If the patient requesting the ambulance
is outside of the hospital, or there is any confusion, the Communications
Specialist should follow regular 911 call procedures.
4. If the hospital then requests an ambulance: If the hospital requests an ambulance
for the patient, the Communications Specialist should properly EMD the call and
assign the appropriate level of response
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E.P.A.B.
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Exams and Subscales
1. Purpose. The Emergency Physicians Advisory Board relies on periodic
examinations as a tool to assess retention of required knowledge and mastery of skill
performance among EMS personnel.
2. Scope. Exams and scores may include, but not be limited to, the review of any Texas
Department of State Health Services EMS certification examination results, periodic
protocol examinations, and periodic skills “check offs.”
3. Procedure.
a. Initial Credentialing of First Responder Agency and MedStar Providers
i. Written Examinations.
1. EPAB requires all personnel to pass the following written exams to remain
permitted:
2. Initial Certification Exam established by receipt of state certification; or
3. Re-certification exam or evaluation, or its equivalent, within the stated time
parameters; and
4. Protocol-based written examination:
a. Multiple choice protocol exam
i. Fill-in-the-blank protocol exam for Level 4-5-6
b. Level 2-3-3-4-5-6 personnel must successfully complete a skills
verifications packet which includes an advanced airway skills checkoff.
ii. The Medical Director may elect to omit a subscale or exam from these criteria
and may, at any time, replace these requirements with other exams or
requirements.
iii. Personnel must pass each examination with at least an 85%. On exams that
contain subscale scores, each subscale must be passed with at least a 75%.
iv. If an individual fails to meet an exam or subscale requirement, upon receiving
notice of test scores, personnel shall contact the Medical Director or designee
and make arrangements for a subscale evaluation at the EPAB office. A re-test
must be completed within 30 days of notification. The candidate’s employer
may only re-schedule an exam for this individual once in the re-test period. If
the rescheduled time is missed, EPAB may elect to not reschedule additional
sittings for the exam.
v. Permit Status in Case of Failure.
a. Personnel who fail to meet an exam or subscale requirement must retest
within the allotted time. Personnel may be issued a temporary permit to
work during this time. The Medical Director or designee may suspend
the permit of personnel who do not re-test within the allotted time.
Failure to make arrangements or to be responsive regarding the retest process may also be grounds for suspension of a personnel
permit.
b. Personnel who fail three (3) or more subscales must take the entire
exam.
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E.P.A.B.
b.
c.
d.
e.
Page:
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vi. Failure of a re-test.
a. The Medical Director or designee may suspend the permit of a person
who fails a re-test. Personnel who fail a re-test may successfully
complete another re-test no earlier than 24 hours and up to 15 days only
when permitted by their employer. A maximum of two re-tests are
allowed. The Medical Director will then make the determination of
that individual’s ability to function within the EPAB System.
EPAB Scenario Based Credentialing Examination.
i. Individuals seeking credentialing at the Level 4-5-6 must successfully pass a
hands-on scenario based credentialing examination performed on simulation
mannequins. This examination is issued by the Education and Training
Department and EPAB.
ii. This process is completed with actual equipment, supplies, and items on a
simulation mannequin (adult, pediatric, and infant). The goal of this process is
to be assured that the individual may provide patient care listed in the EPAB
protocols, procedures, and policies.
iii. The individual may be requested to perform this simulation individually, with
one partner, and/or with a partner and First Responder/MedStar crew.
iv. This examination is a prerequisite of becoming credentialed as a level 4-5-6 in
protocol.
Medical Director Interview.
i. Individuals seeking credentialing at the Level 4-6 must participate in an
interview with the Medical Director to discuss their practice of medicine
together. This meeting will be the final credentialing of that individual.
Maintaining Credentialing
i. All existing credentialed medics within the MedStar System are required to
perform the following in order to maintain their EPAB credentialing:
ii. Follow all requirements listed in the Continuing Education Policy and the
Personnel Permitting Policy.
iii. Successfully pass an EPAB issued written protocol examination every two
years.
Study guides and materials. Personnel are responsible for gathering their own
study materials. EPAB is not responsible for distribution of textbooks or study
guides unless it is an EPAB sponsored specialty course (example: Crash
Airway/PAI).
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First Responder Agency and Personnel Credentialing
1.
2.
3.
4.
5.
6.
7.
Purpose. This policy establishes the levels of credentialing for First Responders
within the MedStar System as required by the Uniform EMS Ordinance.
Scope. The levels of credentialing in this policy apply to the First Responder
Agencies operating within the MedStar System.
Agency Recognition. First Responder Agencies shall meet applicable Texas
Department of State Health Services requirements for recognition as a First
Responder Organization and should hold a current DSHS First Responder
Certification.
Duties. The duty of the First Responder Agency is to provide early care and
intervention in accordance with EPAB protocol. To have their employees, paid
and/or volunteer, to adhere with all EPAB protocols, procedures, and policies listed.
Identification. First Responder personnel shall meet the applicable Texas
Department of State Health Services standards for identification of personnel when
responding to emergencies.
Approval Required. Before responding to medical emergencies, personnel must
meet requirements of EPAB policy entitled “First Responder Personnel Levels of
Care.”
Levels of First Responder Agencies- All levels must be approved by EPAB and the
Medical Director. The Agency must perform all current designated level requirements
for a minimum of 12 continuous months prior to receiving a higher designation. The
minimal requirements are listed for each level below:
a. Level 1 - Basic Life Support
i. Agency Requirements.
1. Appropriate Provider License with the Texas Department of State Health
Services
2. Representative must attend 75% the monthly First Responder Meetings
3. Submit monthly reports mandated by EPAB
4. Participate in continuing education classes approved by the office of the
Medical Director.
5. Have the necessary training equipment and supplies for each employee to
perform the required EPAB Skills Verifications Packet to their specific
level of care.
b. Level 2 - Intermediate
i. Agency Requirements
Services
2. Attend 75% the First Responder Meetings
Medical Director.
level of care.
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This includes advanced airway mannequins for the practice of the
required advanced airway procedures performed at the individual’s
level of care.
c. Level 3 – ALS
i. Agency Requirements.
Services
Medical Director.
level of care.
a. This includes advanced airway mannequins for the practice of the
level of care.
b. If this equipment is not be supplied by the First Responder Agency,
certain aspects of this level may be limited by the Medical Director.
d. Level 4 –ALS Advanced
i. Agency Requirements
Services
Medical Director.
level of care.
a. This includes advanced airway mannequins for the practice of the
level of care.
6. Each Level 4 Paramedic must perform an annual “ride-out” (quarterly is
preferred) on a MedStar Ambulance Primary Paramedic shift.
7. Performance of the specific EPAB training classes for special procedures
including, but not limited to:
a. Crash Airway Training
b. Controlled Substance Technician Course
8. Successful completion and passing of a second EPAB Protocol
Examination with a minimum of 85%.
9. Successful completion and passing of an EPAB Scenario Based
Credentialing Examination. This will be organized, scheduled, and
administered in coordination with EPAB and the Education and Training
Department.
a.
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E.P.A.B.
8.
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Part-Time MedStar Ambulance Paramedics
a. If a First Responder Agency has an employee that is also employed by MedStar
Ambulance, they are credentialed by the Education/Training Department and
EPAB in their current level, they may function at their level in protocol.
i. If the First Responder Agency will provide all necessary supplies and
equipment listed in the specific level’s inventory sheet, an individual may
function at that level of his/her EPAB credentialing.
ii. For example: A First Responder Agency Paramedic is a part time
employee for MedStar Ambulance and is credentialed as an M-5. If the
First Responder Agency will sufficiently carry all items to comply with
Level 5 care in protocol, then that paramedic may function at the F-5 level
in protocol.
b. If the First Responder Agency will not provide all necessary supplies and
equipment listed in the specific level’s inventory sheet, their employee may
function at the level supported by the First Responder Agency’s level of
credentialing. Once the MedStar Ambulance is on-scene, if allowed by the
MedStar Lead Medic, the individual may perform at the level of his/her EPAB
credentialing level.
iii. For example: A First Responder Agency Paramedic is a part time
employee for MedStar Ambulance and is credentialed as an M-5. Prior to
the arrival of the MedStar ambulance, the F-5 credentialed Paramedic may
only function at the Agency’s Level 3 credentialing. Once the MedStar
Ambulance is on-scene, the MedStar Lead Medic may allow that
Paramedic to utilize MedStar’s equipment to perform his/her F-5
credentialed procedures.
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E.P.A.B.
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First Responder Personnel Levels of Care
1. Purpose. EPAB has developed a process to permit personnel within the MedStar
system as required by Uniform EMS Ordinance. Standardized processes increase
objectivity, fairness, and consistency.
2. Scope. This procedure applies to all personnel who will work within the MedStar
System as EMS First Responders. While the Medical Director approves personnel
for their respective medical roles, personnel are members of their respective
organizations and must follow that organization’s employment/membership policies.
3. Overview. The objective of this process is to prepare qualified personnel for duty as
EMS First Responders.
4. The Permitting Process.
a. After acceptance into a first responder agency, candidates are to submit to EPAB:
i. A completed EPAB Personnel Data Form;
ii. Copies of current certifications and qualifications as listed in each person’s
specific permitting level.
iii. Candidates will be issued an EPAB Protocol Book by their employer and
scheduled for a protocol examination.
iv. Personnel will be required to score at least 85% on the EPAB written protocol
exam.
v. All EPAB permitted personnel shall complete the annual EPAB approved
Advanced Airway Management skills “check-off” and EPAB Skills
Verifications Packet; and
vi. Compliance with the EPAB Exams and Subscales policy.
5. Levels of Credentialing - Qualifications and Medical Procedures.
a. Level 1 – Basic Life Support (F-1)
i. First Responder Emergency Care Attendant; (F-1 ECA)
(a) Training Requirements.
a. Texas DSHS ECA Certification;
b. BCLS (CPR) Certification (AHA, ARC, or approved equivalent);
c. Successful completion of the EPAB examination(s);
d. Completion of 20 hours of EPAB approved continuing education each
year;
e. All EPAB permitted personnel shall complete the annual EPAB
approved Advanced Airway Management skills “check-off” and
EPAB Skills Verifications Packet; and
f. Compliance with the EPAB Exams and Subscales policy.
1. Procedures.
a. The F-1 ECA may not administer ANY medications except oxygen.
Standing orders listed through Level 1 in protocol are limited to the
following:
i.
Patient Assessment/Vital Signs;
ii.
Oxygen Administration;
iii.
Bag-valve-mask;
iv.
Oral and Nasopharyngeal Airway insertion;
v.
Bandaging and Splinting;
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E.P.A.B.
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Effective Date:
Replaces:
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All Previous
vi.
CPR;
vii.
AED;
viii.
Other skills specifically approved by the Medical Director
ii. First Responder Emergency Medical Technician; F-1
1. Training Requirements.
a. Texas EMT Certification;
b. BCLS (CPR) Certification (AHA, ARC, or approved equivalent);
c. Successful completion of the EPAB examination(s);
d. Completion of 20 hours of EPAB approved continuing education each
year;
e. All EPAB permitted personnel shall complete the annual EPAB
approved Advanced Airway Management skills “check-off” and
EPAB Skills Verifications Packet; and
f. Compliance with the EPAB Exams and Subscales policy.
2. Duties. An F-1 may either be a current Part-Time MedStar employee
credentialed at the M-1 level or specifically credentialed at the First
Responder F-1 level. They may perform the duties listed in the F-1 level.
3. Procedures.
a. Standing orders listed through Level 1 in protocol;
b. Patient Assessment/Vital Signs;
c. Oxygen Administration;
d. Bag-valve-mask with end-tidal colormetric CO2 monitoring;
e. Continuous waveform capnography acquisition and interpretation;
f. Oropharyngeal and Nasopharyngeal Airway insertion;
g. Oral Suctioning;
h. King LTD Airway insertion;
i. Gastric tube insertion through the King LTD(S)
i. Blood Glucose Measurement
j. Spinal Immobilization;
k. Bandaging/Splinting;
l. CPR;
m. AED Application and Operation;
n. Application of ECG Electrodes;
o. 12-Lead acquisition and transmission (if available);
p. Oral Glucose Administration;
q. Nebulized Updrafts
r. Administration of approved medications in accordance with protocol.
4. Credentialing.
a. The First Responder Agency must submit to the office of the Medical
Director all verification documentation proving the candidate has met
all Training Requirements and verified proficiency in allowed
Procedures listed in policy.
b. Level 2 - First Responder Intermediate; F-2
i. Training Requirements.
1. Texas DSHS EMT-Intermediate Certification;
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Replaces:
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All Previous
2. BCLS (CPR) Certification (AHA, ARC, or approved equivalent);
3. PHTLS or BTLS Certifications;
4. Completion of 30 hours of EPAB approved continuing education each
year;
5. All EPAB permitted personnel shall complete the annual EPAB approved
a. Advanced airway procedures must be practiced on advanced airway
mannequins as outlined in the EPAB Skills Verifications Packet in
order to perform advanced airway procedures;
6. Compliance with the EPAB Exams and Subscales policy.
ii. Duties. An F-2 may either be a current Part-Time MedStar employee
Responder F-2 level.. They may perform the duties listed in the F-2 level if
their First Responder Agency allows and enables them to do so.
iii. Procedures.
1. All Level F-1 listed Procedures;
2. Standing orders listed through Level 2 in protocol;
3. The following skills may only be completed by individuals who are
following the EPAB Skills Verifications Packet:
a. Orotracheal Intubation;
b. Peripheral Venous Access (excluding External Jugular access);
c. Administration of approved medications in accordance with protocol.
iv. Credentialing.
1. The First Responder Agency must submit to the office of the Medical
Director all verification documentation proving the candidate has met all
Training Requirements and verified proficiency in allowed Procedures
listed in policy.
c. Level 3 - First Responder Paramedic; F-3
1. Texas DSHS EMT-Paramedic Certification;
2. BCLS (CPR) Certification (AHA, ARC, or approved equivalent);
3. ACLS or “Megacode” training (Megacode training must be approved by
EPAB);
4. Trauma care training (PHTLS, BTLS-advanced, or approved equivalent);
5. Pediatric emergency care training (PALS, PEPP, or approved equivalent);
year; and
7. All EPAB permitted personnel shall complete the annual EPAB approved
order to perform advanced airway procedures; Compliance with the
EPAB Exams and Subscales policy.
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E.P.A.B.
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Replaces:
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All Previous
Responder F-3 level. They may perform the duties listed in the F-3 level if
iii. Procedures.
1. All procedures listed in the F-1 and F-2 levels;
2. Standing orders listed through the Level 3 in protocol;
3. Three lead ECG Interpretation;
4. Cardiac pacing;
5. Manual defibrillation;
6. Administration of approved medications in accordance with protocol.
iv. Credentialing.
listed in policy.
d. Level 4 – First Responder Advanced Paramedic; F-4
1. Texas DSHS EMT-Paramedic Certification;
2. Texas DSHS EMT-Paramedic License preferred;
3. National Registry Paramedic preferred;
4. BCLS;
5. ACLS or “Megacode” training (Megacode training must be approved by
EPAB);
6. Trauma care training (PHTLS, BTLS-advanced, or approved
equivalent);
7. Pediatric emergency care training (PALS, PEPP, or approved
equivalent);
8. Completion of an approved basic 12-Lead training course;
year;
10. All EPAB permitted personnel shall complete the annual EPAB
approved Advanced Airway Management skills “check-off” and EPAB
Skills Verifications Packet; and
order to perform advanced airway procedures; Compliance with the
EPAB Exams and Subscales policy.
