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Arkansas Department of Health

Section of EMS & Trauma Systems

A R K A N S A S

BASIC LIFE SUPPORT

STATEWIDE PROTOCOLS

This BLS Protocol Manual was approved by the Governor's Advisory Council on EMS on December 1, 1999 and the Arkansas Board of Health on February 17, 2000. If you have any comments regarding these protocols, please submit in writing to: Arkansas Department of Health Section of EMS & Trauma Systems 5800 West 10th Street Little Rock, Arkansas 72204-1763

TABLE OF CONTENTS

PROTOCOLS

TABLE OF CONTENTS -------------------------------------------------------------------PROTOCOL AUTHORIZATION---------------------------------------------------------INSTRUCTIONS FOR USING THE PROTOCOLS-----------------------------------UNIVERSAL PRECAUTIONS------------------------------------------------------------GENERAL ORDERS FOR ALL PATIENTS-------------------------------------------ABDOMINAL PAIN------------------------------------------------------------------------ABDOMINAL TRAUMA------------------------------------------------------------------ALTERED MENTAL STATUS-----------------------------------------------------------AMPUTATED PART-----------------------------------------------------------------------ANAPHYLAXIS-----------------------------------------------------------------------------EPINEPHRINE AUTO-INJECTOR------------------------------------------ARREST, CARDIAC (ADULT)-----------------------------------------------------------BLEEDING CONTROL (EXTERNAL)-------------------------------------------------BURNS- CHEMICAL-----------------------------------------------------------------------BURNS- ELECTRICAL--------------------------------------------------------------------BURNS- THERMAL------------------------------------------------------------------------CEREBROVASCULAR ACCIDENT (CVA)-------------------------------------------CHEST INJURIES---------------------------------------------------------------------------CHEST PAIN---------------------------------------------------------------------------------NITROGLYCERIN---------------------------------------------------------------COLD EMERGENCIES- FROSTBITE--------------------------------------------------COLD EMERGENCIES- SYSTEMIC HYPOTHERMIA-----------------------------DIABETIC EMERGENCY- CONSCIOUS PATIENT--------------------------------ORAL GLUCOSE, ADMINISTRATION-----------------------------------DIABETIC EMERGENCY- UNCONSCIOUS PATIENT----------------------------DRUG OVERDOSE-------------------------------------------------------------------------ACTIVATED CHARCOAL, ADMINISTRATION-----------------------DYSPNEA-(ADULT)----------------------------------------------------------------------PRESCRIBED INHALER, ADMINISTRATION-------------------------EPISTAXIS-----------------------------------------------------------------------------------FRACTURES OF EXTREMITIES-------------------------------------------------------HEAD/NECK/SPINAL INJURIES--------------------------------------------------------HEAT EMERGENCIES--------------------------------------------------------------------IMPALED OBJECTS-----------------------------------------------------------------------JOINT DISLOCATIONS-------------------------------------------------------------------NEONATAL RESUSCITATION---------------------------------------------------------OBSTETRICAL EMERGENCIES-------------------------------------------------------OBSTETRICAL EMERGENCIES- (DELIVERY PROCEDURES)-----------------OBSTETRICAL EMERGENCIES- (ABNORMAL DELIVERIES)----------------1-2 3 4 5 6-7 8 8 9 10 11 12 13 14 15 16 17 18 19 20 20 21 22 23 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38

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TABLE OF CONTENTS (cont.)

GYNECOLOGICAL EMERGENCIES--------------------------------------------------PEDIATRIC RESPIRATORY DISTRESS----------------------------------------------POISONING----------------------------------------------------------------------------------PSYCHIATRIC EMERGENCIES--------------------------------------------------------SEIZURE- (DURING SEIZURE)---------------------------------------------------------SEIZURE- (POST SEIZURE)-------------------------------------------------------------SHOCK----------------------------------------------------------------------------------------HAZARDOUS MATERIALS SCENE MANAGEMENT-----------------------------SUMMONING ALS ROTOR WING AMBULANCE---------------------------------SUMMONING GROUND ALS AMBULANCE ---------------------------------------39 40 41 42 43 44 45 46 47 48

APPENDICES

ACT 101 of 1999, Public access to automated external defibrillators------------------A

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PROTOCOL AUTHORIZATION

We appreciate the considerable time and effort of those who helped develop these pre-hospital treatment protocols. The protocols have been reviewed by numerous EMS personnel and have been approved for EMT use by the Governor's Advisory Council on EMS on 12/01/1999 and the Arkansas Board of Health on 2/17/2000. These protocols will help to assure better statewide uniformity of Basic Life Support (BLS) pre-hospital emergency medical care while allowing for discretion by on-line medical control. The Office of EMS & Trauma Systems will use these protocols as the "model" for BLS care in the State of Arkansas. Procedures outside the limits of these protocols must be approved by the EMS service medical director and can only be performed by the EMT when providing care with that EMS service. While local medical control may limit the services provided by pre-hospital care providers, they MAY NOT authorize EMTs (all levels) to exceed the general scope of practice outlined in these protocols. These protocols present a general guide and are not intended to be a step-by-step approach to patient treatment. Common sense and good judgement will, in some instances, require slight deviation from these protocols. In specific instances, and based on the patient presentation and radio report, on-line medical control may order treatment modifications provided such treatment is consistent with the scope of training. Regarding use of Automated External Defibrillators (AED) all EMTs (all levels) are permitted to use Automated External Defibrillators ONLY if the guidelines and criteria of Act 101 of 1999 (Public access to Automated External Defibrillators) are followed. See Appendices A. To assure the integrity of the protocols, they are copyrighted and cannot be reproduced, in whole or in part, without the written permission of the Arkansas Department of Health. We would like to offer a special thank you to the Montana EMS & Injury Prevention Section for allowing us to use their BLS Protocol as a framework for these protocols. Also, we particularly appreciate the dedication of Arkansas's EMS community for providing quality patient care. If you have any questions concerning these protocols or any other EMS issues, please contact the Section of EMS & Trauma Systems at 501-661-2262.

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INSTRUCTIONS FOR USING THE PROTOCOLS

This protocol manual has been developed for the Arkansas Emergency Medical Services System to guide the Basic Life Support FIELD PERFORMANCE of pre-hospital emergency medical services providers. This assessment-based manual defines the expected BLS performance of pre-hospital personnel when faced with a variety of emergency situations. This is not a procedures manual describing the "how to", but a performance manual which guides the "what to do". It is presented in a field guide format for easy reference. The performance standards are consistent with the acts allowed by law or rule. To use these protocols as they are intended, it is necessary to know the underlying assumptions: 1. Users of these protocols are assumed to have current knowledge of the basic patient management principles found in EMS textbooks and literature appropriate to the EMS provider's level of training. 2. The protocols are NOT intended to be a sequential approach to patient care where everything must be done in the exact order written.