Responder F-4 level. They may perform the duties listed in the F-4 level if
iii. Procedures. The following is a list of the procedures that may be
performed by the Level 4 Paramedic within the MedStar system:
1. Standing orders through “Level 4” level of protocol;
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E.P.A.B.
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2. Needle cricothyrotomy/TTO;
3. Nasotracheal intubation; and
4. Chest needle decompression.
iv. Credentialing.
listed in policy.
e. Level 5 – First Responder MedStar Primary Paramedic; F-5
i. Requirements. This paramedic MUST be a current MedStar Level 5
Paramedic meeting all of the stated requirements in the policy if this
person’s M-5 Level has been suspended, revoked, or placed on
“Conditional”, then this status will no longer be permitted.
6. Special Designations
a. Tactical Paramedic – “T” designation
1. All listed requirements listed in their current Level of certification.
a. Duties. A Tactical Medic is a Lead Medic and is required for each
Tactical event. They must provide patient care during care and
transport of patients who may need tactical procedures/skills during
transport. They may allow another medic to provide care during
transport as described in their specific listed “Procedures” and attend to
the patient during transport as long as no Tactical procedures/skills
have been performed. During transport the Tactical medic must attend
with patient if Tactical procedures/skills have been performed.
b. Procedures. The following is a list of the procedures that may be
performed by the Tactical Medic within the MedStar system:
1. All care listed in their current EPAB Level of Certification;
2. Standing orders through “BSP Orders” level of protocol when
contacting the BSP is prohibited due to specific tactical events;
3. EPAB permitted tactical procedures.
7. Completion of the System Credentialing Process.
a. Final Approval. The Medical Director or designee will give final approval of all
candidates and their permitted credentialing level.
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Helicopter Utilization and Safety
1. Purpose. The Uniform EMS Ordinance mandates that the EPAB shall establish
guidelines for the role of helicopter usage in emergency care. EPAB recognizes the
enormous benefit of such a specialized service but also realizes it must be used
appropriately and safely. In most cases, ground transport can be utilized without
significant delay, more economically, and more safely.
2. Scope. This policy applies to any person who is responsible for initiating a helicopter
response. All helicopter requests must be done through the MedStar Communication
Center.
3. Appropriate use of helicopter transport. There are extenuating circumstances that
will require the expeditious use of emergency helicopter transport. EPAB has
identified six situations as prime indicators for calling helicopter support in the
severely traumatized patient.
a. Critical burn involving the airway.
b. Circumferential burn in danger of causing compartment syndrome or respiratory
difficulty.
c. Extended extrication time (greater than 20 minutes) of a critically injured patient.
d. Patient inaccessible due to terrain or environmental conditions (i.e., high water,
mud, rough terrain).
e. Extended travel time of a critical patient (greater than 30 minutes) to a receiving
facility due to distance or traffic.
f. Multiple or Mass Casualty Incident (MCI) with critically injured patients.
4. Requesting Emergency Helicopter Support.
a. Initiating a Standby/Launch Request. “Standby” status places the helicopter
crew on alert for possible scene response. From initiation of standby to “alert
go,” the helicopter requires approximately five (5) minutes preparation to launch.
A launch order or “alert go” physically orders the helicopter and flight crew to
lift-off and proceed to the requested location. Provide the height and weight of
the patient (if known) at the time of launch request. A standby/launch request
through the MedStar Communication Center may be initiated by any of the
following:
i. Any first responding unit or MedStar unit.
ii. Fire and Civil Defense personnel.
iii. State and Local Law Enforcement personnel.
iv. Industrial safety personnel.
b. Who May Cancel The Helicopter: Once launched the helicopter will only be
cancelled by:
i. The initiating official/agency, or
ii. The MedStar ambulance Lead paramedic on-scene, after conferring with the
Fire Department Incident Commander.
iii. The decision to cancel a helicopter may only be made after:
2. Patient contact has been established
a. Performance of a proper patient assessment, and
b. Notifying Fire Department incident commander of decision
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i. If disagreement concerning cancellation exists between the Fire Department
incident commander and MedStar Lead paramedic, the ultimate decision will
be made by the MedStar Lead paramedic.
c. Safety.
i. The decision to launch is totally under the control of the helicopter pilot.
Factors influencing flight safety for the patient and aero medical personnel
will always take precedence in this decision.
ii. All personnel within the MedStar system shall complete a Helicopter Safety
training program as part of their orientation or continuing education program.
d. Documentation
i. A full patient care form must be completed for each patient transported by a
helicopter.
e. QA/QI
i. All Agencies must submit helicopter utilizations in their monthly CQI
reports.
ii. All helicopter Agencies must submit QA/QI reports to EPAB as stated in the
EPAB Permit Application.
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E.P.A.B.
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Incident Command System
1. Purpose. The uniform EMS Ordinance requires EPAB to set standards for patient
care. Large or complex incidents require specialized policies to establish a unified
command structure, common terminology, and an incident action plan (IAP). The
objective is to assure that rescuers remain safe and that single resources are utilized
effectively and efficiently as they treat and transport patients in an organized fashion.
2. Scope. This policy applies to all MedStar agencies during a large-scale incidents or a
Mass Casualty Incident (MCI).
3. Procedure Overview. All emergency events will be managed in accordance with
the nationally recognized Incident Command System (ICS) as established by the
Federal Emergency Management Administration. The Fire Department Incident
Commander (IC) will direct the overall operation at the scene. Emergency medical
services will operate as a Branch within the ICS structure and will make medical
decisions in cooperation with the IC. Patient care must never be delayed due to a
jurisdictional dispute.
4. Training. Supervisory level personnel within the MedStar system shall complete, at
least, basic level ICS training published by the Federal Emergency Management
Agency Emergency Management Institute or an equivalent course. All medical
personnel should be familiar with ICS and mass casualty response plans.
5. Emergency Medical Services Operation. At any scene requiring a unified
command structure, EMS personnel will provide care according to medical protocols
and within their scope of medical training and qualifications.
a. The Fire Department Incident Commander is in command of the incident and the
scene. In the event that a MedStar ambulance paramedic is the first to arrive at a
scene, that individual will act as the IC until relieved by the Fire Department IC.
b. The first MedStar ambulance personnel on-scene will be responsible for patient
treatment and transport.
c. The MedStar Lead Medic, along with a Firefighter, will be in charge of the
Triage, Treatment, and Transport areas (T-3).
i. The MedStar Secondary Medic, along with a Firefighter, will triage all
patients to the designated areas within the T-3 by utilizing START.
d. The Fire Department personnel on-scene will be responsible for:
i. Initial triage of all victims
ii. Strike Teams to extricate all victims to the casualty collection points.
e. Requests for additional resources shall be directed to the Incident Commander.
i. When emergency helicopter service is needed, the Incident Commander is
responsible for securing an appropriate landing site and for all safety
procedures.
ii. The Appropriate destination-facility decisions will be made with consultation
between the MedStar Lead Medic and helicopter personnel, taking into
consideration patient and/or family wishes when appropriate.
6. Patient hand-offs
a. Patient care initiated by an EPAB certified paramedic first responder shall be
continued until the MedStar ambulance paramedic arrives and assumes care for
the patient, with the exception of a hazmat situation.
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b. In the event of disagreement in patient care, a BSP will be contacted immediately
for appropriate orders. All incidents of this nature will be forwarded to the
Medical Director of EPAB for review.
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Informed Release at Scene
1.
2.
3.
Purpose. This policy establishes the criteria and procedure for use of the Informed
Release At Scene.
Scope. This policy applies to all MedStar Operations personnel and all First Responder
personnel. An Informed Release at Scene form may only be completed by basic and
advanced personnel who have completed the required training.
Criteria. The following criteria will determine if a person with whom EMS has
made contact with qualifies for a Release At Scene. All questions must be answered
“No” for a person to qualify to be released at scene without further assessment. If any of
the criteria are answered “Yes,” transport or an AMA must be completed:
a. Did the person activate 911 for EMS? This question may be answered “No” only
if the person with whom EMS made contact with is refusing assistance AND did
not call 911, or if they called for non-EMS assistance such as fire or police
assistance.
b. Is the person disoriented or confused? This question may be answered “No”
only if he or she is alert and oriented to:
i. Person,
ii. Place,
iii. Time,
iv. Event
c. Was there any loss of consciousness? This question may be answered “No” only
if there is no evidence that the person experienced no loss or changes in level of
consciousness. Evidence may include information from witnesses.
d. Is there any evidence of alcohol or drug use? This question may be answered
“No” only if:
i. Does not appear to be under the influence of any medications or drugs that
could impair judgment; or
e. Is there any complaint of illness, pain or injury? This question may be answered
“No” only if:
i. The person has no complaint of illness, pain or injury;
ii. The person has no apparent illness or injury;
iii. The person does not appear to be in pain or distress; or
iv. The person has no recent history of a possible illness or injury that has
resolved within the last hour such as, but not limited to, recent loss or change
in level of consciousness, seizure, dyspnea, or chest pain.
f. Is there a significant mechanism of injury? This question may be answered
“No” only if there are no signs that the force involved in the event was of sufficient
magnitude to cause a potential injury. In addition to specific MOI criteria on the
release at scene form, persons involved in the following types of events should not
be considered qualified for a release at scene:
i. Electrocution,
ii. Near Drowning,
iii. Falls from heights greater than ground level,
iv. Events resulting from unexplained vertigo, weakness, or changes in level of
consciousness,
v. Motor vehicle accidents in which any victim in the same vehicle was ejected,
vi. High speed vehicle crash,
vii. Vehicle roll over or motorcycle at speeds greater than 20 miles per hour, or
viii. Any mechanism, which in the opinion of EMS personnel could cause an injury
or illness.
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E.P.A.B.
g.
4.
5.
6.
7.
8.
9.
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Were any other occupants in a vehicle the person was in pronounced DOS?
This question can be answered “No” only if no other occupant of the same vehicle
in which the person was a passenger was pronounced DOS.
h. Does anyone related to the person have objections to his or her refusal? This
question can be answered “No” only if no relative of the person requests that the
person seek definitive care or exhibits discomfort with a non-transport decision.
Release at Scene of Minors
a. A minor may not sign a Release At Scene nor should a Release At Scene be
exercised on behalf of a minor by anyone other than a parent or legal guardian.
b. A minor is a person under 18 years of age who is not and has not been married
or who has not had his/her disabilities of minority removed for general purposes
in accordance with the Texas Family Code.
c. If there is no parent, legal guardian or other person authorized by law to give
consent to medical treatment available, a minor cannot refuse evaluation or
transport to a medical facility. They shall be transported or be turned over to law
enforcement personnel.
Call-Back Requests for EMS Assistance.
a. Persons who have requested EMS assistance or for whom assistance has been
requested on their behalf within the last 12 hours may not sign an Informed
Release At Scene.
b. Call-back requests for persons may be managed with an AMA only after:
i.
Making every possible effort to encourage the patient to accept
transportation to a medical facility; AND
ii. Contacting the Field Operations Supervisor to report the situation.
Management of persons who do not qualify for an Informed Release At Scene.
If the person does not qualify for an Informed Release at Scene, every effort should
be made to transport the person in accordance with applicable EPAB policies, or an
Against Medical Advice shall be completed in accordance with EPAB policy.
Procedure. Upon determination that the person has met the requirements for a
Release At Scene:
a. The eight criteria shall be checked “No;”
b. The incident number and MICU number shall be recorded;
c. Contact phone number and home address of the individual shall be recorded;
d. The date of interview shall be recorded;
e. The person interviewed shall sign the Informed Release At Scene form;
f. A parent or guardian’s signature and their relationship to the individual shall be
obtained in the event the person involved is a minor;
g. A witness signature shall be obtained; and
h. EMS personnel shall record and sign all applicable blanks on the Release At
Scene Form.
Refusal to sign. In the unlikely event that the individual refuses to sign, the EMS
personnel will complete the Informed Release At Scene form and have a witness,
preferably neutral to the parties involved, attest to the refusal.
Quality Assurance Review. The First Responders and MedStar Operations shall
submit the monthly QA/QI reports to EPAB. The MedStar Operations and all First
Responder organizations shall report to the Medical Director when EMS is activated
to return to the scene of any incident (EMS call-back), or to any patient, previously
cleared with the Release at Scene or an AMA.
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E.P.A.B.
Medical Professionals on Scene of an Emergency
1.
2.
3.
4.
5.
6.
Purpose. Medical professionals at the scene of an emergency may provide
assistance to pre-hospital care personnel and should be treated with professional
courtesy.
Scope. This policy applies to EPAB credentialed providers
Physician On-Scene before MedStar.
a.
A physician (on-scene physician) who is caring for a patient before the arrival
of the MedStar Lead paramedic may retain responsibility for patient care
provided that physician accepts full legal and medical responsibility. The onscene physician will be placed in radio contact with the BSP (thus establishing
that physician’s authorization to issue orders to a MedStar Lead paramedic).
Once having been authorized by a BSP, the on-scene physician must
accompany the patient to the hospital.
b.
Services and Equipment. The services and equipment of the emergency
vehicle will thereafter be made available to the on-scene physician. Contact
with the BSP will thereafter proceed in the usual manner, and will include
documentation of all orders.
Physician On-Scene after MedStar.
a.
A physician arriving after care has been initiated by the pre-hospital team will
be placed in radio contact with the BSP before becoming involved in patient
care.
b.
The BSP, pre-hospital care team, and on-scene physician will work as a team,
if the BSP grants permission.
Disagreements regarding Treatment.
a.
The on-scene physician will assume medical authority only if he agrees to full
medical/legal responsibility and agrees to accompany the patient to the
hospital.
b.
In such cases, the final authority for online-medical control of pre-hospital
procedures rests with the BSP.
Responding to Physician’s Offices:
a.
The Lead paramedic will comply with medical treatment requests the physician
makes within his/her office as long as the orders are within the paramedic’s
scope of training, certification, and EPAB protocols. Any orders that are in
conflict with above should be discussed with the BSP.
b.
If the physician gives orders that are to be carried out during transport, the
paramedic will discuss these orders with the BSP once in the ambulance to
assure that the BSP agrees with the orders and that the orders comply with the
protocols of the MedStar system.
c.
Lead paramedics should make every effort to begin transport as quickly as
possible.
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E.P.A.B.
Medical Treatment of a MedStar Agency Employee
1.
2.
3.
4.
Purpose. This policy is a process to describe the clinical process of treating
medically ill/injured employees covered by Medical Direction.
Scope. This procedure applies to all personnel who are rendering patient care to a
ill/injured employee in the MedStar System under the Medical Director’s license.
The Medical Director approves and permits personnel for practice in their
respective medical roles as defined in protocol. An Agency’s employee must be
treated as a “patient” and all applicable policies apply during patient care of that
individual.
Overview. If an Agency’s employee is either ill or injured, that person should be
treated as a “patient” and all of the EPAB Protocols, Procedures, and Policies apply
to care for that individual. An employee requiring medical care must have a patient
care record completed whether or not they are transported to a hospital or if they are
released by other means (AMA, RAS, etc.). A medic may not administer any type
of medical treatment to another employee without properly following EPAB
protocols, procedures and policies as this may be construed as “practicing medicine
without a license.”
The Process. The following process is a guideline used by EPAB.
a.
If an Agency’s employee is ill or injured, proper medical attention should be
activated and initiated. The 911 system should be activated if necessary.
b.
If the Agency’s employee refuses the activation of the 911 system, then the
proper AMA documentation should be completed by that Agency. An
incident should be created and the proper patient care form completed.
c.
If any medicine has been administered or dispensed, the proper AMA
documentation should be completed and filed. A medic may not dispense
any medication (antiemetic, bronchodilators, etc.) without a physicians
order, either standing orders or online medical direction.
d.
Any deviation from this process is not only prohibited by the Medical
Director, but it is illegal by the State of Texas.
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E.P.A.B.
Medications in the Field/Controlled Substances
1. Purpose. The Drug Enforcement Administration, the Department Public Safety
Narcotic Control Division and the Texas DSHS require the Medical Director to assure
that all medications purchased under his/her license is stored and secured according to
laws and regulations.
2. Scope. This policy applies to equipment and supplies required on ambulances, first
responder vehicles, and special teams.
3. Procedure
a. Storage of Medications in the Field.
ii. Schedule II & III Medications will be secured by field personnel while on
duty either:
1. On the person of the Paramedic that accepted receipt of the medications
and is assigned to the apparatus, or
2. In a locked container on the apparatus, where the only person with the
key or combination is the Paramedic that accepted receipt of the
medications and is assigned to the apparatus.
iii. When the crew is not physically inside the unit, all other medications will be
secured on the apparatus by locking all exterior doors or compartments. The
crew members assigned to that unit are the only personnel authorized to
unlock the unit.
iv. The Paramedic that accepted receipt of the medications on Special Teams
such as the Bike Team, Mounted EMS Team, or other Ad Hoc teams will
secure all Scheduled medications on their person.
4. Reconciliation.
a. All Schedule medication counts will be reconciled on EPAB approved forms and
will be completed by MedStar Logistics in cooperation with EPAB.
5. Drug Adulteration.
a. All medicines stored in the field must be stored according to current Texas DSHS
rules and regulations. This includes all manufacture temperature
recommendations. Proper temperature storage techniques should be maintained
by each Agency
.
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MedStar Ambulance Designations and Levels of Operation
1.
2.
3.
Purpose. This policy defines the use and designation of all MedStar ambulances
by Operations in the MedStar system to facilitate reliable response to all levels of
ambulance calls.
Scope. This policy applies to MedStar Operations outlining the designation,
staffing, and use of BLS, ILS, ALS-Basic, ALS, and MICU Ambulances in the
MedStar System.
Unit Inventory and Staffing Requirements.
a.
Level 1 Ambulances are “Basic Life Support with MICU Capability” units.
Such units shall be equipped and staffed as required by the Texas Department
of State Health Services EMS Provider License regulations, contractual
requirements, and EPAB requirements. They must be equipped to support the
Level 1 criteria of protocol.
i. Level 1 “L” level personnel may be assigned to work as Lead Medics on
BLS Ambulances with at least an EMT-Basic partner and may function as
stated in policy.
b.
Level 2 Ambulances are “Advanced Life Support with MICU Capability”
units. Such units shall be equipped and staffed as required by the Texas
Department of State Health Services EMS Provider License regulations,
contractual requirements, and EPAB requirements.
i. Level 2 “L” personnel may be assigned to work as Lead Medics on Level
2 Ambulances with at least an EMT partner and may function as stated in
policy.
c.
Level 3 Ambulances are “MICU Ambulance” units. Such units shall be
equipped and staffed as required by the Texas Department of State Health
Services EMS Provider License regulations, contractual requirements, and
EPAB requirements.
i. Level 3 personnel may be assigned to work as Lead Medics on Level 3
Ambulances with at least an EMT partner and may function as stated in
policy.
d.
EPAB requirements.
policy.
e.
EPAB requirements.
policy.
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f.
4.
5.
6.
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EPAB requirements.
Ambulances with at least a Level 4 AND an EMT partner and may
function as stated in policy.
Appropriate use of Level 1 Ambulances
a.
Level 1 Ambulances may be used only for non-emergency Basic Life Support
Priority 4 and 5 transports and operate under the Level 1 protocols and
procedures.
b.
Level 1 Ambulances are utilized to transport patients who are not
experiencing a serious or potentially serious acute medical condition.
c.
Level 1 Ambulances may be assigned to a Priority 1, 2, or 3 if the system is at
Level-0 with calls holding. A Field Operations Supervisor must be assigned
to this call along with the ambulance and if a Supervisor is not available, the
ambulance may not be assigned to the call.
a.
Level 2 Ambulances may be used only for non-emergency Intermediate Life
Support Priority 4 and 5 transports and operate under the Level 2 protocols
and procedures.
b.
Level 2 Ambulances are primarily utilized to transport patients who are not
experiencing a serious or potentially serious acute medical condition.
c.
Level 2 Ambulances may be assigned to a Priority 1, 2, or 3 if the system is
at Level-0 with calls holding. A Field Operations Supervisor must be
assigned to this call along with the ambulance and if a Supervisor is not
available, the ambulance may not be assigned to the call.
d.
Level 2 Ambulances may be requested to respond to a Priority 1, 2, or 3
dispatched call scene if requested by a Level 4-5-6, a Field Operations
Supervisor, or a MedStar manager who is at the scene. A Level 2
Ambulance may transport MCI “Green” patients after appropriate assessment
and triage. This process is not intended to provide an alternate method of
initial response to emergency requests.
a.
Level 3 Ambulances may be used primarily for Priority 3, 4, and 5 and
operate under Level 3 protocols and procedures.
i.
They may not be assigned to priority 3 interfacility calls unless it is a
priority 3 psychiatric emergency transfer that does not require any form
of chemical restraints.
ii.
They may not transport a scheduled priority 4 or 5 transfer patient who
requires continuous pharmacological intervention or requires ventilation
assistance.
iii.
They may not transport a patient who has chest tubes in place.
iv.
They may not transport high risk obstetrical patients.
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b.
7.
8.
9.
10.
11.
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Level 3 Ambulances may be requested to respond to a Priority 1, 2, or 3
dispatched call scene if requested by a Level 4-5-6, Field Operations
Supervisor, or a MedStar manager who is at the scene. A Level 3
Ambulance may transport “Green” patients after appropriate assessment and
triage. This process is not intended to provide an alternate method of initial
response to emergency requests.
c.
Level 3 Ambulances may be assigned to a Priority 1 or 2 if it the system is at
Level-0 with calls holding. A Field Operations Supervisor must be assigned
to this call along with the ambulance and if a Supervisor is not available, the
ambulance may not be assigned to the call.
d.
If they are assigned to any MCI, a Level 4-5-6 will be assigned to the call
when available and assume medical command upon arrival. The Level 3
ambulance will then become a transport unit.
e.
They must strive to have a maximum scene time of 12 minutes.
f.
The number of Level 3 Ambulances should not exceed 25% of the total
number of ambulances in service at any given time unless approved by
EPAB.
a.
Level 4 Ambulances are to be used for all level calls and operate under the
Level 4 protocol and procedures.
b.
They must strive to have a maximum scene time of 12 minutes.
a.
Level 5 Ambulances are to be used for all level calls and operate under the
Level 5 protocols and procedures.
b.
If the Level 5 Ambulance is assigned to any MCI where a lesser designated
ambulance is in command, the Level 5 Ambulance will be assigned to the
call and assume medical command upon arrival. The lesser designated
ambulance will then become a transport unit.
a.
Level 6 Ambulances are to be used for critical care transfers and operate
under the Level 6 protocols and procedures.
Changes in Patient Condition While Engaged in a Transport. Any treatment
beyond the individual’s level of protocol must be ordered by direct on-line medical
direction. In case the condition of a patient deteriorates, personnel should provide
the indicated stabilization, including ALS care within their scope, immediately
notify the BSP and request appropriate orders. If it is an interfacility transfer that
originated at a hospital, the team should return to the facility or, in extreme cases,
proceed to the nearest appropriate facility for additional evaluation of the patient.
Additional Policies Required of MedStar. MedStar shall establish policies for
identifying when the Ambulances have exceeded the scene time of twelve (12)
minutes and/or was utilized for Priority 1 or 2 level calls. This information should
be provided to EPAB monthly.
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MedStar Personnel Credentialing Process
1.
2.
3.
4.
5.
Purpose. EPAB has developed a process to permit personnel within the MedStar
System as required by Uniform EMS Ordinance. Standardized processes increase
objectivity, fairness, and consistency.
Scope. This procedure applies to all personnel who will work for MedStar Field
Operations. While the Medical Director approves personnel for practice in their
respective medical roles, personnel are employed by Operations and must follow the
Operations Division’s policies.
Overview. The objective of this process is to prepare qualified personnel for duty.
In general, the process requires the successful completion of four (4) phases of
training and evaluation. Phase I is the Orientation Academy. Phase II is a Driver
Training Officer (DTO) Internship. Phase III is the Field Training Officer (FTO)
Internship for Level 1-2-3-4 candidates. Phase IV is three-person FTO evaluation of
Level 5 candidates. Phase V is specialized additional training for specialized or
critical care.
Identification. MedStar Field Operations personnel shall meet the applicable Texas
Department of State Health Services standards for identification of personnel when
responding to emergencies.
The Permitting Process.
a. Personnel entry qualifications.
i. Successful completion of the MedStar employment qualifications
ii. Six months of continuous experience in the MedStar system is preferred of Lead
Medic candidates at Level 3-4-5-6 candidates;
iii. 12 months experience as a Level 5 for a Level 6 candidate is preferred.
b. Credentials. After completion of the MedStar’s employment processes, before
the beginning of the new hire academy, MedStar will submit each candidate’s:
i.
EPAB Personnel Data Form;
ii. Copies of:
1. Texas drivers license;
2. Texas EMS certification or reciprocity documentation;
3. National registry certification (if available); and
4. Any current card course certifications listed in MedStar Personnel
Permit Levels and Scope of Practice Policy.
iii. Candidates will be issued an EPAB Protocol, Procedure, and Policy book by
MedStar.
c. Phase I. Phase I includes successful completion of the New Employee
Orientation Academy Process (Academy). The design, content, and criteria for
successful completion of the Academy are to be approved by the Medical
Director. It includes specialized training designed to improve personnel
interaction, appreciation of organizational values, customer service, conflict
management, and professional development. The Operations Department and
Education and Training Department shall review the content of the Academy with
the Medical Director annually or when significant changes are needed. Topics of
this academy include, but are not limited to: HR, Operations, Documentation,
Logistics, Scheduling, Deployment, Protocols, Equipment Training, 12-Lead
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Interpretation, Capnography, applicable Card Courses, MCI/IMS/Disaster
Management, Communications, Mapping, and Driver Training.
d. Phase II. Phase II is a three-person Driver Training Officer (DTO) internship.
This section of the academy includes, but it not limited to a classroom and handson driver training, MAPSCO reading, navigation, VisiNet operations, defensive
driving techniques, and unit operations. The Medical Director may request the
addition of topics based on identified needs.
e. Phase III. Phase III is three-person Field Training Officer (FTO) internship. The
candidate must successfully complete and pass an EPAB protocol examination
with a minimum of 85% prior to entering the Phase III internship. Refer to the
Exams and Subscales Policy for specific passing requirements.
i. The design, content, and criteria for the Phase III FTO internship are to be
approved by the Medical Director. The Education and Training Department
shall review the content of the internship with the Medical Director annually or
when significant changes are needed.
ii. The candidate is required to successfully complete the objectives of the Training
Objective Workbook. The specific Levels of Care in the Phase III internship
will consist of the following training criteria (The Medical Director or designee
may adjust the number of patient contacts based on a candidate’s performance):
1. Level 1 & 2a.
60 patient contacts (50% actually attending the patient)
b.
Completion of the applicable EPAB Skills Verifications Packet
c.
Recommendation from the FTO
2. Level 3a.
b.
c.
d.
Medical Direction interview with the FTO and the candidate
e.
This level is temporary and may not exceed 90 days. It pertains
only to candidates during Level 4 training.
3. Level 4a.
b.
c.
d.
Successful completion and passing of a second EPAB Protocol
e.
Successful completion and passing of an EPAB Scenario Based
administered in coordination with EPAB and the Education and
Training Department.
f. Phase IV. Phase IV is a three-person FTO Evaluation for the Level 5 Paramedic.
i. The FTO should remain with the candidate continuously as an evaluator and
act as a “ghost” allowing the candidate to function as the Lead Paramedic. It
is suggested that the FTO not wear field uniforms, but to instead wear
business casual attire with an appropriate MedStar logo on the shirt. FTOs
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must document each candidate’s performance for each patient encounter;
overall shift performance; and a weekly summary on approved forms. The
objective is to fine-tune the candidate’s advanced patient care skills where the
candidate functions without the guidance of the FTO. Therefore, this is
designed to be mainly an evaluation with minimal assistance. The candidate
should demonstrate the appropriate abilities as stated in the Level 4 criteria.
ii. The following is the criteria for the Level 5 Paramedic (The Medical Director
or designee may adjust the number of shifts based on a candidate’s
performance):
1. Level 5a. Have a minimum of 1100 patient contacts (exception may be made in
cases of prior comparable experience)
b. Completion of the applicable EPAB Skills Verifications Packet
c. EPAB Crash Airway/PAI Permit
d. Advanced Medical Life Support certification or comparable
certification
e. Geriatric Emergency Medical Support or comparable certification
f. Neonatal Advanced Life Support or comparable certification
g. Advanced 12-Lead Interpretation course
h. Advanced Pharmacology course
i. Recommendation from the FTO
j. Successful completion and passing of a Level 5 EPAB Protocol
Examination with a minimum of 85%. Remediation of incorrect
answers will be completed and submitted to EPAB prior to taking the
EPAB Scenario Based Credentialing Examination.
k. Successful completion and passing of a Level 5 EPAB Scenario Based
iii. If the candidate does not successfully complete the Phase IV evaluations, a
determination of the candidate’s functional capacity will be made.
g. Phase V. Phase V is a three-person FTO Evaluation for the Level 6 Paramedic.
The FTO/Supervisor should attend the candidate’s critical care patient transport
and evaluate his/her abilities during the call. The candidate should demonstrate
the appropriate abilities as stated in the Level 5 criteria.
i. The following is the criteria for the Level Paramedic (The Medical Director or
designee may adjust the number of shifts based on a candidate’s performance):
1. Level 6a. Have a minimum of 2000 patient contacts (exception may be made in
cases of prior critical care experience)
b. Completion of the applicable EPAB Skills Verifications Packet
i.
This includes all critical care transfer equipment, supplies,
etc.
c. EPAB approved Critical Care Paramedic Course
d. Recommendation from the Level 6 FTO/Supervisor
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E.P.A.B.
6.
7.
8.
9.
10.
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e. Successful completion and passing of a Level 6 EPAB Protocol
f. Successful completion and passing of a Level 6 EPAB Scenario Based
g. If the candidate does not successfully complete the Phase V
evaluations, a determination of the candidate’s functional capacity will
be made.
Medical Director’s final approval. The Medical Director or designee will interview
all Level 3-4-5-6 Paramedic candidates before they are released to duty. Upon
completion of the Medical Director’s philosophy discussion for Level 4-5-6
candidates, the Medical Director may release them to full duty if all the criteria have
been met.
Failure of a training phase. In the event that a candidate fails any phase in the
permitting process, the following actions may be recommended depending on the
candidate’s performance: Remedial training, repetition of training, or removal from
the program.
FTO assignment. FTO assignments are to be made by the MedStar Education and
Conflicts during FTO rotations. Questions regarding the permitting process will be
directed to the Education and Training Manager. The Medical Director or designee
will review appeals requested by FTO personnel, candidates, or Operations. The
Medical Director reserves the right to remove or reassign any candidate in the
credentialing process. Ultimately it is the Medical Director’s decision.
An existing MedStar Level 2 paramedic may request to enter into the Level 3-4-5
Paramedic evaluation process by properly notifying MedStar’s Education and
Training Department and completing the training and evaluation process.