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UNIVERSAL PRECAUTIONS

Since medical history and examination cannot reliably identify all patients infected with HIV or other blood-borne pathogens, blood and body-fluid precautions should be consistently used for ALL patients. Especially, including those in emergency care settings, in which the risk of blood exposure is increased and the infection status of the patient is usually unknown. 1. All healthcare workers should routinely use appropriate barrier precautions to prevent skin and mucous-membrane exposure when contact with blood or other body fluids of any patient is anticipated. Gloves should be worn for touching blood and body fluids, mucous membranes, or non-intact skin of all patients, and for handling items or surfaces soiled with blood or body fluids. Gloves should be changed after contact with each patient. Masks and protective eyewear or face shields should be worn during procedures that are likely to generate droplets of blood or other body fluid splashes. 2. Hands and other skin surfaces should be washed immediately and thoroughly if contaminated with blood or other body fluids. Hands should be washed immediately after gloves are removed. 3. Although saliva has not been implicated in HIV transmission, to minimize the need for emergency mouth-to-mouth resuscitation, mouthpieces, resuscitation bags, or other ventilation devices should be available for use in areas in which the need for resuscitation is predictable. 4. Healthcare workers who have exposed lesions or weeping dermatitis should refrain from all direct patient care and from handling patient care equipment until the condition resolves. 5. Pregnant healthcare workers are not known to be at a greater risk of contracting HIV infection than healthcare workers who are not pregnant; however, if a healthcare worker develops HIV infection during pregnancy, the infant is at risk of infection resulting from perinatal transmission. Because of this risk, pregnant health-care workers should be especially familiar with and strictly adhere to precautions to minimize the risk of HIV transmission. Implementation of universal blood and body-fluid precautions for ALL patients eliminates the need for use of the isolation category of "Blood and Body Fluid Precautions" previously recommended by CDC (7) for patients known or suspected to be infected with blood-borne pathogens. Isolation precautions should be used as necessary if associated conditions, such as infectious diarrhea or tuberculosis, are diagnosed or suspected. The above text on Universal Precautions is taken fromCenter for Disease Control MMWR Supplement, Morbidity and Mortality Weekly Report, August 21, 1987 1 Vol. 36. No. 25.

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GENERAL ORDERS FOR ALL PATIENTS Patient Assessment/Management - Trauma & Medical Patient

I. Take body substance isolation precautions. II. Scene Size-up A. Scene safety, identify mechanism of injury, number of patients, request additional help, consider stabilization of spine. III. Initial Assessment A. Check Responsiveness, Mini neurological survey: AVPU (A-alert, V-verbal, P-pain, U-unresponsive). B. Airway- Is it patent? Identify and correct existing or potential obstruction. C. Breathing- Present? Obtain rate, quality, rhythm and bilateral breath sounds. Consider oxygen administration, establish device/LPM by individual protocol. Identify and correct existing or potential compromising factors. Follow local protocol during oxygen administration to patients with known past medical history of Chronic Obstructive Pulmonary Disease (COPD). D. Circulation- Pulse present? Obtain- rate, quality, rhythm, check blood pressure, skin temperature and color. Control external bleeding: see Bleeding Control Protocol, page 14. Identify and treat for shock; see Shock Protocol, page 45. No pulse? perform CPR, follow Arrest management protocols: see Arrest Protocol, page 13. E. Identify priority patients/ make transport decision. IV. Focused History and Physical Examination/Rapid Assessment A. Selects appropriate assessment1. Focused exam if patient appears non-critical or specific injury noted. 2. Rapid exam if patient presents with high priority conditions (head to toe exam). a. Poor general impression b. Unresponsive c. Responsive, but not following commands d. Difficulty breathing e. Shock f. Complicated childbirth g. Chest pain with systolic blood pressure less than 100. h. Severe pain anywhere B. Re-assess Vital Signs. C. Obtain SAMPLE history.

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GENERAL ORDERS FOR ALL PATIENTS (cont.)

V. Detailed Physical Examination A. Should be performed in route to hospital, repeated every 5 minutes for high priority patients, 15 minutes for non-critical patients. B. Re-assess head to toe exam. C. Re-evaluate transport decision. VI. Additional Field Treatment and Preparation for Transport See appropriate protocol. VII. Communications A. Identify ambulance service. B. Patient's age and sex. C. Chief complaint or problem. D. Level of consciousness and vital signs. E. Physical assessment findings. F. Pertinent history as needed to clarify problem (medications, illness, allergy, mechanism of injury). G. Treatment given and patient's response. H. Estimated time of arrival (E.T.A.)

Advise emergency department of changes in patient's condition before and during transportation. Provide a verbal report to, and leave a written report with, emergency department. Do not delay transport or treatment of the patient because of communication problems. Protect the dignity of patients during medical care: do not allow a crowd of onlookers to gather and keep the patient(s) covered when appropriate.

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ABDOMINAL PAIN

Assessment and Treatment

· · · · · · · · · · Be alert and treat for shock; see Shock Protocol, page 45. Visualize and palpate abdomen. Obtain and record vital signs. Place patient in position of comfort for transport, if spinal injury ruled out: see Head/Neck/Spinal Injuries Protocol, page 31. Nothing by mouth. Bowel function? Last menstrual period? Possibly pregnant? Rectal Bleeding? Nausea/Vomiting? Request ALS response when appropriate.

ABDOMINAL TRAUMA

I. Assessment and Treatment

· · · · · · · · · Be alert and treat for shock: see Shock Protocol, page 45. Control external bleeding: see Bleeding Control (External) Protocol, page 14. Keep eviscerated bowel covered with a moist dressing. Occlusive dressing applied all four sides secured, (no flutter valve). Follow local protocol. Immobilize impaled objects in place. If injury is in the upper abdomen, consider the possibility of chest injuries; see Chest Injuries Protocol, page 19. Immobilize patient as indicated. Give nothing by mouth. Determine if patient is pregnant. Request ALS response when appropriate.

I.

Evisceration (organs protruding through the wound):

· · · · · Do not touch or try to replace the exposed organ. Cover exposed organs and wound with a sterile dressing, moistened with sterile water or saline, and secure in place. Flex the patient's hips and knees, if uninjured. Be alert and treat for shock; see Shock Protocol, page 45. Request ALS response when appropriate.

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ALTERED MENTAL STATUS

Assessment and Treatment

· · · · · · · · · · · · · · Mini neurological survey. Prepare to handle combative, disoriented patient. Prepare to handle seizures: see Seizure Protocol, pages 43-44. Prepare to handle respiratory and/ or cardiac arrest. Be alert and treat for shock; see Shock Protocol page 45. Administer high flow oxygen via non-rebreather mask. Use bag valve mask to assist with ventilations as needed, 100% oxygen. Identify mechanism of injury and/or etiology and treat as indicated: see specific protocols. It may be necessary to place patient in the coma position. Maintain a high index of suspicion for neck injury in the unconscious patient with unknown etiology: see Head/Neck/Spinal Injury Protocol, page 31. If diabetic emergency is a consideration and patient is unconscious, DO NOT administer oral glucose. While aphasic patients are unable to speak, they are usually acutely aware of their surroundings and very frightened, TALK to the patient, keep the patient INFORMED. Transport patient in coma position as injuries allow. Request ALS response when appropriate.