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MedStar Personnel Permit Levels and Scope of Practice
Purpose. The Uniform EMS Ordinance requires EPAB to certify emergency medical
services personnel services to practice/function (work) within the MedStar System.
This policy establishes the levels of certifications within the MedStar System.
2. Scope. The levels of certification in this policy apply to the Field Operations
personnel employed by the Operation’s Division of MedStar.
3. Conditional Statusa. An individual may still be allowed to function in their designated capacity but
may have certain restrictions as deemed by the Medical Director.
b. The Medical Director may set a deadline for correction of a deficiency. Failure to
correct such a deficiency in the allotted time may result in revocation of status.
4. Levels of Care.
a. Level 1 –Emergency Medical Technician (EMT); M-1
1. Texas DSHS EMT Certification;
2. BCLS Certification (AHA, ARC, or approved equivalent);
year;
4. Attend all quarterly mandatory EPAB CEs in a calendar year;
5. Perform the required EPAB Skills Verifications Packet; and
ii. Levels.
1. M-1 entry level may not be the “Lead” of an ambulance
2. Designation of a “L” may be permitted by EPAB to be the “Lead” of a
BLS Ambulance (i.e. “M-1-L”)
iii. Duties. The M-1 staffs Level 1-2-3-4-5-6 Ambulance with a Lead
Paramedic. During patient care, the Level 1 operates under the direct
supervision of the Lead Paramedic, but may provide patient care during
ambulance transport if there is no anticipated need for advanced life support.
If any one of the following occur or could occur, the Lead Paramedic is
required to attend during transport:
1. Advanced continuous reassessment;
2. Pregnancy related chief complaints;
3. Airway management;
4. Continuous or ongoing ECG monitoring;
5. Continuous Intravenous fluids, at any flow rate;
6. M-1 may attend a patient with a saline lock;
7. Medication administration (whether directly or indirectly) while under
EMS care.
iv. Procedures. The following is a list of the basic life support procedures that
may be performed by the EMT, if trained:
1. Patient assessment/Vital Signs;
2. Oxygen administration;
3. Monitoring pulse oximetry;
4. Monitoring End-Tidal CO2;
1.
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5.
6.
7.
8.
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Obtaining and transmitting three and twelve lead ECGs;
Bag-valve-mask;
Oropharyngeal and nasopharyngeal airway insertion;
King Airway LTD-S insertion in cardiac arrest
a. Gastric tube insertion through King Airway LTD-S
9. Oral suctioning;
10. Application of wave-form capnography devices;
11. Monitoring colorimetric capnography devices;
12. Spinal immobilization;
13. Bandaging/splinting;
14. CPR;
15. AED application and operation;
16. Blood glucose assessment;
17. Aspirin administration;
18. Oral glucose administration;
19. Assisted medication administration of:
a. Metered dose inhaler;
b. Nebulized nebulizer treatments,
c. Nitroglycerin; and
d. Prescribed Epinephrine auto-injector;
20. Charting and radio reporting;
21. Basic Release at Scenes (RAS)
22. Basic Against Medical Advice (AMA)
b. Level 2 - EMT-Intermediate and Basic Paramedic; M-2
1. Texas EMT-Intermediate or EMT-Paramedic Certification/License;
2. BCLS (AHA, ARC, or approved equivalent);
year;
4. Perform mandatory advanced airway skills practice each shift;
6. Successful completion of annual EPAB approved advanced airway
management skills “check-off;”
8. Compliance with the EPAB Exams and Subscales policy
ii. Levels.
1. A Level 2 may not be the “Lead” of an ambulance
2. Designation of a “L” may be permitted by EPAB to be the “Lead” of a
BLS and/or an ILS Ambulance (i.e. “M-2-L”)
iii. Duties.
1. Level 2 Ambulance: The M-2-L may act as the Lead of a Level 2
ambulance and must follow all policies in protocol.
2. Level 3-4-5-6 Ambulance: M-2 medic staffs an ambulance along with a
Lead Paramedic. During patient care, the M-2 operates under the direct
supervision of the Lead Paramedic, but may provide patient care during
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ambulance transport if there is no anticipated need for advanced life
support. If any one of the following occur or could occur, the Lead
Paramedic is required to attend during transport:
a. Advanced continuous reassessment;
b. Pregnancy related chief complaints;
c. Airway management;
d. Continuous or ongoing ECG monitoring;
e. Medication administration, except oxygen, while under EMS care.
iv. Procedures. The following is a list of the procedures that may be performed
by the M-2 while under the supervision of a Lead Paramedic, if trained; these
may also be performed if the M-2-L is acting as the Medic in charge of a
Level 2 Ambulance and the patient condition deteriorates and requires the
immediate performance of these skills:
1. All M-1 level care;
2. Standing orders through the “Level 2” in protocol;
3. Orotracheal Intubation;
4. Tracheal suction;
5. Operation of the Magill forceps;
6. Peripheral venous access
7. IV fluid administration as described in the IV Fluid Therapy Procedure
c. Level 3 – ALS-Basic Paramedic; M-3
1. Texas EMT-Paramedic Certification;
2. Texas EMT-Paramedic License preferred;
3. National Registry Paramedic preferred;
4. BCLS;
5. ACLS;
6. Trauma care training (PHTLS, BTLS-advanced, or approved equivalent);
7. Pediatric emergency care training (PALS, PEPP, or approved equivalent);
8. Completion of an approved basic 12-Lead training course;
year;
10. Perform mandatory advanced airway skills practice each shift;
12. Successful completion of annual EPAB approved advanced airway
management skills “check-off;”
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ii. Duties.
1. Level 3 Ambulance: The M-3 may also act as the Lead Medic of Level 3
ambulance. The M-3 must follow all policies included in protocol.
2. Level 4-5-6 Ambulance: The M-3 may operate on the Level 4-5-6
Ambulance as a M-3 non-lead Paramedic. While functioning as the M-3,
they may perform all listed skills and ride alone with the patient and
provide care, without the oversight of a Level 4-5-6 Paramedic, as long as
it does not exceed their listed protocols and that Lead Paramedic approves.
If the patient has the possibility of requiring additional care that only the
Level 4-5-6 Paramedic may perform, the M-3 may not ride alone
providing patient care enroute to the hospital.
a. Procedures. The following is a list of the procedures that may be
performed by the M-3 within the MedStar system:
3. Standing orders through “Level 3” of protocol;
4. All Level 1-2 procedures;
5. Assistance with Level 4-5-6 procedures when functioning in a “non-lead”
capacity;
6. 3 Lead ECG interpretation;
7. Defibrillation/Cardioversion;
8. Cardiac pacing;
9. Intraosseous access;
10. Gastric tube insertion.
d. Level 4 – ALS Paramedic; M-4
i.
Training Requirements.
1. All Training Requirements listed in Level 3; and
year;
3. Completion of an EPAB approved Intermediate 12-Lead Interpretation
course;
ii. Duties.
1. Level 4 Ambulance The M-4 may also act as the Lead Medic of Level 4
ambulance. The M-4 must follow all policies included in protocol.
2. Level 5-6 Ambulance: While functioning as the M-4, they may perform
all listed skills and ride alone with the patient and provide care, without
the oversight of a Level 5-6 Paramedic, as long as it does not exceed their
listed protocols and that Paramedic approves. If the patient has the
possibility of requiring additional care that only the Level 5-6 Paramedic
may perform, the M-4 may not ride alone providing patient care enroute to
the hospital.
performed by the Level 4 Paramedic within the MedStar system:
2. All Level 1-2-3 procedures;
3. Needle cricothyrotomy;
4. Chest decompression.
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Level 5 – Primary Paramedic; M-5
1. All Training Requirements listed in Level 4; and
2. Completion of an EPAB approved Advanced 12-Lead Interpretation
course;
year;
4. Must have obtained an EPAB Permit for Crash Airway/PAI;
5. Neonatal care training (NRP or approved equivalent): Recommended;
6. Geriatric emergency care training (GEMS or approved equivalent):
Recommended.
ii. Duties. An M-5 is a Lead Paramedic and is required for each Level 5
Ambulance and shall be accompanied by another MedStar Level 1-6 medic.
The M-5 must provide patient care during transportation of patients who
may need continuous monitoring, ongoing ALS care, and advanced
assessment during transport. The M-5 may allow another medic to provide
care during transport as described in their specific listed “Procedures” and
attend to the patient during transport. The M-5 is responsible for the
ambulance, all patient care rendered, and other personnel assigned to the
Level 5 Ambulance at all times.
2. All Level 1-2-3-4 procedures;
3. Chemical Sedation;
4. Melker insertion;
5. Crash Airway;
6. Paralytic Assisted Intubation;
7. Pharmacological Assisted Intubation.
Level 6 – Critical Care Paramedic; M-6
1. All Training Requirements listed in Level 1-2-3-4-5; and
2. Successful completion and passing of an EPAB approved Critical Care
Course.
ii. Duties. A M-6 is a Lead Paramedic and is required for each Level 6
Ambulance and shall be accompanied by another MedStar Level 4-6
ambulance crew. The M-6 must provide patient care during a critical care
transport of applicable patients. The M-6 is responsible for the ambulance,
all patient care rendered on the Level 6 Ambulance, and other personnel
assigned to that Ambulance at all times.
2. All Level 1-2-3-4-5 Procedures;
3. Maintenance of all critical care medications;
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4. Transport ventilator operation.
Special Designations
i.
Lead Medic – “L” designation
a.
All listed requirements listing in their current Level of
Certification.
2. Credentialing Requirements. This level requires proper credentialing
from EPAB. A M-1 or M-2 may receive this credentialing if the
individual has demonstrated to EPAB, the FTO, and the Education and
Training Department that they may properly function as the “Lead
Medic” of that ambulance.
a. The Training and Education Department must notify EPAB in
writing the recommendation for “Lead Medic” credentialing.
3. The Medical Director and/or designee will interview this individual prior
to awarding this designation.
ii.
Tactical Paramedic – “T” designation
a. All listed requirements listed in their current Level of
Certification.
2. Credentialing Requirements. This level requires proper credentialing
from EPAB. Any level of care may receive this credentialing if the
individual has demonstrated to EPAB, the FTO, and the Education and
Training Department that they may properly function as a Tactical
Medic.
a. The Training and Education Department must notify EPAB in
writing the recommendation for “Lead Medic” credentialing.
b. The Medical Director and/or designee will interview this
individual prior to awarding this designation.
3. Duties. A Tactical Medic is a Lead Medic and is required for each
Tactical event. They must provide patient care during care and transport
of patients who have had or who may need tactical procedures/skills
during transport.
4. Procedures. The following is a list of the procedures that may be
performed by the Tactical Medic within the MedStar system:
a. All care listed in their current EPAB Level of Certification;
b. Standing orders through “BSP Orders” level of protocol when
contacting the BSP is prohibited due to specific tactical events;
c. EPAB permitted tactical procedures.
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Miscellaneous Policies and Statements
1. Endorsement Of ACEP Position Statement. The Emergency Physicians Advisory
Board endorses the 1992 revision of the American College of Emergency Physicians
(ACEP) position statement regarding pre-hospital Emergency Medical Services as the
national standard as applicable to our community.
2. Term Of Office For EPAB Officers. Each term of office will be two years. The
Nominating Committee will present a slate of officers every two years.
3. Trauma Surgeons on EPAB. A trauma surgeon from each of the designated adult
trauma receiving facilities may be appointed to the board. In case that more than one
trauma surgeon is appointed to the board, only one trauma surgeon may vote on board
business. Voting privileges shall be rotated among trauma surgeons on alternate
years.
4. EPAB Permitted Specialty Providers. Representatives will be officially invited to
the EPAB board meetings as a non-voting guest of the Emergency Physicians
Advisory Board.
5. Emergency Department Audit Investigator. Each hospital emergency department
director or a doctor from his department is to assume responsibility of investigating
audits and reporting results to the EPAB medical director.
6. Non-Medstar Standbys. Any non-MedStar provider contracting for a standby
function is required to be certified in advance through the City of Fort Worth to meet
EPAB requirements (2/11/87).
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Patient Transportation
1. Purpose. The purpose of this policy is to establish transportation guidelines for nonemergency and emergency patients to the extent that EPAB is empowered to do so by
the Uniform EMS Ordinance.
2. Scope. This policy includes all patient transports within the jurisdiction of the Area
Metropolitan Ambulance Authority (AMAA).
3. Definition of “Patient.” In the Uniform EMS Ordinance, a patient is defined as “An
individual who is ill, sick, injured, wounded, or otherwise incapacitated and is in need
of, or is at risk of needing, medical care during transport to or from a health care
facility.” This would include, but is not limited to, persons who need IVs, persons
who may require oxygen for an acute condition, or persons who may require cardiac
or oxygen saturation monitoring during transport. Paramedics are to treat all their
encounters as “patients” and care according to protocol.
4. Policy. Except during MCI or disaster operation, all patients shall be transported by
an EPAB permitted ambulance, an EPAB permitted air ambulance, or an EPAB
permitted specialty care ambulance.
5. Who may be transported by a Critical Care MICU: A patient may be transported
by an EPAB permitted specialty care ambulance if any of the following exist:
a. The patient is needing transport and:
i. Has an active infusion of a medication that is not approved by EPAB included
on MedStar’s drug inventory sheet.
ii. Is on a cardiac balloon pump.
iii. Requires any other specialty equipment or medications that the MedStar
Paramedic is not capable of managing (as decided by the Operations
Supervisor and/or EPAB).
6. Selection of a Destination Facility. MedStar’s goal is to deliver the highest possible
patient care while respecting the patient’s rights and desires as an individual. To
accomplish this, patients will be transported to the closest, most appropriate facility
using the following criteria in the order listed.
a. The patient is to be taken to the hospital of patient request, if medically
appropriate. As long as patients are in control of their faculties, their informed
decision will be honored.
b. If the patient is unable to communicate, the patient is to be taken to the hospital of
immediate family request.
c. If the facility of family preference is unavailable, the patient is to be taken to the
closest, most appropriate facility.
d. MedStar paramedics must not encourage patients to utilize one facility over the
other.
e. Special patient needs may dictate transport to a hospital that may not be the
closest, but is the most appropriate facility for that patient’s medical care needs (i.e.
burns, major trauma, stroke, STEMI).
f. Cardiopulmonary Arrest patients should be transported to the closest facility.
7. Resolving Conflicts. The following guidelines are to be used if the decision to
transport the patient to the closest, appropriate or other facility results in a conflict
with the patient or family of the patient.
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a. In all cases, the patient or family are to be assisted to make an informed decision.
As long as patients are in control of their faculties, their informed decision will be
honored. The patient’s present medical condition and the reasons for transport to
the closest appropriate medical facility should be discussed with the patient or
family. If the patient or patient’s family, as allowed in 6(a) or (b) above, insists
on transport to another “preferred” facility, their informed decision will be
honored as described in this policy.
b. Divert complications are to be managed by applying the following principles:
i. Patient’s and families are to be assisted in making an informed decision when
selecting a destination facility including providing information about a
destination facility’s capabilities, current divert status, and the BSP’s
concerns;
ii. If the patient or patient’s family, as allowed in 6(a) or (b) above, insists on
transport to another “preferred” facility, their informed decision will be
honored as described in this policy.
8. Adult-Child Transports. In the event of adult and child trauma, which has met
trauma criteria, and medical conditions dictate, the following options should be used
to protect patients. Within the Age Specific Transport Guidelines,
a. Option 1. Child is transported to CCMC and the adult to HMFW;
b. Option 2. Adult declares self not a patient, signs an AMA form, and is not
transported, but the child continues to CCMC. Full warnings/disclosures must be
given to the adult as to potential risks of injury or death that may result by not
being examined/treated in a Trauma Receiving Facility.