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AMPUTATED PART

I. Assessment and Treatment

· · · · · · · Control external bleeding: see Bleeding Control (External) Protocol, page14. Place pressure dressing over the stump. Never complete a partial amputation. Immobilize to prevent further injury. Be sure amputated parts accompany ALL patients, including D.O.A.s. Be alert and treat for shock: see Shock Protocol, page 45. Request ALS response when appropriate.

II.

Care of amputated part

· · · · · · · · Rinse the part gently with normal saline to remove loose debris. DO NOT SCRUB Wrap amputated part in gauze moistened with saline. Place wrapped part into plastic bag and seal with tape (do not pour fluid into bag). Label bag with name, date and time. Place bag in a pan of water kept cool by cold packs. DO NOT immerse the amputated part directly in water or saline. DO NOT let the part come in direct contact with ice or it may freeze. DO NOT use dry ice.

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ANAPHYLAXIS

I.

· ·

Assessment and Treatment

Perform the initial assessment and care for immediate life-threatening problems with airway, breathing, or circulation. Perform focused history and physical exam. · History of allergies. · What was patient exposed to? · How were they exposed? · What effects? · Progression? · Interventions? Assess baseline vital signs and obtain SAMPLE history. Check for Medical Alert tags. Administer Oxygen-select appropriate device and liter flow. Determine if patient has prescribed preloaded epinephrine available. Contact medical direction. Facilitate administration of preloaded epinephrine. See Epinephrine Auto-Injector Protocol page 12. The rescuer MAY assist the patient in administration of the patient's own prescribed medications. If patient does not have epinephrine auto-injector available, transport immediately. Request ALS response when appropriate.

· · · · · · · · ·

II.

·

Other Considerations

Patient has come in contact with substance that causes allergic reaction without signs of respiratory distress or shock (hypoperfusion). · Continue with focused assessment. · Patient not wheezing or without signs of respiratory compromise or hypotension should not receive epinephrine. Presence of edema of tongue, mouth, and / or throat is an indicator for immediate transport. Anticipate acute airway obstruction and / or respiratory arrest. See appropriate protocol. Be alert and treat for shock: see Shock Protocol, page 45. Be alert for dyspnea; see Dyspnea Protocol, page 27. Request ALS response when appropriate.

· · · · ·

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EPINEPHRINE AUTO-INJECTOR

Administration

· · · · · · · · Obtain order from medical direction either on-line or off-line. Obtain patient's prescribed auto-injector. Ensure: · Prescription is written for the patient experiencing allergic reaction. · Medication is not discolored (if able to see). Remove safety cap from the auto-injector. Place tip of auto-injector at a 90-degree angle firmly against the patient's thigh. · Lateral portion of the thigh. · Midway between the waist and the knee. Push the injector firmly against the thigh until the injector activates. Hold the injector in place until the medication is injected (at least 10 seconds). Record activity and time. Dispose of injector in biohazard container.

Note: Continue focused assessment of airway, breathing and circulatory status. Additional administration of epinephrine may be given if directed by medical control.

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ARREST CARDIAC (ADULT)

Assessment and Treatment

· Initiate CPR according to knowledge and skills course in CPR and AED use based upon current American Heart Association scientific guidelines, standard, and recommendations for providing CPR and the use of AEDs as published in American Heart Association, American Red Cross, or equivalent course materials. Medical patient > 12 years old ­ CPR with AED. Medical patient < 12 years old or < 90lbs. ­ CPR. For hypothermic patients, see Cold Emergencies ­ Cold Emergencies, Systemic Hypothermia Protocol, see page 22. Suction Secretions as needed. Consider foreign body obstruction. Administer high flow oxygen via appropriate oxygen delivery device. Obtain SAMPLE history. Protect limbs from injury during movement. Maintain a high index of suspicion for neck injury in the unconscious patient with unknown etiology: see Head/Neck/Spinal Injury Protocol, see page 31. Request ALS response when appropriate.

· · · · · · · · · ·

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BLEEDING CONTROL (EXTERNAL)

Assessment and Treatment

· · · Perform the initial assessment and care for immediate life-threatening problems with airway, breathing, or circulation. Request ALS response when appropriate. Bleeding control · Apply fingertip pressure directly on the point of bleeding with your GLOVED hand (use dressing if immediately available). · Elevation of a bleeding extremity may be used secondary to and in conjunction with direct pressure. · Large gaping wounds may require packing with sterile gauze and direct hand pressure if direct fingertip pressure fails to control bleeding. · Pressure Points may be used in upper and lower extremities. Methods to control external bleeding if direct pressure fails · Splints · Reduction of motion of bone ends will reduce the amount and aggravation of tissue damaged and bleeding associated with a fracture. · Splinting may allow prompt control of bleeding associated with a fracture. · Pressure Splints · The use of air pressure splints can help control severe bleeding associated with lacerations of soft tissue or when bleeding is associated with fractures. · Pneumatic counterpressure devices (pneumatic antishock garment) can be used as an effective pressure splint to help control severe bleeding due to massive soft tissue injury to the lower extremities (leg compartments only) or traumatic pelvic hemorrhage (all compartments). Tourniquet · Use as last resort to control bleeding of an amputated extremity when all other methods of bleeding control have failed. Monitor dressing and vital signs continuously.

·

· · NOTE· ·

Consider removal of impaled objects in the cheek only if necessary to assure patent airway. Do not apply pressure to an open or depressed skull injury.

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BURNS- CHEMICAL

Assessment and Treatment

ENSURE YOUR OWN SAFETY · Take the necessary scene safety precautions to protect yourself from exposure to hazardous materials. · Check Material Safety Data Sheets or call Poison Control Center for appropriate treatment. Arkansas Poison Control Center 1-800-376-4766. · Use North American Emergency Response Guidebook to select appropriate measures to ensure scene safety. · Use on-line medical control if needed for appropriate care. · Stop burning process. · Be alert for progressing airway problems with patients who have burns involving face, head, neck or chest. · Be alert for smoke inhalation. · Remove jewelry and non-adherent clothing from burned areas. · Use "rule of nines" to estimate percent of body surface area injured. · Be alert and treat for shock; see Shock Protocol, page 45. · Request ALS response when appropriate. NOTE: · ·

Burns to eyes--- If burn is chemical, flush eyes for 20 minutes en route to hospital. Do not open eyelids if burned. Apply sterile gauze pads to both eyes to prevent sympathetic movement. RULE OF NINES

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BURNS- ELECTRICAL

Assessment and Treatment

ENSURE YOUR OWN SAFETY · · · · · · · · If the patient is still in contact with the electrical source or you are unsure, do not touch the patient. Identify all electrical contact points. Be sure electrical source is de-energized. Be alert for progressing airway problems with patients who have burns involving face, head, neck or chest. Remove jewelry and non-adherent clothing from burned areas. Prepare to manage cardiac arrest; see Arrest, Cardiac Protocol, page 13. Be alert for and treat for shock; see Shock Protocol, page 45. Request ALS response when appropriate.

RULE OF NINES

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BURNS-THERMAL

Assessment and Treatment

ENSURE YOUR OWN SAFETY · · · · · · · · · · · · · NOTE: · Determine mechanism of injury and be alert for other trauma. Stop the burning process, initially with water or saline. Remove smoldering clothing and jewelry. Be alert for progressing airway problems with patients who have burns involving face, head, neck or chest. Prevent further contamination. Cover the burned area with a dry sterile dressing. For large surface burns place patient between clean dry burn sheets. Do not use any type of ointment, lotion or antiseptic. Do not break blisters. Keep patient warm. Use "rule of nines" to estimate percent of body surface area injured. Be alert and treat for shock; see Shock Protocol, page 45. Request ALS response when appropriate.

Burns to eyes--- Do not open eyelids if burned. Be certain burn is thermal, not chemical. Apply sterile gauze pads to both eyes to prevent sympathetic movement. If burn is chemical, flush eyes for 20 minutes en route to hospital. RULE OF NINES

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CEREBROVASCULAR ACCIDENT (CVA)

Assessment and Treatment

· · · · · · · Calm and reassure the patient. Monitor and maintain patent airway. Administer high concentration oxygen. Place patient in recovery position if unconscious. Be aware and treat for head, neck, and spinal injuries: see Head/ Neck/Spinal Injury Protocol, page 31. Be aware and treat for seizures: see Seizure Protocol, pages 43-44. Be alert and treat for shock: see Shock Protocol, page 45.

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CHEST INJURIES

Assessment and Treatment

· · · · · · · · NOTE: · · Sucking chest wound- dress with occlusive dressing secured to the chest wall on three sides, forming a flutter valve. In open chest wounds, watch the patient closely for signs of developing tension pneumothorax. Stabilize rib fracture or flail segment. Impaled object should be stabilized in place. Check for tracheal deviation and/or subcutaneous emphysema. Continually assess and document respiratory status. Be alert and treat for shock: see Shock Protocol, page 45. Request ALS response when appropriate.

Consider abdominal injuries with chest injuries. Consider chest injuries with abdominal injuries.

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CHEST PAIN

· · · · · ·

(NITROGLYCERIN)

Assessment and Treatment

Perform initial assessment. Perform focused history and physical exam. Place patient in position of comfort, loosen tight clothing and reassure. Important questions to ask- Onset, Provocation, Quality, Radiation, Severity, Time Do not allow the patient to ambulate. If patient has prescribed nitroglycerin (NTG) and nitro is with the patient do the following: · Obtain order from medical direction either on-line or off-line. · Take blood pressure ­ if systolic BP is >100mmHg. Continue with care. · Assure right medication, right patient, right route, and patient alert. · Check expiration date of nitroglycerin. · Question patient on last dose administration, effects, and assures understanding of route of administration. · Ask patient to lift tongue and place tablet or spray dose under tongue (while wearing gloves) or have patient place tablet or spray under tongue. · Have patient keep mouth closed with tablet under tongue (without swallowing) until dissolved and absorbed. · Recheck blood pressure within 2 minutes. · The rescuer may assist the patient with self administration of the patients own prescribed nitroglycerin (1 tablet) repeated at 3 to 5 minute intervals, to a maximum of 3 tablets, if discomfort is not relieved and the systolic BP is > 100mmHg. Patient does not have prescribed nitroglycerin (NTG) ­ continue with elements of focused assessment. Expedite transport. Be alert for irregular pulse rhythm. Be alert and treat for shock; see Shock Protocol, page 45. Request ALS response when appropriate.

· · · · · NOTE: ·

Reassess patient and vital signs after each dose.

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COLD EMERGENCIES ­ FROSTBITE

Assessment and Treatment

· · · · · · Remove the patient from the environment. Assess all frost bitten patients for systemic hypothermia; see Cold Emergencies, Systemic Hypothermia, page 22. Protect the cold injured extremity from pressure, trauma and friction. Administer warmed (<104 degrees F) oxygen is preferred, when available. Remove wet or restrictive clothing. If early or superficial injury · Splint extremity · Cover the extremity · Do not rub or massage · Do not re-expose to the cold If late or deep cold injury · Remove jewelry · Cover with dry clothing or dressings · DO NOT: · Break Blisters · Rub or massage area · Apply heat · Rewarm · Allow the patient to walk on the affected extremity When an extremely long or delayed transport is inevitable, then active rapid rewarming should be done. · Immerse the affected part in warm water. · Monitor the water to ensure it does not cool from the frozen part. · Continuously stir water. · Continue until the part is soft and color and sensation return. · Dress the area with dry sterile dressings. If hand or foot, place dry sterile dressings between fingers or toes. · Protect against refreezing the warmed part. · Expect the patient to complain of severe pain Be alert and treat for shock; see Shock Protocol, page 45. Request ALS response when appropriate.

·

·

· ·

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COLD EMERGENCIES ­ SYSTEMIC HYPOTHERMIA

Assessment and Treatment

· · · · · · Remove the patient from the environment ­ protect the patient from further heat loss. Remove wet clothing and cover with blanket. Avoid rough handling of the patient. Administered warmed (<104 degrees F) oxygen is preferred, when available. Assess pulses for 30-45 seconds before starting CPR. If the patient is alert and responding appropriately, actively rewarm. · Warm blankets. · Heat packs or hot water bottles to the groin, axillary and cervical regions. · Turn the heat up high in the patient compartment of the ambulance. If the patient is unresponsive or not responding appropriately, rewarm passively: · Warm blankets. · Turn the heat up high in the patient compartment of the ambulance. · Do not allow the patient to eat or drink stimulants. · Do not massage extremities. Be alert and treat for shock; see Shock Protocol, page 45. Request ALS response when appropriate.

·

· ·

NOTE:

· · When practical, major rewarming should be left for a hospital setting. Do not delay transport. Chest compressions should never be done if clinical signs of functional cardiac activity are present even if a pulse is not palpable under field conditions. This includes victims who show any movement, spontaneous respiration, response to positive pressure ventilation, or other signs of life. Chest compressions should be done if functional cardiac activity is absent (take up to 1-2 minutes to feel for a pulse) or if the victim loses a palpable pulse.

·

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DIABETIC EMERGENCY ­ CONSCIOUS PATIENT

Assessment and Treatment

· · Maintain patent airway. Obtain pertinent and SAMPLE medical history including: · Insulin or oral hypoglycemic medications: type, dosage, time. · How much and when was the patients last oral intake (food/drink). · Recent or current illness, heavy exercise or high stress. · Pregnant Maintain body heat. Administer an oral substance high in simple sugar (if tolerated by patient). · Obtain order from medical direction either on-line or off-line. · Assure signs and symptoms of altered mental status with a known history of diabetes. · Assure patient is conscious and can swallow and protect their airway. · Administer glucose. · Between cheek and gum. · Place on tongue depressor between cheek and gum. · Perform ongoing assessment. Transport in position of comfort. Do not delay transport for the administration of oral glucose agents. Request ALS response when appropriate.