9. Age Specific Transport Guidelines. Any unresponsive patient with secondary sex
characteristics shall be treated as an adult patient and transported to an adult-care
facility. The following table establishes the age related guidelines for selecting adult
or pediatric destination facilities.
Adult Care Facility
Cook Children’s
< 15 Years1
Medical Emergencies ≥ 15 Years
< 15 Years
Trauma Emergencies ≥ 15 Years2
3
< 13 Years
Psychiatric Care
≥ 13 Years
1
Under certain circumstances, such as medical patients who are 15 years old or older
and who have established relationships with pediatric specialists, may be transported
to a pediatric care facility. If in doubt, consult with a BSP.
2
Patients 15 years old and greater should be transported to EPAB recognized traumareceiving facilities.
3
psychiatric unit.
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10. Family Member Riding Along with Pediatric Patient. While one family member
may ride along in the patient care compartment, a second family member of a
pediatric patient may be allowed to ride along in the passenger compartment of the
ambulance to avoid complications to patient care.
11. Emancipated Minors. Current laws dictate who may be declared as an emancipated
minor.
12. Specially Trained Operators on Transfer Runs. MedStar Ambulance shall not
transport any patients who are receiving medications or other therapy beyond the
scope of the paramedic practice unless accompanied by a licensed professional skilled
in the administration of said therapy unless approved by EPAB.
13. Application for detention. A patient who is under the custody of a police officer
and who is being transported to a hospital for assessment/treatment under an
application for detention may be transported to any hospital that is selected by the
police officer as long as the patient meets the age requirements in paragraph 9 of this
policy.
14. Correctional Facility Patients. Patients being transported from the Correctional
facilities are to be transported as follows:
a. Most federal correctional facilities have agreements with local hospitals. Patients
should be transported to facilities in accordance with such agreements. MedStar
Lead paramedics should ask an appropriate official who is responsible for the
patient to select the destination facility.
b. Other jails or detention facilities – patients are transported to facilities selected by
the police officer responsible for the patient.
15. Other Policies Affect Patient Transportation Decisions. Transport decisions are
complex and are addressed in other policies in greater detail. Other policies that
provide greater detail about patient transport decisions include, but may not be
limited to, the following:
a. Helicopter Utilization and Safety policy
b. Specialty Hospital Designation policy
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Priority Radio Traffic
1.
Purpose. Communication with BSPs promotes coordinated patient care. This
policy establishes the guidelines that should be followed when calling in a Radio
Report with patient information
2. Scope. This policy applies to the MedStar Operation’s providers
3. Priority Radio Traffic:
a. Priority-One Radio Traffic: Used when notifying a receiving facility of an
incoming cardiac arrest.
b. Priority-Two Radio Traffic:
i. Priority-Two – “Information.” Used when calling the hospital to notify of a
critical patient being transported to their facility (i.e., transporting a critical
trauma or medical patient to a facility in which all therapy has been
accomplished understanding order). Either a nurse or physician may take this
information. It is the responsibility of the hospital to pass the information to
the appropriate personnel.
ii. Priority-Two – “Orders.” Used when calling for orders or when seeking
consultation with a BSP about a specific patient’s care.
c. Priority- Three Radio Traffic. Used when updating hospitals about patients
being transported to their facilities.
4. Receiving Orders From a Facility Other Than the Destination Facility. If
transporting a patient to a different hospital than the one that has issued orders, the
paramedic should request the hospital issuing the orders to call the receiving facility.
If the hospital cannot, the paramedic will be obligated to call the destination facility
using a Priority 3 designation.
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Protocol Maintenance and Revision
1.
2.
3.
Purpose. The Protocols, Procedures and Policies of the Emergency Physicians
Advisory Board were developed using current scientific data. Because research and
development are dynamic and, as accepted methods used by Paramedics and EMT’s
change, these documents will need to be revised to reflect current practice.
Scope. This policy applies to the Office of the Medical Director.
Procedure.
a.
Eligibility to Request Review. Only a member of the MedStar system (First
Responder or a member of his/her agency, employee of the MedStar
Operation’s Division or a member of his/her agency, BSP or a member of
his/her facility, or a sitting EPAB board member) may request a formal
protocol review by the Medical Director’s office.
b.
Formal Review. Once a review request is made, the Medical Director or his
designee will research currently accepted practice, and compare it to current
EPAB practice to determine if changes need to be made to the protocol,
procedure or policy under review.
c.
Recommendations. Once research has concluded, if changes are
recommended by the Medical Director or his designee, a draft reflecting
those recommendations will be submitted to the Protocol/QA committee of
the Emergency Physicians Advisory Board at the next regularly scheduled
meeting. The Protocol/QA committee will decide whether to recommend the
changes to the full Board. If so, the committee will make any revisions they
deem necessary and forward the revised Draft to the board for its
consideration.
d.
Immediate Notification. If the recommended changes, in the opinion of the
Medical Director, should be implemented before the next regularly scheduled
meeting, those changes will be implemented immediately and submitted to
the Board at the next regularly scheduled meeting.
e.
Approval of revisions, notification to affected personnel and necessary
training. Once the Board approves changes to the Protocol, Procedure or
Policy, the Office of the Medical Director will replace the existing document
in the Master Protocol book and electronic file with the revised document.
The EMS coordinator of each First Responder Organization and the MedStar
Operations Division will be notified of the change and given copies of the
revised document. If training is needed on the approved changes, the Office
of the Medical Director may develop such training in conjunction with all
applicable agencies.
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Quality Management Plan
1.
2.
3.
4.
5.
6.
Purpose: This quality management plan is the vessel in ensuring the quality and
performance of the delivery of emergency medical services as required by the
Uniform EMS Ordinance. EPAB is charged with setting forth the clinical standards
for the MedStar system. EPAB will collaborate with MedStar system stakeholders to
review and monitor system clinical performance using common quality management
tools.
Scope: This policy applies to the MedStar System which includes First Responder
Organizations and MedStar at large.
Overview: The objective of this process is to establish the groundwork and minimum
expectations of a quality management plan.
Protection of Quality Review Documents: All proceedings of any MedStar System
quality committee, its subcommittees, and the contents of the MedStar Data Systems
are confidential and protected under Section 773.095 of the Texas Health & Safety
Code: "The proceedings and records of organized committees of hospitals, medical
societies, emergency medical services providers, emergency medical services and
trauma care systems, or first responder organizations relating to the review,
evaluation, or improvement of an emergency medical services provider, a first
responder organizations, an emergency medical services and trauma care system, or
emergency medical services personnel are confidential and not subject to disclosure
by court subpoena or otherwise."
Quality Philosophy: Quality improvement begins with leadership and their
commitment to a Quality Plan. As a starting point for an EMS leader, the NHTSA
document entitled, “A Leadership Guide to Quality Improvement for Emergency
Medical Services (EMS) Systems” may offer some insight into EMS quality
improvement. Each agency should develop and follow a plan for quality and a manual
of quality practices to follow.
Committees and Team Workgroups: The Quality Management Plan includes
standing committees and teams that monitor quality performance. They include, but
are not limited to:
a. Protocol/Quality Assurance Committee: Responsible for the medical oversight of
the MedStar System protocols and the major changes made to them. The Protocol
Committee Chairperson reports to the EPAB Board.
a. The Medical Director may make necessary minor protocol changes as needed
to ensure proper clinical care is provided and report them to this committee.
b. Reportable audits and quality metrics are reported to the Protocol Committee
by the Medical Director when applicable.
c. Acute Coronary Syndromes (ACS) and Stroke Sub-Committees: Receiving
facility representatives that collaborate with the Protocol Committee to
oversee care that relates to cardiac and stroke care.
b. First Responder Organizations (FRO) Committee: Collaborative group that work
with the First Responder Organization partners of the MedStar system.
Representatives include Medical Director staff representative(s), FROs, and
MedStar Operational stakeholders.
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c. Medical Control Team: Specific to MedStar. Collaborative group that works
together to oversee the clinical and operational related activities of the MedStar
System. Quality reports are reviewed by this team at intervals as agreed upon by
the team. It shall consist of the Medical Director, Medical Director staff
representative(s), and any MedStar Operational stakeholder(s).
d. Audit Review Team: Review the clinical audits reported by the Medical Director
representative(s). These include audits concerning any member or EPAB
permitted service in the MedStar System. It shall consist of the Medical Director,
Medical Director staff representative(s), and MedStar Operational stakeholder(s).
e. Ad-hoc Teams or Sub-Committees: A team or committee may initialize a specific
group of stakeholders to manage a specific project or task.
7. Quality Management Terminology:
a. Quality assurance (QA) – the method of monitoring a process.
b. Quality improvement (QI) – the changing or intervention of a process with the
intention of improving the quality of service delivered. The term “QI or QA
report” is used generically in this policy and includes any quality related or
performance report agreed upon or required by the involved parties.
c. Continuous quality improvement (CQI) – ongoing activities that include
assurance and improvement activities.
d. Total Quality Management (TQM) – the overall quality management plan that
includes all quality activities.
e. Performance Improvement (PI) – performance as it relates to a system. This is
usually intended to measure an individual’s or specific aspect’s performance and
compares that performance with the overall system’s performance.
f. Key Performance Indicator (KPI) – an identified and defined performance
measurement. KPIs typically include data definitions, method of data collection,
method of reporting, and frequency of reporting.
8. System Performance: The Medical Director staff in collaboration with MedStar
Operation leadership is responsible for developing the monitoring and reporting of
system performance. Any quality initiatives should include all relevant system
stakeholders that relate to the process being measured and reported. Common tasks
that should be considered, but are not limited to:
a. Development of a Quality Plan
a. Development of plan objectives
b. Process mapping
c. Development of KPIs
d. Clearly defined and validated data collection tools and metrics
e. Monitoring and analysis of data
b. Determine process stability
c. Development action plans, if necessary
d. Evaluating the effectiveness of the Quality Plan
9. Quality initiatives shall involve system stakeholders and include, but not be limited to
the following activities:
a. Prospective - designed to prevent potential problems
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b. Concurrent - designed to identify problems or potential problems during patient
care
c. Retrospective - designed to identify potential or known problems and prevent
their recurrence
d. Reporting/Feedback - all quality activities will be reported in a manner to be
jointly determined. As a result of quality assurance activities, system
improvements may be made. These may include system or individual education,
protocol, procedure, or policy changes, system design changes.
10. First Responder Organizations
a. Committees and workgroup participation is strongly encouraged;
b. Regular First Responder QI reports are expected by the Medical Director and the
Texas Department of State Health Services requires QI reporting for First
Responder Organization licensure. Monthly reporting is the most common
expectation, however the frequency of QI reports may be collaboratively
determined with the FRO Committee.
c. When the volume of runs to be reviewed is large, an FRO may request that the
Medical Director set a sample size to be reviewed and reported.
d. QI reports include, but not limited to:
a.
Compliance with documentation standards
b.
Compliance with each protocol used
c.
Skill performance by each responder
d.
Analysis of the KPIs identified by the Medical Director
e.
Current personnel roster and certification status report
f.
Response time data for all responses according to metrics established by the
Medical Director
g.
Electronic copy of all cardiac arrest files (as possible by organization)
h.
Submission of data into EPAB registries including, but not limited to, the
Early Defibrillation/Cardiac Arrest Registry
e. All MedStar System partners and stakeholders are encouraged to participate in
committees and workgroup teams established for quality initiatives.
11. Key Performance Indicators: The Medical Director has identified the following
standard KPIs as important clinical measurements. At times the system may identify
through audits or other quality processes additional KPIs worthy of tracking. It should
be understood that KPIs are limitless and subject to change at anytime.
a. Cardiac Arrest/Dead On Scene
a.
100% review
b.
Utstein template data collection
c.
Reports available annually
b. Advanced Airway Management
a.
100% review
b.
Endotracheal intubation, supraglottic airway, cricothyrotomy, procedure
compliance
(1) Single intubation attempt policy
(2) Capnography
(3) Hypoxia recognition
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c.
System and individual performance
d.
Reports available monthly
c. Pharmacological Assisted Intubation Audits
a.
100% review
b.
Protocol and procedure compliance
c.
d.
Reports available to the Medical Director and the Audit Review Team
d. Vascular Access
a.
Sampled review
b.
c.
Reports available monthly
e. New procedures should be monitored for performance until satisfactory results are
obtained.
Unless otherwise noted, monthly reports should be published by the 10th day of each
month. Annual reports should be published by the 31st day of January of the following
year.
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Reporting of Equipment Failures
1.
2.
3.
4.
Purpose. This policy is a process to describe the clinical process of reporting
equipment failures
Scope. This procedure applies to all personnel who are providing patient care in the
MedStar System and an experience an equipment failure.
Overview. If during the course of rendering patient care, a medic experiences a
failure of any piece of equipment, it must be reported to the proper entities. This
includes the medic’s employer, EPAB, the manufacturer, and the proper state/federal
agencies.
The Process.
a. The medic experiencing the equipment failure should retain the specific item if
at all possible. Package the item in a biohazard bag if it is contaminated with
human fluids.
b. Turn the item into their Agency’s designated individual as stated in their SOPs
and/or Policies & Procedures.
c. The Agency should then report the failure to the Office of the Medical
Director/EPAB.
d. The Agency should then report the failure to the manufacturer.
e. Together, the Agency, EPAB, and the manufacturer will determine if a report to
State and/or Federal agencies should be made
.
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Selection of Field Training Officers
1. Purpose. The Uniform EMS Ordinance requires EPAB to permit emergency medical
services personnel. That process depends on the integrity of the Field Training
Officer (FTO) program within the MedStar Education and Training Department and
the First Responder Organizations. The objective of the FTO Selection Process is to
assure that a standardized method for selection of FTOs will be used in a consistent
manner and to assure that the Medical Director or designee will participate in the
selection process.
2. Scope. The FTO assignment procedure applies to the MedStar Training and
Education Department or the First Responder Organization. While the Medical
Director is a participant in the selection of FTOs, these personnel are employees of
that individual Agency and must comply with their specific policies.
3. The Selection Process. The MedStar Education and Training Department or the
First Responder Organization is responsible for organizing the FTO selection process.
At minimum, the Agency shall implement a non-biased, non-discriminatory selection
process that allows candidates to compete based on their qualifications. The Medical
Director or designee shall be a participant in the selection process.
4. Final Selection. The Medical Director or designee will provide Agency a written
confirmation of recommended candidates. The Medical Director, in cooperation with
the Agency, shall have final approval of all FTO personnel.
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Supplies and Equipment
1. Purpose. The uniform EMS Ordinance requires EPAB to set standards for patient
care. Standards are to include vehicles and onboard equipment. This procedure
establishes the standards for equipment and supplies.
2. Scope. This policy applies to equipment and supplies required on ambulances, first
responder vehicles, and special teams.