· ·

· · · NOTE: · ·

Be aware and treat for Seizures; see Seizure Protocol, pages 43-44. Be aware and treat for Shock; see Shock Protocol, page 45.

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DIABETIC EMERGENCY ­ UNCONSCIOUS PATIENT

Assessment and Treatment

· · · · Maintain patent airway, be alert and treat for respiratory compromise; see Dyspnea Protocol, page 27. Be aware and treat for head, neck, and spinal injuries: see Head/Neck/Spinal Injury Protocol, page 31. Be aware and treat for seizures; see Seizure Protocol, pages 43-44. Obtain pertinent and SAMPLE history including: · Insulin or oral hypoglycemic medications: type, dosage, time. · How much and when was the patients last oral intake (food/drink). · Recent or current illness, heavy exercise or high stress. · Pregnant. Request ALS response when appropriate.

·

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DRUG OVERDOSE

Assessment and Treatment

· · · · · · · · · · Remove pills, tablets or fragments with gloves from patient's mouth, as needed, without injuring oneself. Be alert and treat for respiratory compromise; see Dyspnea Protocol, page 27. Be alert for seizures; see Seizures Protocol, pages 43-44. If altered level of consciousness: see Altered Mental Status Protocol, page 9. Be alert and treat for shock: see Shock Protocol, page 45. Identify substance, and have container taken to the hospital. Estimate quantity. Time since exposure. Consult medical direction ­ activated charcoal; see Activated Charcoal, Administration, page 26. Request ALS response when appropriate.

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ACTIVATED CHARCOAL, ADMINISTRATION

Administration

· · · · · · · Obtain order from medical direction either on-line or off-line. Consult medical direction for dose. Container must be shaken thoroughly. Since medication looks like mud, patient may need to be persuaded to drink it. A covered container and a straw may improve patient compliance since the patient cannot see the medication this way. If patient takes a long time to drink the medication, the charcoal will settle and will need to be shaken or stirred again. Record the name, dose, route, and time of administration of the medication.

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DYSPNEA ­ ADULT- (Respiratory Distress)

Assessment and Treatment

· · · · · · Administer oxygen with correct oxygen adjunct and correct litter flow per minute. Use appropriate delivery device to assist respirations as needed. Consider foreign body obstruction. Follow American Heart Association (Health Care Provider) or American Red Cross (Professional Rescuer) guidelines to relieve airway obstruction. Obtain pertinent medical history. Allow patient to seek position of comfort if no suspicion of spinal injury is present. Patient has a prescribed inhaler available. · Consult medical direction · Facilitate administration of inhaler; see Prescribed Inhaler, Administration Protocol, page 28. Be alert and treat for shock; see Shock Protocol, page 45. Altered mental status may be present; see Altered Mental Status Protocol, see page 9. Request ALS response when appropriate.

· · · NOTE: · · · · ·

The conscious, dyspneic patient may rapidly deteriorate to respiratory crisis. PREPARE TO INTERVINE. Allergic reactions are frequently responsible for dyspneic episodes; thus inquiry for known allergies must include substances other than medications. Chronic obstructive pulmonary disease patients may react adversely to high flow oxygen administration. DO NOT withhold oxygen if it is needed. Prepare to assist ventilation. Use on-line or off-line direction for oxygen administration. DYSPNEA is a symptom, not a disease/injury. Reassess for cause and correct as necessary. Assess bilateral breath sounds.

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PRESCRIBED INHALER, ADMINISTRATION

Administration

· · · · · · · · · · · · · · Obtain order from medical direction either on-line or off-line. Assure right medication, right patient, right route, right dose, and patient alert enough to use inhaler. Check the expiration date of the inhaler. Check to see if the patient has already taken any doses. Assure the inhaler is at room temperature or warmer. Shake the inhaler vigorously several times. Remove oxygen adjunct from patient. Have the patient exhale deeply. Have the patient put his lips around the opening of the inhaler. Have the patient depress the handheld inhaler as he begins to inhale deeply. Instruct the patient to hold their breath for as long as he/she comfortably can (so medication can be absorbed). Replace oxygen on patient. Allow patient to breathe a few times and repeat second dose per medical direction. If patient has a spacer device for use with their inhaler, it should be used.

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EPISTAXIS (NOSEBLEED)

Assessment and Treatment · · · · Place the patient in a sitting position leaning forward. Apply direct pressure by pinching the fleshy portion of the nostrils together. Keep the patient calm and quiet. Rule out head/neck/spine injuries; see Head/Neck/Spinal Injuries, see page 31. · Bleeding from the nose or ears may occur because of a skull fracture. If the bleeding is the result of trauma, do not attempt to stop the blood flow. Collect the blood with a loose dressing, which may also limit exposure to sources of infection. Be alert and treat for shock; see Shock Protocol, page 45. Request ALS response when appropriate.

· ·

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FRACTURES OF EXTREMITIES

Assessment and Treatment

· · · · · · · · · · · · Apply manual stabilization. Check pulses and sensation distal to the injury BEFORE and AFTER splinting. Protect injury from excessive movement. Control any external bleeding; see Bleeding Control (External), page 14. Fractures are splinted in the position found; however, realignment of a fracture may be necessary to facilitate packaging a patient or to correct a circulatory compromise. Careful assessment prior to and following manipulation is critical. Immobilize hand/foot in position of function. Elevate injured limb if possible. Apply cold packs to injured site when practical. Apply manual traction when signs and symptoms suggest possible femur fracture. Apply a traction splint when signs and symptoms suggest possible femur fracture. Be alert and treat for shock; see Shock Protocol, page 45. If pelvic injury and/or lower extremity fractures are present with direction from online medical control PASG may be applied and inflated. Contraindicated with signs and symptoms of chest injuries (pulmonary edema). Only inflate lower chambers of PASG if patient is pregnant. Request ALS response when appropriate.

· NOTE: ·

Do not allow the obvious fracture to obscure other assessment findings.

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HEAD/NECK/SPINAL INJURIES

Assessment and Treatment · · · · · · · · · · · Manually stabilize head, neck and spine until secured on appropriate device. Place the head in a neutral in-line position unless the patient complains of pain or the head is not easily moved into position. DO NOT HYPEREXTEND THE NECK. Maintain constant manual in-line immobilization until the patient is properly secured to a backboard with the head immobilized. Careful assessment prior to and after realignment is critical. Note cerebrospinal fluid or blood from ears/nose/mouth; see Epistaxis Protocol, see page 29. With any head injury, the EMT-Basic must suspect spinal injury. Immobilize the spine. Closely monitor the airway, breathing, pulse, and mental status for deterioration. Control Bleeding · Do not apply pressure to an open or depressed skull injury. Be alert and treat for shock; see Shock Protocol, page 45. Request ALS response when appropriate.