3. Procedure. All vehicles will be equipped per the approved inventory. Proposed
changes in the inventory are to be submitted to EPAB for approval.
a. Brand Specific Items: In certain cases EPAB may specify a particular brand of
supply or equipment. The decision to specify a particular brand will be based on
evaluation of available products and through participation of representatives from
some of the agencies that will use the item.
b. Approved Inventory. The following documents shall be signed by the Medical
Director, dated, and carried in the Official Protocol document assigned to each
vehicle to meet state requirements. The Official Protocol document assigned to
the vehicle shall be in the vehicle at all times while the vehicle is in-service.
i. Ambulances: Vehicle/Kits Inventory;
ii. Fire Apparatus: First Responder Vehicle/Kit Inventory; or
iii. Special Teams such as the Bike Team, Mounted EMS, or other Ad hoc teams:
Kit Inventory and Modified Protocols, if any.
c. Evaluation of New Equipment. This procedure is to assure that all new
equipment is introduced into the MedStar system with the Medical Director’s
approval in accordance with EPAB policy. The process for implementation of all
new equipment will be as follows:
i. The Agency will research and suggest new equipment.
ii. The Agency and the Medical Director agrees to perform a field trial (if
necessary) on the specific equipment.
iii. The recommendation is brought to the Medical Control Team (MCT) meeting
for approval.
iv. The MCT accepts or rejects trial proposal.
v. If the trial proposal is accepted the Agency Field Training Officers or
designated personnel will perform a clinical field trial.
vi. If the trial proposal is rejected the item will be dropped from consideration,
but may be reviewed again at a later time by the MCT if deemed necessary.
vii. Once a clinical field trial is completed a representative of the Agency will
present all available data to the MCT for review.
viii. The MCT members will approve or reject the implementation of the new
item based on the following:
1. Logistics
2. Training requirements
3. Implementation constraints
d. Implementation of New Equipment
i. If approved by the MCT:
1. The new equipment will be ordered by the Agency in a timely fashion.
2. The Agency will perform all the necessary training of field personnel.
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3. EPAB will compose the applicable protocol and/or procedure for the new
item.
4. After the Agency has deemed that the proper training has been completed,
the new equipment will be implemented in the field.
ii. If rejected by the MCT the item will be dropped from consideration, but may
be reviewed again at a later time if deemed necessary.
e. Expiration of medications and supplies
i. Expiration dates should be checked monthly and items replaced as they
expire.
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Specialty Hospital Designation
1. Purpose. The Uniform EMS Ordinance mandates that the EPAB establish standards
for patient care. Certain patients present a special situation because they require rapid
response, intervention, and transport to a designated specialty center. This policy
establishes the specialty triage guidelines.
2. Scope. This policy applies to the MedStar Operations personnel who are responsible
for determining patient destinations and transporting patients.
3. Designated Specialty Receiving Facilities. EPAB has recognized Harris MethodistFort Worth and John Peter Smith Hospital as Adult Trauma Receiving Facilities.
Cook Children’s Medical Center is recognized as a Pediatric Trauma Receiving
Facility.
a. Trauma- Patients who meet American College of Surgeons trauma activation
criteria should be transported to an EPAB approved trauma facility. A list of
approved trauma facilities is available at epabonline.org.
b. Pediatric-
Age Guidelines
Any unresponsive patient with secondary sex characteristics shall be treated as an adult
patient and transported to an adult-care facility.
Medical Emergencies
Trauma Emergencies
Psychiatric Care
Adult Care Facility
≥ 15 Years
≥ 15 Years2
≥ 13 Years3
Cook Children’s
< 15 Years1
< 15 Years
< 13 Years
1
Under certain circumstances, such as medical patients who are 15 years old or older and
who have established relationships with pediatric specialists, may be transported to a
pediatric care facility. If in doubt, consult with a BSP.
2
Patients 15 years old and greater should be transported to EPAB recognized adult
trauma-receiving facilities.
3
psychiatric unit.
c. Cardiac- Patients experiencing ST elevation myocardial infarction should be
transported to an EPAB approved interventional facility. A list of approved
cardiac facilities is available at epabonline.org.
d. Stroke- Patients experiencing acute stroke symptoms should be transported to an
EPAB approved stroke facility. A list of approved stroke facilities is available at
epabonline.org.
4. Registries.
a. EPAB has further approved that all hospitals that wish to participate as traumareceiving facilities will keep a trauma registry and share outcome information
with EPAB so as to determine appropriateness of triage.
b. EPAB recommends that MedStar comply with the Texas Department of State
Health Services Trauma Reporting Guidelines.
12-62
E.P.A.B.
Page:
12-63
Effective Date:
Replaces:
February 25, 2010
All Previous
5. Definitions of Hospital Divert Status.
a. Green Status – A hospital emergency department that is open to normal traffic
and may not divert medical patients.
b. Yellow Status – DESIGNATED TRAUMA FACILITIES ONLY. A designated
trauma facility emergency department may request yellow status. Temporary
diversions of patients from a trauma hospital may occur with prior arrangement
and mutual consent of the involved facilities’ emergency physicians and prior
notification to MedStar. During such times, the MedStar Communications Center
will aid with the alternating distribution of trauma patients being transported by
MedStar ambulances.
c. Red Status – A formally declared internal disaster. A hospital is closed to ALL
patients. Criteria for a disaster include only the following:
i.
Power/electrical failure
ii.
Water failure
iii. Situations requiring evacuation of patients (fire, bomb threat, flooding, etc.)
12-63
E.P.A.B.
Page:
12-64
Effective Date:
Replaces:
February 25, 2010
All Previous
System Abusers
1.
2.
3.
4.
5.
6.
Purpose. The contract for services between the Area Metropolitan Ambulance
Authority and the ambulance service Operations requires EPAB to provide
protocols and standards of care for individuals who are chronic abusers of the EMS
system. This policy defines the procedure for identification of a potential chronic
system abuser.
Scope. This policy applies to the ambulance Operations. EPAB has responsibility
to determine if an individual may be a chronic system abuser and whether the
Operations may deny transportation services to that individual.
Procedure.
a.
Documentation. When Operations feels that an individual may be
chronically abusing the EMS system a report shall be provided to EPAB with
the following information:
i.
Identity of the individual;
ii.
Location(s) where the individual is requesting service;
b.
Description of the nature of abuse. This should include a summary of the
number of requests for service, interactions, and a description of the frequency
of such. Copies of source documents and/or CAD reports should be attached.
i.
Copies of the patient record forms completed by medics who have
interacted with the patient previously. EPAB will use the information in
the charts to assist in the decision making process. Charts must be
thorough, complete, and legible.
Processing. The Medical Director and/or designee will review the report and, if
indicated, consult with other EPAB physicians and/or medical professionals. If the
individual is considered a chronic system abuser, EPAB will register the individual
as such and issue a memorandum to Operations.
Response and Refusal to Transport. All persons who request service from
MedStar shall receive care for any real or perceived medical need in accordance
with the EPAB approved protocols. All persons who request an ambulance shall
receive an appropriate response. A careful assessment should be documented on all
patients, including those who may be system abusers, because medical conditions
may change. A MedStar ambulance Lead paramedic may decide not to transport an
EPAB registered system abuser. In such cases, the MedStar Field Operation’s
Supervisor shall be notified for final approval. MedStar ambulance paramedics
must stay with the person until receiving final approval from the supervisor to
refuse transport and clear from the scene.
Review. Operations shall maintain a file on each EPAB registered system abuser.
Copies of all charts for that individual shall be added to the file, including transport
and non-transport events, for review by the Medical Director or designee
12-64
E.P.A.B.
Page:
12-65
Effective Date:
Replaces:
February 25, 2010
All Previous
Upgrading Ambulance Responses
1.
2.
3.
4.
5.
Purpose. This policy establishes the circumstances under which EPAB approved
first responder personnel may request a MedStar Ambulance response upgrade, the
process for upgrading a response, and related QI activities.
Scope. This policy applies to First Responder personnel and affects response
priority upgrades. The call would be upgraded based on the EMD criteria.
Procedure. Certain conditions may become apparent during initial contact with a
patient that may not have been identifiable by an EMD, or that had a delayed onset,
and that may warrant a response upgrade by MedStar.
a.
If a first responder arrives at the patient’s side and identifies any of the
following findings, conditions, or situations, a response upgrade to Priority 1 is
warranted:
i.
Airway:
1. There is complete airway obstruction; or
2. The patient’s airway cannot be maintained.
ii.
Breathing:
1. The patient has severe difficulty breathing;
2. The patient cannot be ventilated.
iii. Circulation:
1. An unanticipated cardiac arrest occurs or has occurred;
2. Uncontrollable bleeding is present; or
3. Severe loss of blood has occurred.
4. Altered Level of Consciousness:
a. The patient becomes unresponsive; or
b. Status seizures.
b.
An upgrade to a Priority 2 may be requested if the first responder finds the
patient’s medical condition to be urgent.
Requesting a Response Upgrade. The first responder shall request a response
upgrade by contacting their respective dispatch center and asking them to contact the
MedStar Communication Center for the purpose of upgrading a response priority.
The reason for the upgrade is required when making such a request. The MedStar
Communication Center will upgrade the response based on current EMD criteria.
Audit of Upgrade Requests. The MedStar Operations and each First Responder
agency that has requested a response upgrade during the month shall conduct a
100% QI review of upgrade requests. The QI review shall meet the following
requirements:
a.
A cooperative review shall be conducted each month by the MedStar
Operation’s EMD QA Supervisor, the First Responder EMS coordinator,
EPAB representative, and other personnel who may be needed;
b.
Together, they shall
i.
Review the initial dispatch and the request for the upgrade;
ii.
Review of the first responder patient care report and the ambulance
medic patient care report;
12-65
E.P.A.B.
c.
Page:
12-66
Effective Date:
Replaces:
February 25, 2010
All Previous
A QI report shall be provided to the Medical Director and shall include the
total number of upgrade requests, the number of appropriate requests, and a
qualitative summary of possible improvements to the process.
12-66
E.P.A.B.
Page:
12-67
Effective Date:
Replaces:
February 25, 2010
All Previous
Walk In Patients and “Baby Moses” Events
1. Purpose. The purpose of this policy is to establish a uniform method of managing a
person’s arrival at fire stations requesting (explicit or implied) medical assistance.
2. Scope. This policy applies to all First Responder agencies and their personnel within
EPAB medical control and to the MedStar Operations and its personnel.
3. Compliance with Safe Haven Law(s). An EPAB approved first responder agency
that is recognized by the Texas Department of State Health Services under Chapter
773 of the Health and Safety Code as a First Responder Organization, in-service fire
apparatus, or any MedStar ambulance, or ambulance station may be considered a
“Safe Haven” for voluntary drop-off (abandonment) of children who appear to be 60
days old or younger in accordance with Texas Family Code.
4. Procedure.
a.
Walk-ins. When a person arrives at a fire or ambulance station requesting
medical assistance or who is in obvious medical distress, personnel should:
i. Perform initial assessments and administer indicated care in accordance
with EPAB protocol;
ii. Make indicated notifications as required by internal policy; and
iii. Request a MedStar ambulance.
b.
Baby Moses. When a child that appears to be 60 days of age or younger is
delivered to a fire station, fire crew onboard an apparatus, ambulance crew in an
ambulance, or ambulance station, personnel should follow steps in paragraph 4a
i. through iii. in this policy. MedStar ambulance personnel shall transport
patients to the nearest pediatric receiving facility.
12-67
E.P.A.B.
Page:
13-0
Effective Date:
Replaces:
February 25, 2010
All Previous
13 MEDICAL DIRECTIVES
Medical Directives are documents that describe specific clinical changes or
updates within the System, issued by the Medical Director to designated
points of contact within each agency of the System. Medical Directives are
numbered by date and designate specific levels of Provider impacted by the
Directive. The Medical Directive is distributed electronically to all agency
contacts. Individual agencies are responsible for disseminating Medical
Directives to all Credentialed Providers in each Agency.
13-0
Page:
13-0
Effective Date:
Replaces:
February 25, 2010
All Previous
E.P.A.B.
On-Board Supply Inventory List - FRO
All Levels (L-1 thru 4)
Oxygen Accessories
L-2 thru 4
Vascular Prep, Access, & Medication
Delivery
Syringe 3cc
Qty
Qty
Manual Vital Sign Tools
Qty
O2 - D Cylinder with Regulator (>700 psi)
1
BP Cuff Adult / Pedi / Infant
1 ea
O2 - Ring
1
BP Cuff Thigh or Adult XL
1
Syringe 10cc
2
O2 - Oxygen Tank Handle
1
Stethoscope
1
Veniguard
4
Glucometer
1
IV Tourniquets
2
Glucometer Test Strips
5
IV Cath. 24G 3/4"
2
Qty
Disposable Lancets
3
IV Cath. 22G 1"
2
Oral Airway - (50 / 60 / 80 / 90 / 100 / 110)
1 ea
Sharps Shuttle
1
IV Cath. 20G 1 1/4"
2
Nasal Airway - (22 / 24 / 26 / 28 / 30)
1 ea
Alcohol Preps
5
IV Cath. 18G 1 1/4"
2
5
Thermometer
1
IV Cath. 16G 1 1/4"
2
Broslow Tape or Pedi Wheel
1
IV Tubing
2
Intraosseous Needle
1
22g Needle 1 1/2"
2
18g Needle 1 1/2"
2
Nasal Atomizer Device
2
Airway & Oxygen Delivery - BLS
Water-Soluable Lubricant
Bag Valve Mask - Adult / Pedi / Infant
1 ea
Nasal Cannula - Adult
2
Non-Rebreather - Adult
2
Non-Rebreather - Pedi
1
Nebulizer
2
Immobilization/Patient
Movement
Backboards w / 3 straps
1
KED w/Straps & Pads
1
C-Collars - Adult & Pedi
Suction & Accessories
Suction - Portable w/Canister & Lid
Suction - Rigid Tip
Suction - Tubing
Suction - Cath 6/14/18 Fr
Hemmorhage Control / Bandaging / Splinting
Qty
Qty
Head Immobilizer
1 Ea
1
1
1
1
1 ea
Qty
Personal Protective Equipment /
Cleaning / Biohazard
Hand Sanitizer
Qty
1 bottle
1 Box
Gloves - Lrg
2
Airway and O2 delivery (Optional)
Qty
ETT - Laryngoscope Handle
1
ETT - Curved Blades 2, 3, 4
1 ea
ETT - Straight Blades 0, 1, 2, 3
1 ea
ETT - Size 2.5, 3.5 thru 9.0
1 ea
1 ea
Gown
3
ET Tube Holder Adult and Pedi
Goggles/Face Shield
3
Stylette - Adult and Pedi
1 ea
Masks
3
Magill Forceps - Adult and Pedi
1 ea
1 ea
Bandaids
5
Safety Vest
3
King Airway Sizes 3-5
Burn Sheet
2
EMS Scissors
1
CPAP-Boussignac
1
Multi Trauma Dressing
2
Penlight
1
ETC02 Nasal
1
Roller Gauze
6
Ringcutter
1
ETC02 ETT
1
Sterile 5X9 Gauze Pad
6
Bio Hazard Bags
2
6
Occlusive Dressing
2
Triangular Bandages
6
Sam Splints
2
Pelvic Fracture Sling
1
1" Tape
1
2" Tape
1
Saline or Sterile Water for Irrigation
1
Cold Pack
4
L-3 & 4
MCI
Triage Tape/Tags
Electrical Therapy
AED with pads
Monitor/Supplies
Qty
1 Roll
Qty
1
Cardiac Monitor
Qty
1
Quick Combo Pads Adult/Pedi
1 ea
ECG Electrodes
1 set
ECG Paper
1 roll
Level 4 Optional
Obstetrics/Labor & Deliver Items
Transtracheal Oxygen Device (TTO)
Qty
OB - Kit
1
OB - Suction Bulb
1
OB - Foil Blanket
1
L-1 Optional Items
Last Updated: May 3, 2010
Replaces: October 1, 2009
Approval date: October 1, 2009 - October 1, 2012
13-0
1
Qty
Tactical/Combat Tourniquet
1
Quickclot
2
Traction Splint
1
Pedi Immobilizer
1
King Airway Sizes 3-5
1
ETC02 Nasal
1
Page:
13-1
Effective Date:
Replaces:
February 25, 2010
All Previous
E.P.A.B.
On-Board Supply Medication List - FRO
Generic Name
How Supplied
Adenosine
Albuterol Sulfate
Aspirin
Atropine
Calcium Chloride 10%
Captopril
Dextrose 50%
Diphenhydramine Hydrochloride
Dopamine
Epinephrine 1:10,000
Epinephrine 1:1,000 Multi-Dose
Epinephrine 1:1,000
12 mg / 2 ml
2.5 mg / 3 ml
81 mg each
1 mg / 10 ml
1 gm / 10 ml
25 mg Tablet
25 gm / 50 ml
50 mg / ml
800mg / 500 ml
1mg / 10 ml
30 ml Vial
1 mg/ 1 ml
EpiPen Auto-Injector Adult & Jr
(Adult-0.3 mg & Jr-0.15 mg) AutoInjector
Glucagon
1 mg (1 unit)
Glucose Paste
15 gms
Ipratropium Bromide
500 mcg / 3 ml
Lidocaine 2%
100 mg / 5 ml
Lidocaine 4%
2 gm / 500 ml
Naloxone
2 mg / 2 ml
Methylprednisolone
125 mg Reconstitutable
Nitroglycerin Paste
30 gm
Nitroglycerin (Any Sub/Trans-Lingual Preparation)
0.4 mg per Dose
Solution Soduim Chloride 0.9%
250 ml
1000 ml
IV Flush (Prefilled or Vial)
Oxygen
D Cylinders
Promethazine
25 mg / 1 ml
Sodium Bicarb 4.2%
10 ml (.5 meq / ml)
Sodium Bicarb 8.4%
50 ml (1 meq / ml)
Ondansetron
4 mg / 1 ml
Ondansetron ODT
4 mg Tablets
Controlled Substances (Optional)
Generic Name
Fentanyl
Midazolam
Morphine Sulfate
How Supplied
100 mcg/2 ml
5 mg / 2 ml
10 mg / 1 ml
Optional
Generic Name
Mark I Auto-Injector
Magnesium Sulfate 50%
Pralidoxime Chloride
Atropine
Pediatric Atropine (Atropen)
Infant Atropine (Atropen)
How Supplied
(amounts may vary)
5 gm / 10 ml
600 mg / 2 ml
7 mg / 0.7 ml
1 mg Auto-Injector
0.5 mg Auto-Injector
Last Updated: March 2012
Approval Period: March 2012-March 2013
13-1
L-1
L-2
L-3
L-4
0
0
0
1
3
3
3
3
1 bottle 1 bottle 1 bottle 1 bottle
0
0
4
4
0
0
1
1
0
0
0
2
0
2
2
2
0
0
1
1
0
0
0
1
0
0
4
4
0
0
1
1
0
0
1
1
1 ea
0
2
2
0
0
0
0
0
1
0
0
0
1
0
0
0
0
0
1 ea
0
2
2
0
0
1
0
0
1
0
2
1
1
0
0
0
0
0
0
1
2
2
2
0
1
1
0
1
0
2
1
1
0
1
1
1
1
0
1
2
2
4
1
2
1
1
1
2
2
1
1
1
1
1
1
1
L-1
L-2
L-3
L-4
0
0
0
0
0
0
0
2
0
2
2
2
L-1
L-2
L-3
L-4
12
12
12
12
1
Located in ChemPacks not on the Apparatus
Page:
13-2
Effective Date:
Replaces:
February 25, 2010
All Previous
E.P.A.B.
On-Board Supply Inventory List – MedStar Ambulance
Vascular Prep, Access, & Medication Delivery
Qty
O2 - Key
Oxygen Accessories
Qty
2
ECG - Cardiac Monitor
1
Alcohol Preps
25
Misc - Duct Tape
2
O2 - Flow Meter
2
ECG - Monitor Battery
1
Iodine Preps
2
Misc - Blankets
3
ECG - Monitor Charger
ECG - Monitor Cord Power
1
1
IV - Tourniquets
IV - Veniguards
2
2
Misc - Pillows
Misc - Cooler
3
1
O2 - Humidifier
1
Oxygen Requirements Located on Medication List
Qty
ECG / Oxygenation Monitoring Accessories
Qty
Miscellaneous Items
Qty
ECG - Motion Load Tester (at post 4)
1
IV - Short Board
2
Misc - Flashlight
2
ECG - 4-Lead Cables
1
IV - Start Kits
7
Misc - Triage Tags
10
1
IV Cath - 16 ga
5
Misc - DOT book
1
2 ea
2 pk
2
1
2
IV Cath - 18 ga
IV Cath - 20 ga
IV Cath - 22 ga
IV Cath - 24 ga
Needles - 25 ga
8
8
5
5
2
Misc - Field Responder Guide
Misc - No Smoking Sign
Misc - Tincture Benzoin
Misc - Rubber Band
Misc - Fire Extinguisher
1
2
4
5
1
Oral Airway - Infant thru Adult (50 - 110 mm)
2 ea
ECG - 12-Lead Cables
Nasal Airway - (22 Fr - 30 Fr)
Nebulizer - Adult
Nebulizer with Mask - Adult
Nebulizer - Pedi
2 ea
2 ea
3
3
3
ECG - Combo Pads - Adult & Pedi
ECG - Electrodes Adult & Pedi
ECG - Paper
ECG - QCPR Device
ECG - QCPR Adhesive Tape
5
Pulse Ox - Adult
1 ea
Needles - 21 ga
4
Misc - Pen Light
2
Nasal Cannula - Pedi
5
3
Pulse Ox - Pedi
Pulse Ox - Extension Cable
2 ea
1
Needles - 18 ga
Syringe - 1 cc
4
6
Misc - Trauma Shears
Misc - Flares
2
6
3
5
Tracheostomy Mask
King Airway Sizes 3 thru 5
1
2 ea
Airway & Oxygen Delivery - ALS
ETT - Straight / Curved Blades 0-4
ETT - View Max Handle
ETT - View Max Blade - Adult
ETT - View Max Blade - Pedi
EtCO2 - Nasal Adult
6
EtCO2 - Nasal Pedi
2
EtCO2 - Inline Filter
NIBP Cuff - Adult Lg & Sm
4
1 ea
NIBP Cuff - Pedi & Infant
1 ea
Qty
2
1 ea
1
1
1
Qty
Syringe - 3 cc
6
Misc - Hot packs
1
Syringe - 10 cc
6
Misc - Cold packs
5
Syringe Luer Lock - 30 cc
Syringe Cath Tip - 60 cc
1
2
Misc - Safety Razor
3
Twin Pack Vial Access
10
Carpujects
2
EZ-IO Kit with Drill
1
Triangle Bandages
6
EZ-IO Needles - Pedi / Adult / Adult Lg 1 ea
Roller Bandage
10
15
IO Needle - Manual
Volutrol/Buretrol
1
1
Nitro Admin set
1
4
4
Trauma Dressing
4
IV Admin Pump Set - Full
2
Optional Items
ETT - Size 5.5, 9.0
ETT - Size 2.5, 3.5-8.5 (except 5.5)
1 ea
2 ea
Petroleum Gauze
Burn Sheets
3
2
IV Admin Pump Set - Half
IV Admin Manual Set
2
3
Quickclot
ETT - Tube Holder Adult & Pedi
1
ETT - Size 3.0
3 ea
Clear Plastic Tape - 1 inch
1
IV Pump
ETT - Flex Tube
3
2
Nasal Atomizers
3
ETT - Introducer
ETT - Whistle Tip ETT Detector
2
2
Silk Tape - 1 inch
Silk Tape - 2 inch
1
2
Tablet Cutter/Crusher
1
ETT - Spare Bulb for Lg & Sm Blade
1
Band Aids
10
Magill Forceps - Adult
Magill Forceps - Pedi
1
2
Sterile Water - 250 cc
Sam Splint
4
2
CPAP - Boussignac
2
Pelvic Sling
1
CPAP - Mask
CPAP - Head Strap
2
2
Traction Splint
1
Personal Protective Equipment / Cleaning /
Biohazard
PPE Kits
Gloves - Small
Qty
3
1 bx
CPAP - Boussignac Nebulizer Adapter
1
Gloves - Medium
1 bx
1
Gloves - Large
1 bx
Melker Crash Airway Kit
Pneumothorax Kit
1
2
Gloves - X-Large
Gloves - XX-Large
1 bx
1 bx
1 ea
Qty
Immobilization/Patient M ovement
Qty
Stretcher
1
Gloves - Sterile 7.0 & 8.0
Stair Chair
1
Restraint - Soft
1
3
Chux
Goggles
4
Suction - Canister & Lids
2
1
Scoop
Back Boards
4
3
Suction - Tonsil Tip
3
KED w/Straps & Pads
1
Mask - Hepa Lg & Sm
Suction - Tubing
4
Pediatric Immobilizer
1
Bio Hazard Bags
4
Suction - Cath 6 Fr
Suction - Cath 14 Fr
2
2
C-Collars - Adult
C-Collars - Pedi
5
2
Trash Bags
Cleaning Solution
5
1 btl
9 ea
2
Soft Stretcher
1
Myclyns Spray
Suction - Gastric Sump Tube 10 Fr
1
Patient Slide
3
Sanitizer Wipes
1 btl
2
Cot Strap Extension
Adult Head Immobilizer
1
4
Paper Towel
Spit Hood
1 bx
1
2
Patient Belongings Bags
3
Urinal
1
Bed Pan
Wash Basin
Fitted Sheets
1
2
10
Qty
Pediatric Head Immobilizer
Qty
1
B/P Cuff - Adult Lg & Sm
2 ea
B/P Cuff - Pedi & Infant
Stethoscope
Thermometer
2 ea
3
2
OB - Kit
OB - Foil Blanket
OB - Cloth Baby Blanket
Thermometer Sheaths
1 bx
OB - Baby Cap
2
Flat Sheets
10
OB - Meconium Aspirator
1
Pillow Cases
10
OB - Syringe Bulb
2
Emesis Bags
Broom
5
1
Glucometer
Glucometer Strips
Lancets
2
1 ctn
10
2
2
2
Approval Period: October 1, 2009 - October 1, 2012
13-2
Sharps Container
2
Sharps Container - Bullet
Trash Can
1
1
Qty
1
Page:
13-3
Effective Date:
Replaces:
February 25, 2010
All Previous
E.P.A.B.
On-Board Supply Medication List – MedStar Ambulance
Generic Name
Activated Charcoal
Adenosine
Albuterol Sulfate
Asprin
Atropine
Calcium Chloride 10% or Gluconate
Captopril
Dextrose 50%
Diphenhydramine
Dopamine
Epinephrine 1:1000
Epinephrine 1:1000 Multi-Dose
Glucagon
Glucose Paste
Haloperidol
Ipratropium Bromide
Lidocaine 2%
Lidocaine 4%
Methylprednisolone
Naloxone
Nitroglycerin Paste
Ondansetron
Ondansetron
Oxytocin
Procainamide
Promethazine
Sodium Bicarb 4.2%
Sodium Bicarb 8.4%
Oxygen (> 700 psi)
Oxygen (> 700 psi)
Sodium Chloride 0.9%
Generic Name
EpiPen Auto-Injector Adult
EpiPen Auto-Injector Pediatric
Generic Name
Fentanyl
Midazolam
Morphine Sulfate
Generic Name
Etomidate
Rocuronium
Succinylcholine
How Supplied
Narc
Pouch
50 gm
12 mg / ml
2.5 mg / 3 ml
81 mg ea.
1 mg / 10 ml
1 gm / 10 ml
25 mg Tablet
25 gm / 50 ml
50 mg / ml
800 mg / 500 ml
1 mg / 10 ml
1 mg / ml
30 ml vial
1 mg (1 unit)
15 gms
5 mg / ml
500 mcg / 3 ml
100 mg / 5 ml
2 gm / 500 ml
5 gm / 10 ml
2 mg / 2 ml
30 gm
0.4 mg per Dose
4 mg / 2 ml
4 mg tablet
10 units / 1 ml
1 gm / 10 ml
25 mg / 1 ml
10 ml (.5 meq / ml)
50 ml (1 meq / ml)
4 D Cylinders
1 M Cylinder
500 ml
250 ml
10 ml prefilled syringe
Only on BLS Ambulances
How Supplied
40 mg / 20 ml
100 mg / 10 ml
200 mg / 10 ml
Approval Period: March 2012 - March, 2013
13-3
2
-
1
2
4
1
2
1
1
5
1
2
4
1
1
2
2
3
1
6
3
9
back
pack
1
3
1
1
1
1
1
1
1
2
1
1
1
1
1
1
1
1
O2 bag
3
3
2
-
2
Pedi
Bag
EZ IO
Total
1
1
1
-
1
1
3
9
2
8
2
2
3
2
1
9
2
1
2
3
2
6
6
1
1
3
3
5
2
3
2
1
1
2
1
2
4
1
7
3
12
Red
Case
Truck
Red
Bag
Blue
Bag
Pedi
Bag
EZ IO
Total
-
-
1
1
-
-
-
-
1
1
Narc
Pouch
Red
Case
Truck
Red
Bag
Blue
Bag
Pedi
Bag
EZ IO
Total
-
-
-
-
-
-
3
2
2
Narc
Pouch
Red
Case
Truck
Red
Bag
Blue
Bag
Pedi
Bag
EZ IO
Total
2
2
1
-
-
-
1
-
-
-
2
2
2
3
100 mcg / 2 ml
2
10 mg / 2 ml or 5 mg / 1ml
2
10 mg / 1 ml
Only on MICU (L-5) Ambulances
How Supplied
6
1
2
1
1
2
4
1
2
4
1
2
1
1
Truck
Narc
Pouch
Controlled Substances
How Supplied
Red
Case
Page:
13-4
Effective Date:
Replaces:
February 25, 2010
All Previous
E.P.A.B.