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HEAT EMERGENCIES

Assessment and Treatment I. Patient with moist, pale, normal to cool temperature skin

· · · · · · · · Remove from heat source and place in a cool environment. Loosen or remove clothing. Cool patient by fanning. Put in supine position with legs elevated. If patient is alert and oriented: follow off-line or on-line directions for administration of oral fluid intake. No heated fluids or alcohol. If the patient is unresponsive or is vomiting, transport to the hospital with patient on his left side. Rule out head/neck/spine injury: see Head/Neck/Spinal Injuries Protocol, page 31. Be alert and treat for shock; see Shock Protocol, page 45. Request ALS response when appropriate.

II.

Patients with hot, dry or moist skin

· · · · · · · · Remove the patient from the hot environment and place in a cool environment. Remove clothing. Apply cool packs to neck, groin and armpits. Keep the skin wet by applying water by sponge or wet towels. Fan aggressively. Transport immediately. Be alert and treat for shock; see Shock Protocol, page 45. Request ALS response when appropriate.

NOTE: · · · Do not delay transport for cooling in heat stroke patients. High body temperature may cause seizures, particularly in preschool age children or patients with known seizure disorder, see Seizure Protocol, page 43-44. Not all heat emergencies are environmental in nature. They may have infectious, neurological or pharmacological etiology.

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IMPALED OBJECTS

Assessment and Treatment

· · · · · · · Do not remove the impaled object, unless it is through the cheek, it would interfere with chest compressions, or interferes with transport. Manually secure the object. Expose the wound area. Control bleeding: see Bleeding Control (External), page 14. Utilize a bulky dressing to help stabilize the object. Be alert and treat for shock: see Shock Protocol, page 45. Request ALS response when appropriate.

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JOINT DISLOCATIONS

Assessment and Treatment

· · · · · · · · · · Dislocations are splinted in position found. Check pulse, motor and sensation to the injury before and after splinting. Contact medical control when diminished or absent neurovascular function is noted distal to injury. Protect injury from excessive movement. Immobilize the site of injury. Immobilize bone above and below the site of injury. Elevate injured limb if possible (not hips). Apply cold packs to injury site when practical. Be alert and treat for shock; see Shock Protocol, page 45. Request ALS response when appropriate.

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NEONATAL RESUSCITATION

ASSESSMENT AND TREATMENT

· · · · · Establish and protect airway. Suction secretions (mouth, oropharynx then nose) dry infant to provide stimulation and prevent chilling, keep infant warm, keep head covered. Assess patient's rate of respiration. The infant should be able to breathe alone at a rate of forty to sixty breaths per minute with good chest rise. If the infant is breathing without assistance but there is a bluish color at the chest, abdomen, and/or lips, EMTs should give BLOW-BY SUPPLEMENTAL OXYGEN, holding the oxygen tubing about one-half inch from the infant's mouth and nose. Set the flow rate at 5 l/m. If the child remains blue around the lips and tongue after oxygen delivery, EMTs should begin assisted ventilation at a rate of forty breaths per minute. Indications for positive-pressure ventilation include · Apnea or gasping respirations. · Heart rate less than 100 beats per minute. · Persistent central cyanosis despite 100% oxygen. Assess the infant's heart rate. · If the heart rate is less than 100 beats per minute, then provide positive-pressureassisted ventilations at a rate of 40 to 60 per minute. · If the heart rate is less 60-80 beats per minute and not rapidly increasing positivepressure-assisted ventilations should be continued and chest compressions initiated. · Chest compressions in the neonate should be delivered at a rate of 120 compressions per minute. The ratio of compressions to breaths is 3 compressions to 1 breath. Request ALS response when appropriate.

·

·

·

Apgar Score

Assessment Pulse rate Respirations Muscle tone Irritability Color 0 Absent Absent Limp No response Blue or pale 1 Below 100 Slow, irregular Some flexion Some grimace Body pink, blue hands and feet. 2 Over 100 Normal, crying Active, good, flexion Cough, sneeze, or cry Completely pink

A total score of:

Zero to Two- indicates severe distress Three to Six- indicates moderate to mild distress Greater than Six- indicates minimal distress

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OBSTETRICAL EMERGENCIES

Assessment and Treatment

· It is best to transport an expecting mother, unless delivery is expected within a few minutes based on assessment of: · Are you pregnant? · How long have you been pregnant? · Are there contractions or pain? · Onset, frequency and duration of contractions? · Any bleeding or discharge? Is crowning occurring with contractions? · Does the patient feel as if she is having a bowel movement with increasing pressure in the vaginal area? · Does she feel the need to push? Rock hard abdomen? Do not touch vaginal areas except during delivery. Do not let the mother go to bathroom. Recognize your own limitations and transport even if delivery must occur during transport. If delivery is eminent with crowning, contact medical direction for decision to commit to delivery on site; see Obstetrical Emergencies Delivery Procedures; page 37. If delivery does not occur within 10 minutes contact medical direction for permission to transport. If no visible signs of impending delivery, transport patient on her left side or elevate right hip gently shifting uterus to the left side. Transport patient at a normal rate of speed. In instances where delivery is not proceeding normally and in which the mother displays sudden onset of severe abdominal pain, place on high-flow oxygen and treat for shock; see Shock Protocol, page 45. Transport immediately. Consider the possibility of pregnancy in any female of child bearing age with complaints of vaginal bleeding, menstrual cycle irregularity, abdominal pain (cramping), low back pain not associated with trauma, or shoulder pain not associated with trauma. Spontaneous or induced abortions may result in copious vaginal bleeding, reassure the mother, provide emotional support, and treat for shock; see Shock Protocol, page 45. Notify receiving facility immediately. Have fetus and tissue taken to hospital with the patient. Greatest risk to the mother is postpartum hemorrhage; watch closely for signs of hypovolemic shock and excessive vaginal bleeding. When the placenta is delivered, externally massage the uterus. Greatest risk to the newborn infant is airway obstruction and hypothermia. KEEP BABY COVERED, WARM, DRY AND KEEP AIRWAY SUCTIONED.

· · · ·

· ·

NOTE:

·

·

· ·

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OBSTETRICAL EMERGENCIES- Delivery Procedures

Assessment and Treatment

· · · · · · · · · · · · · · · · · · · NOTE: · · · Vaginal bleeding following delivery- up to 500cc of blood loss is normal following delivery. With excessive blood loss, massage the uterus. Regardless of estimated blood loss, if mother appears in shock, treat as such and transport prior to uterine massage. Massage en route. See Shock Protocol; page 45. Apply gloves, mask, gown, and eye protection for infection control precautions. Have mother lie with knees drawn up and spread apart. Elevate buttocks ­ with blankets or pillow. Create sterile field around vaginal opening with sterile towels or paper barriers. When the infant's head appears during crowning, place fingers on bony part of skull (not fontanel or face) and exert very gentle pressure to prevent explosive delivery. Use caution to avoid fontanel. If the amniotic sac does not break, or has not broken, use a clamp to puncture the sac and push it away from the infant's head and mouth as they appear. As the infant's head is being delivered, determine if the umbilical cord is around the infant's neck; slip over the shoulder or clamp, cut and unwrap. After the infant's head is delivered, support the head; suction the mouth two or three times and the nostrils. Use caution to avoid contact with the back of the mouth. As the torso and full body is delivered, support the infant with both hands. As the feet are born, grasp the feet. Wipe blood and mucus from the mouth and nose with sterile gauze, suction mouth and nose again. Wrap infant in a warm blanket and place on its side, head slightly lower than trunk. Keep infant level with vagina until the cord is cut. Clamp, tie and cut umbilical cord (between the clamps) as pulsations cease approximately 4 fingers width from infant. Observe for delivery of placenta while preparing mother and infant for transport. When delivered, wrap placenta in towel and put in plastic bag; transport placenta to hospital with mother. Place sterile pad over vaginal opening, lower mother's legs, help her hold them together. Record time of delivery and transport mother, infant and placenta to hospital. Request ALS response when appropriate.

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OBSTETRICAL EMERGENCIES- Abnormal Deliveries

Assessment and Treatment I Prolapsed Cord

· · · Position mother with head down or buttocks raised using gravity to lessen pressure in birth canal Insert sterile gloved hand into vagina pushing presenting part of the fetus away from the pulsating cord. Rapidly transport, keeping pressure on presenting part and monitoring pulsations in the cord.

II

Breech Birth Presentation

· · · · Newborn at great risk for delivery trauma, prolapsed cord more common, transport immediately upon recognition of breech presentation. Support infant's body as it is delivered. If head delivers spontaneously, proceed as in Obstetrical Emergencies Delivery Procedures; see Obstetrical Emergencies (Delivery Procedures) Protocol, page 37. Delivery does not occur within 10 minutes. · Emergency medical care: · Immediate rapid transportation upon recognition. · Place mother in head down position with pelvis elevated.

III

Limb Presentation

· · Immediate rapid transportation upon recognition. Place mother in head down position with pelvis elevated.

VI

· ·

Multiple Births

Be prepared for more than one resuscitation. Call for assistance.

V

· · · ·

Meconium

Do not stimulate before suctioning oropharynx. Suction. Maintain airway. Transport as soon as possible.

VI

Premature

· · Always at risk for hypothermia. Usually requires resuscitation, should be done unless physically impossible.

REQUEST ALS RESPONSE WHEN APPROPRIATE

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GYNECOLOGICAL EMERGENCIES

Assessment and Treatment I Vaginal Bleeding

· · · · · Body substance isolation. Be alert for and treat for shock; see Shock Protocol, page 45. Control bleeding, bulky dressing or sanitary pad. Transport Request ALS response when appropriate.

II

Trauma to the External Genitalia

· · · · · Mechanism of injury? Be alert and treat for shock: see Shock Protocol, page 45. Control bleeding with direct pressure over a bulky dressing or sanitary pad. See Bleeding Control, External Protocol, page 14. Do not pack the vagina. Request ALS response when appropriate.

III

Allege Sexual Assault · · · · · · · ·

Non-judgmental attitude during SAMPLE focused assessment. Crime scene protection. Examine genitalia only if profuse bleeding present. Control external bleeding; see Bleeding Control, External Protocol, page 14. Use same sex EMT-Basics for care when possible. Discourage the patient to bathe, void, or clean wounds. Be alert and treat for shock; see Shock Protocol, page 45. Request ALS response when appropriate.

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PEDIATRIC RESPIRATORY DISTRESS

Assessment and Treatment

· If adequate respiratory effort · Let child assume position of comfort. DO NOT LAY CHILD DOWN. · Administer high flow oxygen with a non-rebreather or "BLOW BY". If inadequate respiratory effort · Consider foreign body obstruction. · If child has croupy cough or epiglottis is suspected: · Put child in position of comfort. · DO NOT attempt any procedure or maneuver which may increase child's anxiety unless absolutely necessary to preserve airway (this includes examination of the oropharynx). · Administer high flow oxygen. Use appropriate oxygen device to deliver oxygen or to assist with ventilations. · Epiglottitis may require forceful ventilation. Constantly monitor airway for patency in any unconscious child. Be alert and treat for shock; see Shock Protocol, page 45. Request ALS response when appropriate.

·

· · · NOTE · · ·

When dealing with pediatric patients consider allowing a parent to accompany. The conscious, dyspneic child may rapidly deteriorate to respiratory crisis. PREPARE TO INTERVENE. Be prepared to ventilate. Allergic reactions are frequently responsible for dyspneic episodes; thus inquiry for known allergies must include substances other than medications.

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POISONING

Assessment and Treatment

PROTECT YOURSELF FROM POSSIBLE EXPOSURE · Identify substance, and if reasonable, have it taken to the hospital with the patient. · Estimate quantity. · Time since exposure. · Obtain SAMPLE history within past 24 hours. · Contact Poison Control Center as soon as possible. Arkansas Poison Control Center PH# 1-800-376-4766. · Request ALS response when appropriate.

Inhaled Poisons:

· · · Be aware of enclosed or confined areas. Have trained rescuers remove patient from poisonous environment. Be alert for vomiting.

Absorbed Poisons:

· · · · Skin - remove contaminated clothing while protecting oneself from contamination. Powder - brush powder off patient, then continue assessing for other absorbed poisons. Liquid - irrigate with clean water for at least 20 minutes (and continue en route to facility if possible. Eyes ­ irrigate with clean water away from affected eye for at least 20 minutes and continue en route to facility if possible.

Ingested Poisons: · Remove pills, tablets or fragments with gloves from patient's mouth, as needed,

without injuring oneself. · Consult medical direction- activated charcoal; see Activated Charcoal, Administration Protocol, page 26. NOTE: · · · · · Be alert and treat respiratory compromise; see Dyspnea Protocol, page 27. Be alert and treat for shock; see Shock Protocol, page 45. Be alert for seizures; see Seizure Protocol, pages 43-44. If patient is unconscious or semi-conscious, transport on left side, protect the airway and DO NOT administer oral agents. If patient is unconscious consider head/neck/spinal injuries; see Head/Neck/Spinal Injuries, see page 31.

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PSYCHIATRIC EMERGENCIES

Assessment and Treatment

Protect yourself and others · Obtain SAMPLE history, consider medical etiology. · Prescription or non-prescription drugs. · Underlying organic causes: brain tumor, chemotherapy, hypoglycemia, hyperglycemia. · Previous psychiatric disorders. Assess and treat life-threatening injuries. Ask questions in a calm, reassuring voice. Calm the patient ­ do not leave patient alone. Speak in a calm, quiet voice. Move slowly when approaching and caring for patient. Restrain if necessary. Seek on-line medical direction when considering restraining a patient. Consider need for law enforcement. Avoid unnecessary physical contact. Call additional help if needed. RESCUER must assume control of the situation: Multiple people attempting to intervene may increase the patient's confusion and agitation. Request ALS response when appropriate. Transport with patient consent. · Transport in position of comfort if not contraindicated by injuries. · Keep environment as quiet as possible. IF patient refuses transport, contact Law Enforcement Agency according to local requirements.