On-Board Supply Inventory List - CCT/APP
Vascular Prep, Access, & Medication Delivery
Qty
O2 - Key
Oxygen Accessories
Qty
2
ECG - Cardiac Monitor
1
Alcohol Preps
25
Misc - Duct Tape
3
O2 - Flow Meter
2
ECG - Monitor Battery
1
Iodine Preps
2
Misc - Blankets
3
ECG - Monitor Charger
ECG - Monitor Cord Power
1
1
IV - Tourniquets
IV - Veniguards
9
9
Misc - Pillows
Misc - Cooler
3
1
ECG - Monitor Load Tester
1
IV - Short Board
2
Misc - Flashlight
2
ECG - 4-Lead Cables
1
IV Cath - 14 ga 1 1/4"
4
Misc - Triage Tags
10
O2 - Humidifier
1
Oxygen Requirements Located on Medication List
Qty
Qty
Miscellaneous Items
Qty
Oral Airway - Infant thru Adult (50 - 110 mm)
2 ea
2 ea
ECG - 12-Lead Cables
ECG - Combo Pads - Adult & Pedi
1
2 ea
IV Cath - 16 ga
IV Cath - 18 ga
4
8
Misc - DOT book
Misc - Field Responder Guide
1
1
Nebulizer - Adult
2 ea
3
3
ECG - Electrodes Adult & Pedi
ECG - Paper
ECG - QCPR Device
2 pk
2
1
IV Cath - 20 ga
IV Cath - 22 ga
IV Cath - 24 ga
8
5
5
Misc - No Smoking Sign
Misc - Tincture Benzoin
Misc - Rubber Band
1
4
5
Nebulizer - Pedi
3
ECG - QCPR Adhesive Tape
Saline Locks
6
Misc - Fire Extinguisher
1
3
Pulse Ox - Adult
1 ea
Needles - 25 ga
2
Misc - Pen Light
2
3
Pulse Ox - Pedi
2 ea
Needles - 21 ga
4
2
Nasal Cannula - Pedi
3
Pulse Ox - Extension Cable
1
Needles - 18 ga
4
Misc - Flares
6
3
EtCO2 - Nasal Adult
6
Syringe - 1 cc
6
Misc - Hot packs
2
5
EtCO2 - Nasal Pedi
2
Syringe - 3 cc
6
Misc - Cold packs
5
Tracheostomy Mask
1
2 ea
Syringe - 10 cc
Syringe Luer Lock - 30 cc
6
1
Misc - Safety Razor
3
Airway & Oxygen Delivery - ALS
2
EtCO2 - Inline Filter
NIBP Cuff - Adult Lg & Sm
4
1 ea
NIBP Cuff - Pedi & Infant
1 ea
Qty
Qty
1
11
Carpujects
2
3
EZ-IO Kit with Drill
1
ETT - View Max Handle
1
Roller Bandage
8
EZ-IO Needles - Pedi / Adult / Adult Lg 1 ea
ETT - View Max Blade - Adult
1
15
IO Needle - Manual
1
ETT - View Max Blade - Pedi
1
4
Volutrol/Buretrol
1
ETT - Straight / Curved Blades 0-4
2
Syringe Cath Tip - 60 cc
Twin Pack Vial Access
1 ea
Triangle Bandages
4
Trauma Dressing
5
Nitro Admin set
1
Optional Items
ETT - Size 2.5, 3.5 thru 9.0
2 ea
Petroleum Gauze
1
IV Admin Pump Set - Full
2
Impedence Threshold Device
ETT - Tube Holder Adult & Pedi
3 ea
ETT - Size 3.0
ETT - Flex Tube
ETT - Introducer
2
2
Qty
1
Burn Sheets
2
IV Admin Pump Set - Half
2
Tactical/Combat-Type Tourniquet 1
2
2
IV Admin Manual Set
IV Pump
3
1
Quickclot
1
ETT - Whistle Tip ETT Detector
1
Silk Tape - 1 inch
2
Nasal Atomizers
3
ETT - Inline Nebulizer
1
Silk Tape - 2 inch
2
Tablet Cutter/Crusher
1
ETT - Spare Bulb for Lg & Sm Blade
1
Band Aids
10
Bed Pan
2
Magill Forceps - Adult
Magill Forceps - Pedi
1
2
Sam Splint
4
2
Urinal
Wash Basin
2
3
Biohazard
Qty
CCT Additional Supplies
Qty
CPAP - Boussignac
2
Pelvic Sling
1
Suction Canister / Lid
4
CPAP - Mask
2
Traction Splint
1
PPE Kits
3
Fleece Blanket
3
CPAP - Head Strap
2
Vasoline Dressing
3
Gloves - Small
1 bx
Paper Towels
1
CPAP - Boussignac Nebulizer Adapter
1
1
Gloves - Medium
Gloves - Large
1 bx
1 bx
IVAC 3 Channel Pump
MP2 Cardiac Monitor
2
1
1 bx
Impact Ventilator / Accessories
1
Melker Crash Airway Kit
1
Pneumothorax Kit
2
Qty
Gloves - X-Large
Immobilization/Patient Movement
Qty
Gloves - XX-Large
1 bx
Cascade System / Main O2
1
Stretcher
1
Gloves - Sterile 7.0 & 8.0
1 ea
Low Sorbing set (IV Drip Sets)
8
Stair Chair
1
Restraint - Soft
2 ea
Dressing 4X4, Non Sterile Gauze
3 blk
Suction - Canister & Lids
2
Scoop
1
Chux
4
Vent Circuits
1
Back Boards
3
Goggles
3
(Isothermal Vent Circuits)
3
Suction - Tonsil Tip
3
KED w/Straps & Pads
1
Mask - Hepa Lg & Sm
9 ea
Skin Probe (Temperature)
3
Suction - Tubing
Suction - Cath 6 Fr
4
2
Pediatric Immobilizer
C-Collars - Adult
1
6
Bio Hazard Bags
Trash Bags
3
5
2
C-Collars - Pedi
2
Cleaning Solution
1 btl
2
Head Immobilizer
6
Myclyns Spray
2
Soft Stretcher
1
Sanitizer Wipes
1 btl
Lucas CPR System
1
2
Patient Slide
3
Paper Towel
1 bx
Weight Scale
1
1
Spit Hood
1
Patient Belongings Bags
3
Urinal
Bed Pan
1
1
Cot Strap Extension
B/P Cuff - Adult Lg & Sm
B/P Cuff - Pedi & Infant
Stethoscope
Thermometer
Qty
2 ea
2 ea
OB - Kit
Qty
2
1
3
2
OB - Foil Blanket
OB - Cloth Baby Blanket
2
2
Wash Basin
Fitted Sheets
2
10
Thermometer Sheaths
Glucometer
1 bx
2
OB - Baby Cap
OB - Meconium Aspirator
2
1
Flat Sheets
Pillow Cases
10
10
Glucometer Strips
1 ctn
OB - Syringe Bulb
1
Emesis Bags
6
Broom
1
Sharps Container
2
Sharps Container
Trash Can
1
1
1
Lancets
10
Approval Period: January 1, 2012 - January 1, 2013
13-4
Rectal Probe (Temperature)
Pressure Monitoring Kit /
3
Transducer
4
iStat System
1
Page:
13-5
Effective Date:
Replaces:
February 25, 2010
All Previous
E.P.A.B.
On-Board Supply Medication List – CCT/APP
Generic Name
Activated Charcoal
Adenosine
Albuterol Sulfate
Asprin
Atropine
Calcium Chloride 10%
Captopril
Dextrose 50%
Diltiazem
Diphenhydramine
Dopamine
Epinephrine 1:1000
Glucagon
Glucose Paste
Haloperidol
Ipratropium Bromide
Lidocaine 2%
Lidocaine 4%
Methylprednisolone
Naloxone
Nitroglycerin Paste
Ondansetron
Ondansetron
Oxytocin
Procainamide
Promethazine
Sodium Bicarb 4.2%
Sodium Bicarb 8.4%
Oxygen (> 700 psi)
Oxygen (> 700 psi)
Generic Name
Fentanyl
Midazolam
Morphine Sulfate
Generic Name
Etomidate
Rocuronium
Succinylcholine
Generic Name
How Supplied
Narc
Pouch
50 gm
12 mg / ml
2.5 mg / 3 ml
81 mg ea.
1 mg / 10 ml
1 gm / 10 ml
25 mg Tablet
25 gm / 50 ml
50 mg / 10 ml
50 mg / ml
800 mg / 500 ml
1 mg / 10 ml
1 mg / ml
30 ml vial
1 mg (1 unit)
15 gms
5 mg / ml
500 mcg / 3 ml
100 mg / 5 ml
2 gm / 500 ml
5 gm / 10 ml
2 mg / 2 ml
30 gm
0.4 mg per Dose
4 mg / 2 ml
4 mg tablet
10 units / 1 ml
1 gm / 10 ml
25 mg / 1 ml
10 ml (.5 meq / ml)
50 ml (1 meq / ml)
4 D Cylinders
1 M Cylinder
1000 ml
250 ml
10 ml prefilled syringe
Controlled Substances
How Supplied
Narc
Pouch
2
-
1
2
1
4
1
2
1
1
5
1
2
4
1
1
2
2
3
1
2
2
9
Red
Bag
Blue
Bag
Pedi
Bag
EZ IO
Total
2
3
1
1
1
1
1
1
1
1
2
1
1
1
1
1
1
1
1
1
2
3
3
2
1
1
1
1
1
-
1
1
4
9
3
8
1
2
3
2
2
1
9
2
1
2
3
2
6
6
2
1
3
3
5
2
3
2
1
1
2
1
2
4
1
3
3
12
Truck
Red
Bag
Blue
Bag
Pedi
Bag
EZ IO
Total
-
-
-
-
-
-
3
2
2
Red
Case
Truck
Red
Bag
Blue
Bag
Pedi
Bag
EZ IO
Total
1
-
-
-
1
-
-
-
2
2
2
Narc
Pouch
Red
Case
Truck
Red
Bag
Blue
Bag
Pedi
Bag
Narc
Pouch
40 mg / 20 ml
2
100 mg / 10 ml
2
200 mg / 10 ml
Only on CCT Ambulance
How Supplied
6
1
2
1
1
1
1
4
1
2
4
1
2
1
1
Truck
Red
Case
3
100 mcg / 2 ml
2
10 mg / 2 ml or 5 mg / 1ml
2
10 mg / 1 ml
Only on MICU (L-5) Ambulances
How Supplied
Red
Case
EZ IO
Total
Dobutamine (Drip)
Nicardipine (Premix)
Levophed (Ampule)
250 mg / 250 ml
20 mg / 200 ml
4 mg / 4 ml
-
-
1
1
1
-
-
-
-
1
1
1
Hydralazine (Vial)
Labetalol (Vial)
(Pending) Nitroglycerine
(Pending) Propofol
2 mg / ml
200 mg / 40 ml
50 mg / 250 ml
-
-
1
1
1
1
-
-
-
-
1
1
1
1
Approval Period: January 1, 2012 - January 1, 2013
13-5
Page:
13-6
Effective Date:
Replaces:
February 25, 2010
All Previous
E.P.A.B.
On-Board Medication and Inventory List – BERT Team
Oxygen Accessories
Vascular Prep, Access, &
Medication Delivery
Qty
O2 - Regulator
O2 - Key
1
1
Airway & Oxygen Delivery
Qty
Oral Airway - Infant thru Adult (50 - 110 mm) 1
1
2
EtCO2 - Nasal Adult
2
2
1 ea
2
ETT - Size 2.5 thru 4.5
1 ea
ETT - Tube Holder Pedi
1
1 ea
Qty
Portable Handheld Suction
Syringe - 1 cc
Syringe - 3 cc
Syringe - 10 cc
IV - Tourniquets
IV - Veniguards
Saline Locks
IV - Saline Flush 10cc
IV Cath - 18 ga
IV Cath - 20 ga
IV Cath - 22 ga
IV Cath - 24 ga
Needles - 21 ga
IO Needle - Manual
IV Admin Selec - 3
Nasal Atomizers
Carpujects
Qty
2
2
4
4
4
4
4
2
4
2
1
2
1
2
2
1
1
Hemmorhage Control /
Bandaging / Splinting
Qty
AED
AED Combo Pads Adult / Pedi
MP2 Monitor
MP2 Electrodes
1
2 ea
1
1 pkg
Qty
BP Cuff - Adult / Child
Stethoscope
Thermometer
Thermometer Sheaths
Glucometer
Glucometer Strips
Lancets
Braslow Tape
1
1
1
1
1
1 btl
5
1
Trauma Dressing
QuickClot
Burn Sheets
Band Aids
Vasoline Dressing
Sam Splint
Roller Bandage
Triangle Bandages
Silk Tape - 1 inch
Silk Tape - 2 inch
Qty
C-Collar - Adult / Pedi
1 ea
Qty
OB - Bulb Syrine
1
Biohazard
Qty
Bio Hazard Bags
Emesis Bags
Gloves - Team Member Size
2
2
1
1
Miscellaneous Items
Qty
20
2
1
1
1
20
1
1
2
4
1
1
1
Qty
Misc - Safety Razor
1
1
Misc - Cold packs
6
Misc - Pen Light
1
Clipboard w/10 Patient Care Forms
1
HT Radios
Personal Pagers
Protocol/Policy Books
2
2
1 ea
Medications
How Supplied
Qty
Albuterol Sulfate
Aspirin
Dextrose 50%
Diphenhydramine
Glucose Paste
Ipratropium Bromide
Lidocaine 2%
Naloxone
Ondansetron
Ondansetron ODT
Oxygen (> 700 psi)
2.5 mg / 3 ml
81 mg ea.
25 gm / 50 ml
50 mg / ml
30 ml vial
15 gms
500 mcg / 3 ml
100 mg / 5 ml
2 mg / 2 ml
0.4 mg per Dose
4 mg / 2 ml
4 mg tablet
C Cylinder
250 ml
4
1 btl
2
2
1
2
4
2
2
1
1
1
1
2
Lead Medic Narc Pouch
Medications
Fentanyl
Midazolam
Morphine Sulfate
Approval Period: March 2012 - March 2013
13-6
How Supplied
Qty
100 mcg / 2 ml
10 mg / 2 ml or 5 mg / 1ml
10 mg / 1 ml
3
2
2
Page:
13-7
Effective Date:
Replaces:
February 25, 2010
All Previous
E.P.A.B.
On-Board Medication & Inventory List – Mounted Team
Oxygen Accessories
Vascular Prep, Access, &
Medication Delivery
Qty
O2 - Regulator
O2 - Key
1
1
Airway & Oxygen Delivery
Qty
Oral Airway - Infant thru Adult (50 - 110 mm) 1
1
2
EtCO2 - Nasal Adult
2
2
1 ea
2
ETT - Size 2.5 thru 4.5
1 ea
ETT - Tube Holder Pedi
1
1 ea
Qty
Portable Handheld Suction
Syringe - 1 cc
Syringe - 3 cc
Syringe - 10 cc
IV - Tourniquets
IV - Veniguards
Saline Locks
IV - Saline Flush 10cc
IV Cath - 18 ga
IV Cath - 20 ga
IV Cath - 22 ga
IV Cath - 24 ga
Needles - 21 ga
IO Needle - Manual
IV Admin Selec - 3
Nasal Atomizers
Carpujects
Qty
2
2
4
4
4
4
4
2
4
2
1
2
1
2
2
1
1
Hemmorhage Control /
Bandaging / Splinting
AED
AED Combo Pads Adult / Pedi
MP2 Monitor
MP2 Electrodes
Qty
1
2 ea
1
1 pkg
Qty
BP Cuff - Adult / Child
Stethoscope
Thermometer
Thermometer Sheaths
Glucometer
Glucometer Strips
Lancets
Braslow Tape
1
1
1
1
1
1 btl
5
1
Trauma Dressing
QuickClot
Burn Sheets
Band Aids
Vasoline Dressing
Sam Splint
Roller Bandage
Triangle Bandages
Silk Tape - 1 inch
Silk Tape - 2 inch
Qty
C-Collar - Adult / Pedi
1 ea
Qty
OB - Bulb Syrine
1
Biohazard
Qty
Bio Hazard Bags
Emesis Bags
Gloves - Team Member Size
2
2
1
1
Miscellaneous Items
Qty
20
2
1
1
1
20
1
1
2
4
1
1
1
Qty
Misc - Safety Razor
1
1
Misc - Cold packs
6
Misc - Pen Light
1
Clipboard w/10 Patient Care Forms
1
HT Radios
Personal Pagers
Protocol/Policy Books
2
2
1 ea
Medications
How Supplied
Qty
Albuterol Sulfate
Aspirin
Dextrose 50%
Diphenhydramine
Glucose Paste
Ipratropium Bromide
Lidocaine 2%
Naloxone
Ondansetron
Ondansetron ODT
Oxygen (> 700 psi)
2.5 mg / 3 ml
81 mg ea.
25 gm / 50 ml
50 mg / ml
30 ml vial
15 gms
500 mcg / 3 ml
100 mg / 5 ml
2 mg / 2 ml
0.4 mg per Dose
4 mg / 2 ml
4 mg tablet
C Cylinder
250 ml
4
1 btl
2
2
1
2
4
2
2
1
1
1
1
2
Lead Medic Narc Pouch
Medications
Fentanyl
Midazolam
Morphine Sulfate
Approval Period: March 2012 - March 2013
13-7
How Supplied
Qty
100 mcg / 2 ml
10 mg / 2 ml or 5 mg / 1ml
10 mg / 1 ml
3
2
2

E.P.A.B. i

Transcription

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