· · · · · · · · · · ·

Use physical restraint only as necessary for the protection of yourself or the patient.

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SEIZURES- During Seizure

Assessment and Treatment

· · · · · · · · Assure patency of airway. Have suction ready. Position patient on side if no possibility of cervical spine trauma. See Head/Neck/Spinal Injuries Protocol, page 31. Protect patient from injury. Remove hazards from immediate area. Loosen restrictive clothing. Avoid unnecessary physical restraint. Obtain pertinent medical history from family and bystanders. · Known seizure disorder. · Medications, what medication/when last taken. · Check for medical tag. · Alcohol or drug intake. · Recent trauma: see Head/Neck/Spinal Injuries Protocol, page 31. · Note fever particularly in children. · Duration of seizure. Be alert and treat for Shock; see Shock Protocol, page 45. Be alert and treat for dyspnea; see Dyspnea Protocol, page 27. Request ALS response when appropriate.

· · ·

Note:

· · · ·

Do not attempt to insert tongue blade or other instruments in the mouth of a patient who is having a seizure. If transport during seizure becomes necessary, pad stretcher side rails to protect patient. Protect the dignity of the patient during a seizure; do not allow a crowd of onlookers to gather. Be aware of history of diabetes. See Diabetic Emergencies Protocol, pages 23-24.

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SEIZURE- Post Seizure

Assessment and Treatment

· · · · · · Assure patency of airway. Have suction ready. Determine level of awareness and orientation. Neurological evaluation including; speech pattern, eye movement, motor function. Place patient on his/her side facing you to facilitate airway management. Consider Head/Neck/Spinal Injuries; see Head/Neck/Spinal Injuries Protocol, page 31. Obtain Sample history including: · Known seizure disorder. · Medications, what medication / when last taken. · Check for medical tag. · Alcohol or drug intake. · Recent trauma; see Head/Neck/Spinal Injuries Protocol, page 31. · Note fever particularly in children. · Duration of Seizure. Treat injuries sustained during the seizure, see specific protocol. Expect additional seizures. Request ALS response when appropriate.

· · ·

Note:

·

·

Patients in postictal state may appear lethargic, drift into sleep, and have short term memory loss or become violent. They should be allowed to rest and should be reassured. It may be helpful to reorient patients by telling them where they are, what happened, who you are, etc. Protect the dignity of the patient during a seizure; do not allow a crowd of onlookers to gather.

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SHOCK

Assessment and Treatment

· · · · · · · · Maintain airway/artificial ventilation. Administer high-concentration of oxygen with appropriate oxygen delivery device. Control external bleeding; see Bleeding Control (External) Protocol, page 14. Prevent loss of body heat by covering the patient with a blanket when appropriate. Identify mechanism of injury or illness. Splint any suspected bone or joint injuries. See appropriate protocol. Elevate the lower extremities approximately 8 to 12 inches. If the patient has serious injuries to the pelvis, lower extremities, head, chest, abdomen, neck or spine, keep the patient supine. Place in trendelenburg position. Accomplished by having the patient lie flat and elevating the legs a few inches or if the patient is on a spine board so the legs are a few inches higher than the head. Patients with suspected head injuries must remain supine with the head and feet at the same level. Take and record vital signs every five minutes. If signs of shock (hypoperfusion) are present and the lower abdomen is tender and pelvic injury is suspected, with no evidence of chest injury, apply and inflate the pneumatic antishock garment if APPROVED BY ON-LINE MEDICAL CONTROL. Request ALS response when appropriate. Immediate transport.

· ·

· ·

NOTE:

· Infant and child patients can maintain their blood pressure until their blood volume is more than half-gone, so by the time their blood pressure drops they are close to death. The infant or child in shock has less reserve.

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HAZARDOUS MATERIALS SCENE MANAGEMENT

Assessment and Treatment

When approaching the scene of any accident potentially involving hazardous material or any cargo: · Slow down, assess scene as you approach. · Size up the situation from a safe distance. · Position vehicles uphill and upwind. · Use binoculars to look for identifying signs, labels or placards from a safe distance. · Isolate the area. · Keep people out. · Do not enter unless fully protected with proper equipment, protective clothing and Self-Contained Breathing Apparatus. · Assess immediate danger to responders or public. · Do not walk into or touch spilled materials. · Do not walk into confined spaces without self-contained breathing devices. · Do not walk into, touch or breathe any smoke, fumes or vapors. · If you have any doubt stay back, keep people from the site and get additional help. RESOURCES · · · · · · · Local hazardous materials response team. CHEMTREC 1-800-424-9300 Hazardous Materials, The Emergency Response Handbook, published by the United States Department of Transportation. Arkansas Poison Control Center 1-800-376-4766. Material Safety Data Sheets (MSDS), invoices, bills of lading, and shipping manifests if you can safely obtain them. Local law enforcement agencies. Local fire services.

NOTE:

· · Find out who is in COMMAND when you are involved in an emergency response to a hazardous material scene. Prior designation of an emergency response command structure is highly recommended to avoid confusion and misdirection at the scene.

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SUMMONING AN ALS ROTOR WING AMBULANCE.

· Consider summoning an ALS Rotor Wing ambulance when: · A critical patient with a transport time to the facility that is greater than the ALS ROTOR WING response. · Multiple casualty accident, disaster or incident which overwhelms or taxes the local EMS systems. · Critical patient(s) that require a long on scene time due to extrication, evacuation or other delay. · Remote patient locations inaccessible by normal means. Once you determine an ALS ROTOR WING ambulance is needed, dispatch them through your local dispatch. If the patient is ready for transport and the ALS ROTOR WING ambulance ETA is prolonged, consider making arrangements to meet the ALS ROTOR WING ambulance ENROUTE to the medical facility. When or if the determination has been made that the ALS ROTOR WING ambulance is not needed, cancel them through your local dispatch.

· · ·

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SUMMONING A GROUND ALS AMBULANCE

· Consider summoning a ground ALS ambulance when: · Patient condition warranting a level of care beyond your capability. · Multiple casualty accident, disaster or incident which overwhelms or taxes the local EMS system. · Critical patient(s) that require a long on scene time due to extrication, evacuation or other delay. · A critical patient with a transport time to the facility that is less than the ALS rotor wing response. Once you determine a ground ALS ambulance is needed, dispatch them through your local dispatch. Transport of the patient should not be delayed for the arrival of the ground ALS ambulance service. Arrange for appropriate enroute patient transfer. When the determination has been made that the ground ALS ambulance is not needed, cancel them through your local dispatch.

· · ·

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